key: cord-014581-pj4iv6wp authors: nan title: national preparedness month — september 2017 date: 2017-09-15 journal: mmwr morb mortal wkly rep doi: 10.15585/mmwr.mm6636a1 sha: doc_id: 14581 cord_uid: pj4iv6wp nan every september, cdc, private and public health institutions, and approximately 3,000 government organizations support preparedness efforts and encourage americans to take action before, during, and after an emergency. every community in the united states should be ready to respond to an infectious disease outbreak, chemical or radiological release, or natural disaster (1) . public health systems should have the capacity to scale up and respond to the varying demands of public health emergencies (2) . many emergencies happen without warning; it is important for all persons to take steps ahead of time to keep themselves and their loved ones safe and healthy. research shows that only 46% of persons think a natural disaster is likely to occur in their community (3) . it is vital to take immediate and appropriate actions in the event of an emergency. this year, cdc's office of public health preparedness and response focuses on empowering individuals to better prepare for public health emergencies. the 2017 theme "the power of preparedness" highlights the importance of building and updating an emergency kit, having and reviewing an emergency plan, inspiring others to prepare, and taking immediate action to save lives. this issue of mmwr includes a report describing a series of unannounced mystery patient drills that were conducted in new york city emergency departments to assess response to potential infectious disease threats. individual and community preparedness resources are available at https://www.cdc.gov/phpr/preparedness_month.htm. in an emergency you can't respond effectively if you are not ready cdc's evolving approach to emergency response mary m.k. foote, md 1 ; timothy s. styles, md 1,2 ; celia l. quinn, md 1, 2 recent outbreaks of infectious diseases have revealed significant health care system vulnerabilities and highlighted the importance of rapid recognition and isolation of patients with potentially severe infectious diseases. during december 2015-may 2016, a series of unannounced "mystery patient drills" was carried out to assess new york city emergency departments' (eds) abilities to identify and respond to patients with communicable diseases of public health concern. drill scenarios presented a patient reporting signs or symptoms and travel history consistent with possible measles or middle east respiratory syndrome (mers). evaluators captured key infection control performance measures, including time to patient masking and isolation. ninety-five drills (53 measles and 42 mers) were conducted in 49 eds with key: cord-007354-tn90igih authors: nan title: national preparedness month: opportunities for nurse engagement date: 2015-08-30 journal: aorn j doi: 10.1016/s0001-2092(15)00706-1 sha: doc_id: 7354 cord_uid: tn90igih nan nurses are respected health professionals in the community, often recognized as an approachable resource for valid health information among friends and family members. nurses can use this position to provide accurate medical information and advocate best practices. for example, in the case of airborne disease outbreaks, nurses can dispel misinformation presented by the media and encourage simple steps (e.g., hand hygiene, proper cough etiquette) to limit the spread of infectious diseases. nurses looking to become more actively involved in public health education should seek outreach opportunities in their communities. special attention should be paid to helping at-risk populations understand the special considerations they should take in emergency situations. emergency preparedness in medical facilities relies heavily on the commitment of health care workers to be properly trained and have ready access to the appropriate equipment and medical supplies. whether preparing for a natural disaster, mass casualty event, or disease outbreak, health care workers should endeavor to keep their emergency response skills up-to-date. nurses need to be aware of the most recent care recommendations and research to provide evidence-based care to patients in all types of emergency care situations. participating in drills and simulations can be an important way to identify any part of the emergency response that might be inadequate so that corrective measures can be taken. nurses can also play a role in emergency preparedness on a global scale through travel and mission work. when health care workers travel abroad for any reason, they must be cognizant of potential pathogens that may return with them, especially as they return to work at domestic health care facilities. the outbreak of middle east respiratory syndrome coronavirus in saudi arabia demonstrated how easily medical facilities can become the center of a disease outbreak 2 and the spread of the virus to other countries highlighted the role of travel in spreading disease through our interconnected modern world. 3 nurses can play important roles in emergency preparedness in their community, at their facility, and globally. in emergency situations, prepared medical personnel and a well-educated public are important components to limit the extent of human injury or loss or spread of disease. nurses are a frontline resource for educating the public because they are looked to for reliable information. mers-cov outbreak in jeddah-a link to health care facilities who statement on the ninth meeting of the ihr emergency committee regarding mers-cov key: cord-335163-gy1ck66p authors: damien, nagi m.; chappell, douglas j.; van der hoeven, ransome title: teaching emergency medicine in a dental school during the time of covid‐19 date: 2020-07-21 journal: j dent educ doi: 10.1002/jdd.12322 sha: doc_id: 335163 cord_uid: gy1ck66p nan medical emergencies can occur at any time in the dental clinic; therefore, it is vital the entire dental team must be properly trained to manage any scenario. at the university of texas school of dentistry at houston (utsd), dental (doctor of dental surgery [dds] ) and dental hygiene (dh) students take courses in the management of medical emergencies. emergency procedures ii, is a fourth-year dds course that brings together all of the individual medical emergency procedures that have been presented throughout their dental education. students in smalls groups are required to attend a 4-hour scheduled problem-based learning session that covers basic management of various medical emergencies and a lab that focuses on setting up an emergency cart and hands-on practice of ventilation, intubation, and the administration of intravenous (iv) lines. dental emergencies is a first-year dh course comprised of a didactic component that entails a series of presentations on the management of various medical emergencies. this is followed by a lab that assesses students' handling of mock emergencies on a simman. as the pandemic began to spread in mid-march, a stay-at-home order required our institution to transition to remote learning. we were challenged by the absence of learners in the classroom and the inability for them to participate in simulation and hands-on activities. challenges with in-person delivery of the emergency procedures ii course were addressed by hosting problembased learning sessions and live demonstrations of starting an iv ( figure 1 ) and airway management using manikins ( figure 2 ) via webex 1 to students in small groups. prior to attending the sessions, students were required to view malamed 2 videos on basic management of various medical emergencies provided on canvas. 3 problem-based discussions were created on the content of the videos. at the completion of the sessions, students were required to submit a written report giving 3 important concepts that they learned. didactics in the dental emergencies course were presented via webex and an exit quiz was administered using canvas after the completion of each lecture. open book case-based exams administered on canvas replaced proctored multiple-choice question exams. the simulation sessions were substituted by virtual emergency training sessions. all students were required to attend the first session, which provided an overview of components of a sound medical emergency plan, basic emergency drugs and equipment, and management of various medical emergencies. this session was followed by small group sessions focusing on live demonstrations of airway management, cardiopulmonary resuscitation (cpr), use of an automated external defibrillator (aed), and the contents j dent educ. 2020;1-3. © 2020 american dental education association 1 wileyonlinelibrary.com/journal/jdd f i g u r e 1 webex demonstration of starting an iv on a manikin arm f i g u r e 2 webex demonstration of proper technique of using a bag-valve mask during respiratory distress of a crash cart. exit quizzes were administered via canvas after the completion of the large and small group sessions. students provided positive feedback in the course evaluations with respect to the transition to the online format and the delivery of material. however, they regretted the inability to participate in simulation and hands-on learn-ing. good time management and organization, sequencing of content, and the availability of multiple web-cameras were key factors that contributed to the successful delivery of content for remote learning. we thank dr. richard halpin, mr. gordon finnerty, and mr. darrel gonzales of the office of technology services and informatics, utsd for helping to set up, monitor, and record the webex sessions. we also thank ms. anita rodriguez (department of diagnostic and biomedical sciences) for assisting us during the webex sessions and dr. amity gardner (department of general practice and dental public health) for providing the schedules and her support. the authors declare that they have no conflict of interest. available from www.webex.com medical emergencies in the dental office the canvas learning management platform key: cord-009181-23w2r74p authors: burstein, jonathan l. title: you shall not stand by date: 2007-04-21 journal: ann emerg med doi: 10.1016/j.annemergmed.2007.01.001 sha: doc_id: 9181 cord_uid: 23w2r74p nan the threat of pandemic influenza or other very-large-scale natural, accidental, or terrorist-caused disasters has challenged society to develop methods to provide large-scale, long-term health care surge capacity. the needs of such an effort would include a large number of health care staff, in addition to training, equipment, medications, and, perhaps most notably, organization. 1 issues to be settled include how to recruit, train, protect, and provide liability and workers compensation protection for health care workers who may be thrust into unusual situations, providing care at the limits of their training, in unaccustomed venues. the american college of emergency physicians, among others, strongly supports making such volunteer efforts possible while recognizing the difficulties. 2 in this issue of annals, schultz and stratton 3 describe a method for tackling the difficult issue of staffing: where will the caregivers be found? theirs is hardly the first or only method proposed for recruiting and credentialing staff to provide disaster care. as the authors note, for example, the federal government has established the emergency system for advance registration of volunteer health professionals. all states and several large cities in the united states are required to implement components of this system. so why do we need to even discuss the method described by this proposal? simply because it answers problems that emergency system for advance registration of volunteer health professionals may be unable to address, and in a nimble, rapid, and unencumbered fashion. as they point out, emergency system for advance registration of volunteer health professionals depends on pre-event volunteers who are willing to submit information and remain involved for years, perhaps without ever being called to help. in addition, as a bureaucratically driven system, it is only slowly being implemented; the current and tentative federal expectation is that this program, started in 2002, may not be fully functional until 2010 (c. mclaughlin, written communication, november 2006; available from the author on request). under the emergency system for advance registration of volunteer health professionals, those not enrolled pre-event have no way to offer their services once a disaster strikes. in contrast, by enrolling all hospitalcredentialed staff, a database can provide a large list of potential volunteers who may not even know themselves whether they want to help until an event occurs. the 2 systems are complementary, not competitive, and both may be needed in the event of a society-wide disaster. and we have seen, after twa flight 800, the september 11 attacks, and hurricanes katrina and rita, that thousands of health care workers have spontaneously volunteered. we can reasonably expect that if an earthquake, or numerous simultaneous bombings, or even a flu pandemic, or the next severe acute respiratory syndrome epidemic strikes, physicians, nurses, emergency medical services (ems) personnel, and many others will step forward, freely, spontaneously, and willingly. we can expect people to help; it's a basic human desire. the systems we design now should allow for and expect that to happen. for example, in a true pandemic, it is hard to imagine that a willing and knowledgeable person would be turned away, but that may occur if he or she did not sign up for the emergency system for advance registration of volunteer health professionals program, perhaps "years ago." we need to accept, plan for, and support the universal impulse of health care personnel to help. perhaps our society should consider paying completely for nursing, ems, and physician education, in return for expecting help in a disaster; it is reasonable to expect that many would help anyway, and the more who are trained, even if nonpracticing, the more resilient we will be as a society. perhaps we should require that all high school graduates throughout the nation have completed training as a basic emergency medical technician, or basic patient-care and first-aid skills, or even just cardiopulmonary resuscitation training! now is the time to expend money and effort for the benefit of all, in return for greatly increasing our capacity and strength as a society. to judge by recent events, planners can rely on spontaneous volunteerism and can expect it to occur. it seems we do indeed live by the principle of lo ta'mod; perhaps that is what makes us truly human. murder or mercy? hurricane katrina and the need for disaster training american college of emergency physicians. acep policy statement on disaster response improving hospital surge capacity: a new concept for the emergency credentialing of volunteers supervising editor: michael l. callaham, md funding and support: the author reports this study did not receive any outside funding or support.reprints not available from the author. key: cord-321740-5reldbrb authors: werdehoff, steven title: emergency medicine manual, sixth edition date: 2004-09-21 journal: ann emerg med doi: 10.1016/j.annemergmed.2004.03.048 sha: doc_id: 321740 cord_uid: 5reldbrb unknown the on call series consists of handbooks designed to assist physicians with the initial evaluation and management of patients by using a problem-oriented approach. emergency medicine on call is a notable addition to this series, the goal of its editor being ''to provide the house officer and student with a valuable tool to initiate effective evaluation and care of the emergency patient.'' one hundred twenty-five presenting complaints spanning pediatrics, adult medicine, geriatrics, trauma, and toxicology are presented in an easy-to-follow format. each chapter starts with a sample case that transitions into immediate questions, differential diagnosis, key physical and laboratory findings, and management plans. common international classification of diseases, 9th revision (icd-9) diagnoses for each problem are also listed. for the medical student, teaching questions and answers are included at the end of each chapter to highlight an important point. finally, 2 to 4 articles are referenced per chapter, providing the reader with an excellent starting point for research. there are several exceptional features in this book that make it unique among handbooks. a 40-page laboratory diagnosis section includes the reference ranges for more than 100 laboratory tests. short explanations of each test are provided, along with conditions in which one would see values out of the reference range. the procedures section is concise, yet thorough. helpful diagrams and step-by-step instructions can be quickly reviewed before performing common emergency department (ed) procedures such as lumbar punctures, central lines, wound care, and abscess drainage. furthermore, a bedside ultrasonography portion provides instructions, figures, and diagrams for basic ed imaging. although this segment certainly does not substitute for an ultrasonography course, it does provide fundamental information on imaging commonly performed in the ed. lastly, the appendices contain an assortment of useful information such as pda web sites, medication tables, and temperature and weight conversion charts. after reviewing this book, i would offer 2 suggestions. there are 140 pages devoted to commonly used medications with information on indications for use, dosage, and additional notes. this material is widely available on pda programs that most physicians and medical students reference daily, and this section is less helpful than the other sections of the handbook. also, a blood component therapy section could be improved by including suggestions on the amount of blood or plasma component therapy one should anticipate transfusing in various clinical situations. in summary, emergency medicine on call is an outstanding tool for medical students and residents working in the busy ed. the text clearly meets its editor's goals, and i strongly recommend it to anyone seeking a comprehensive emergency medicine handbook. (4) increase coordination between authors of complementary chapters. the new edition does very well on the first aspect. there is a new chapter on bioterrorism, a new subsection dedicated to severe acute respiratory syndrome (sars) (amazing, considering the sars epidemic was only last year), and new toxicologic chapters on theophylline toxicity and hypoglycemic agents. also new are 12 color plates of dermatologic conditions, which are rather superfluous because most of these entities, including varicella and fifth disease, should be readily familiar to the practicing emergency physician. on keeping the content up to date, the new edition is hit or miss. on some subjects, such as indications for a computed tomographic scan before lumbar puncture and the benefit of dexamethasone in meningitis for adults, the latest recommendations from robust clinical trials are deftly interwoven into the text. 1, 2 however, in the chapter on head injury, the text suggests computed tomography for isolated loss of consciousness despite a major clinical trial and an american college of emergency physicians clinical policy recommending more restrictive indications. 3, 4 the authors have succeeded in increasing the utility and accessibility of knowledge in this edition. a constant threat with books of this size that are meant to be all encompassing is a cookbook mentality without the appropriate clinical context. adding nuance and clinical reasoning into a book of this breadth without doubling its size is certainly a challenge. improvement in this area gives confidence that the respective authors have thoroughly overhauled their subjects, making them more available to the reader. an example includes a discussion of the proper use of d-dimer with its various assays in ruling out pulmonary embolism, which is helpful when explaining to colleagues of other services why testing for d-dimer is not supported in patients with at least a moderate pretest probability. this is opposed to the previous edition, which simply stated the sensitivity of d-dimer and its high rate of false positives. as in all texts with multiple authors, there is some redundancy and some failure of clinically similar chapters to complement each other. the redundancy is actually beneficial if it helps the clinician find the sought information. however, the failure to complement may leave readers to scratch their heads. for example, the chapter on peripheral vascular disease uses wells criteria for risk stratifying patients with possible deep venous thrombosis, yet the pulmonary embolism chapter does not use wells criteria for pulmonary embolism. why not? are the wells criteria for pulmonary embolism not as sound as the criteria for deep venous thrombosis? in conclusion, emergency medicine manual, sixth edition, is of undisputed utility to the practicing emergency physician in daily practice. nonetheless, as with all works of great endeavor, there is room for improvement in the next edition. i am relieved to see that the authors and publishers did not subtitle geriatric emergency medicine ''a comprehensive study guide,'' because it is not. however, the chapters cover body systems in a systematic manner, and each is divided into uniform sections: ''high yield facts,'' ''epidemiology,'' ''pathophysiology,'' ''clinical features,'' ''diagnosis and differential,'' and ''emergency department care and disposition.'' the first section of the book has chapters dealing with special considerations in geriatric emergency medicine, including the physiology of aging, pharmacotherapy and drug-related events, functional assessment, abuse and computed tomography of the head before lumbar puncture in adults with suspected meningitis dexamethasone in adults with bacterial meningitis indications for computed tomography in patients with minor head injury clinical policy: neuroimaging and decisionmaking in adult mild traumatic brain injury in the acute setting key: cord-283368-j2vjylum authors: erika, poggiali; andrea, vercelli; cillis, maria grazia; ioannilli, eva; iannicelli, teresa; andrea, magnacavallo title: triage decision-making at the time of covid-19 infection: the piacenza strategy date: 2020-05-09 journal: intern emerg med doi: 10.1007/s11739-020-02350-y sha: doc_id: 283368 cord_uid: j2vjylum nan since its detection in china in december 2019, coronavirus disease 2019 (covid-19) rapidly spread throughout the world becoming a public health emergency of international concern. in january 2020, the who emergency committee decided to declare a global health emergency. on february 21, 2020, the first case of covid-19 had been reported in northern italy (codogno, lombardy), becoming the beginning of the covid-19 pandemic and humanitarian crises in italy. the covid-19 outbreak in northern italy has been the cause of the healthcare system crisis with a massive influx of patients to the emergency departments, particularly in piacenza due to its proximity to codogno. in few days, the covid-19 epidemic paralysed our public health system and hospital organization, becoming a challenge for our emergency department. at the beginning of the italian covid-19 outbreak, we based the suspicion of covid-19 infection upon the epidemiological risk: the exposure to confirmed covid-19 case or prolonged contact with people in the geographical area with confirmed covid-19 cases in the past 14 days. unfortunately, with the global and severe spread of covid-19 and the dramatically increased number of infected patients in piacenza, despite being a relatively small city, our hospital became one of the epicentres of the italian epidemic with 2276 cases and 447 deaths at this moment. the situation quickly turned critically with overcrowded emergency department and intensive care unit, nearing collapse. as consequence, our own hospital became a quite totally dedicated covid-19 hospital with 80% of beds reserved for ill covid-19 patients. we felt deeply concerned both by the alarming levels of spread and severity, and by the number of critically ill patients who required an immediate hospitalization in the intensive care unit. to avoid the complete collapse of our healthcare system because of the lack of expertise in epidemics and the presence of limited human resources, we needed to change our perspectives and develop a long-term plan against catastrophic consequences to warrant a "covid-19-free way" in the emergency room and prevent covid-19 spread in "covid-19-free wards" in our hospital. from the literature, we have learned that fever and cough are the most common signs of covid-19 infection, and the infection can progress to pneumonia with dyspnoea and chest symptoms in approximately 75% of patients. based on these evidences, in the absence of flu-like symptoms, patients are considered "low-risk of covid-19". we partially agree with this consideration: some patients can complain symptoms as abdominal pain, vomiting, diarrhoea, fatigue, and general malaise even in the absence of fever and respiratory symptoms and even asymptomatic patients can have abnormalities on chest ct [1] . as reported in the literature, lung ct scan is the gold standard technique to diagnose covid-19 pneumonia and nowadays, ct protocols are used to estimate the pulmonary damage. unfortunately, in a mass influx situation, ct scan is not feasible for all the patients admitted to the emergency department, particularly in developing countries and small hospitals with limited resources. in this contest, point-of-care lung us can be an effective alternative, being a safe, low-cost, and easy technique commonly used by emergency physicians at the bedside for early diagnosis of pneumonia. data reported in the literature confirmed that lung us gives results like chest ct scan and superior to chest x-ray in patients with according to the current appraisal of the who, we strongly believe that preventive measures and early diagnosis of covid-19 are crucial to interrupt virus spread and avoid local outbreaks. starting from this idea and to avoid misunderstanding covid-19 diagnoses, we established a bold triage strategy based on an algorithm to investigate all the patients admitted to our emergency department with point-of-care lung us, even in the absence of clinical suspicious of covid-19 infection (fig. 1) . for this reason, we created a "key area" in the triage room and a clear triage process based on the strictly collaboration between the triage nurse, who scheduled the patient, and the emergency clinician, who performed the point-of-care lung us to quickly identify ultrasound signs of interstitial syndrome. patients, who did not complain classical symptoms of covid-19 infection but with positive lung us, have been considered as probable cases and needed further investigation before admission to "covid-19-free wards". the primary goal was to increase as better as possible measures to prevent covid-19 infection and avoid covid-19 spread among hospitalized patients in "covid-19-free ward" of our own hospital. here we report our experience and preliminary results in the first month of italian epidemic. from february 23, 2020, to march 24, 2020, ten patients (six males, four females) presented to our emergency department complaining of syncope, proctorrhagia, rectorrhagia, abdominal pain, vomiting, right foot and leg pain, and neurological symptoms. patients' characteristics are reported in table 1 . none of them referred flu-like symptoms or dyspnoea, even though four out of ten (40%) had severe hypoxemia with pulse oxygen level (spo2) below 95%. fever (body temperature above 37.5 °c) was present in four patients, three of them with hypoxemia. even in the absence of respiratory symptoms, the patients were immediately investigated with lung us, which showed in all the cases ultrasonographic findings of covid-19 interstitial pneumonia. the diagnosis of covid19 pneumonia has been confirmed by chest ct scan in all the patients. interestingly, nasopharyngeal (np) swabs for 2019-ncov by real-time pcr confirmed the diagnosis of covid-19 pneumonia only in five out of nine (55%) patients; in four patients (45%) it was negative. unfortunately, in one case (pt 3, table 1 ), the result was unavailable due to a technical problem. we collected a second np swab from this patient after 48-72 h, which resulted positive. our data confirm that despite high specificity, the reported sensitivity of rrt-pcr testing is as low as 60-70% [4] . our experience demonstrates that in the epidemic phase of covid-19, diagnosis of covid-19 pneumonia is a real challenge for emergency physicians and point-of-care lung us can help us to early detect pulmonary and pleural findings in patients without respiratory symptoms and/or fever. for this reason, we strongly recommend us lung to assess covid-19 pneumonia in all the patients referred to emergency department even in the absence of suspicious symptoms of covid-19, especially if pulse oxygen levels are lower than normal values. our results highlight the role of point-of-care us lung in the triage decision-making at the time of worldwide covid-19 infection and global healthcare system crisis. we hope that our experience will be helpful for other emergency departments to solve quickly these pandemic and humanitarian crises, particularly in developing countries with limited resources and emergency departments where ct scan is not available. abdominal pain: a real challenge in novel covid-19 chinese critical care ultrasound study group (ccusg) (2020) findings of lung ultrasonography of novel corona virus pneumonia during the 2019-2020 epidemic can lung us help critical care clinicians in the early diagnosis of novel coronavirus (covid-19) pneumonia? radiology correlation of chest ct and rt-pcr testing in coronavirus disease 2019 (covid-19) in china: a report of 1014 cases the authors are grateful to all the emergency staff of their hospital for the help, strength, and energy to face such a difficult public health crisis. conflict of interest the authors declare that they have no conflict of interest. the study is a retrospective study and the local ethics committeet of guglielmo da saliceto hospital has approved the publication of the data. compliance with ethical standards was adhered to through institutional review board approval and the study including human participants have been performed in accordance with the ethical standards of the declaration of helsinki and its later amendments.informed consent for this type of article, informed consent is not required. key: cord-280983-95574k6h authors: kudo, daisuke; sasaki, junichi; ikeda, hiroto; shiino, yasukazu; shime, nobuaki; mochizuki, toru; morita, masanori; soeda, hiroshi; ohge, hiroki; lee, jong ja; fujita, masahisa; miyairi, isao; kato, yasuyuki; watanabe, manabu; yokota, hiroyuki title: a survey on infection control in emergency departments in japan date: 2018-07-30 journal: acute med surg doi: 10.1002/ams2.360 sha: doc_id: 280983 cord_uid: 95574k6h aim: infection control in the emergency department is important for hospital risk management; however, few clinical guidelines have been established. this study aimed to determine whether hospitals in japan have infection control manuals, and investigate the contents of manuals, consulting systems, and isolation facilities for emergency departments. methods: a total of 517 hospitals certified as educational institutions for board‐certified acute care physicians in japan were requested between march and may 2015 to provide a written evaluation of the infection control in the emergency department. results: a total of 51 of 303 (16.8%) hospitals had no manuals regarding infection control in the emergency department. among 250 hospitals having emergency department manuals, 115 (46.0%) did not include contents regarding disinfection and sterilization for imaging examination rooms, and only 44 (17.6%) had criteria for contacting the emergency medical service when patients are suspected of, or diagnosed with, communicable diseases. of the 303 hospitals, 277 (91.4%) prepared specific manuals for the 2009 pandemic influenza. of the 303 hospitals, 80 (26.4%) did not prepare manuals for the ebola virus disease outbreak in west africa in 2014. furthermore, 92 (30.4%) of the 303 hospitals did not have any negative‐pressure isolation rooms. conclusions: practices and guidelines necessary for infection control in the emergency department were not sufficiently covered in the hospitals studied. education, information sharing, and a checklist for preparing manuals are needed to establish better infection control systems in emergency departments. e mergency departments are the entrance to hospitals for all patients with diseases or injuries, including emerging and re-emerging infectious diseases. some infectious diseases cause risks for secondary infection in health-care providers and other patients, 1 and most patients with infectious diseases are not diagnosed before admission. patients with multidrug-resistant organisms admitted to the emergency department could cause a hospital outbreak. 2 infection control in the emergency department is important for risk management in hospitals and regions. various infectious disease outbreaks have recently occurred around the world, including severe acute respiratory syndrome in 2002, 3 pandemic influenza worldwide in 2009, 1 ebola virus disease in west africa in 2014, 4 and middle east respiratory syndrome in korea in 2015. 5 it was reported that 31 patients contracted severe acute respiratory syndrome from exposure in the emergency department at a university hospital in taiwan. 3 a single patient admitted to an emergency department in korea caused the korean outbreak of middle east respiratory syndrome in 2015. 5 these reports suggest that emergency departments can be key locations for the spread of emerging infectious diseases. however, in the abovementioned cases, the appropriateness of preparation, triage, and treatment in the emergency departments have not been reviewed. few clinical guidelines for infection control in emergency departments have been established, 6 and not all institutions have their own manuals. in addition, current situations and issues related to infection control in emergency departments have not been examined or recognized. therefore, this study aimed to determine whether japanese association for acute medicine (jaam)-certified hospitals have infection control manuals for the emergency department, and to investigate manual contents, consulting systems, and isolation facilities. the results could contribute to establishing essential lists for preparing infection control manuals for emergency departments. t his survey was undertaken by the committee for infection control for the emergency department (jaam) and a joint working group. some emergency departments in japan have inpatient units. however, this study focused on the outpatient unit of emergency departments. a total of 517 hospitals certified as educational institutions for board-certified acute care physicians in japan (jaam-certified hospitals) received a written request between march and may 2015 to provide written evaluation of infection control in the emergency department. the questionnaire (table s1 ) covered the following: (i) demographics of the hospitals, (ii) contents of infection control manuals for emergency departments, (iii) consulting systems between emergency departments and infection control departments, (iv) negative-pressure isolation rooms in emergency departments. the need for ethical approval was waived because the survey did not include clinical or personal data. v alid responses were received from 303 hospitals (58.6%). of 303 hospitals, 178 (58.7%) had tertiary care emergency centers (treating severe patients), and 125 (41.3%) had general emergency departments (not treating severe patients) ( table 1 ). the number of physicians with board certification in tertiary care emergency centers and general emergency departments is shown in table s2 . only 154 (50.8%) of 303 hospitals had at least one board-certified physician designated by the japanese association for infectious disease (jaid-certified physicians; table s3 ). of 303 hospitals, 225 (74.3%) had hospital infection control manuals that included content for emergency departments t his survey was the first in japan to clarify the current situation and issues in infection control in emergency departments. we found that not all jaam-certified hospitals had manuals or content in manuals regarding infection control in the emergency department. the importance of infection control in radiology and emergency settings has been previously reported. 7 however, in the current survey, only a few hospitals described disinfection and sterilization of imaging examination rooms for emergency patients in their manuals. the guidelines of the association for professionals in infection control and epidemiology mention the risks for communicable diseases in the ems setting. 8 however, only a few hospitals in our survey had manuals with criteria for contacting the ems. to prevent secondary infection among personnel and other patients, a system for sharing information about potentially infectious patients is necessary. in this survey, few hospitals prepared specific manuals for the ebola virus disease, despite the risk that residents or travelers from west africa could transmit the virus to other countries. 9 as 86% of the hospitals with more than three jaid-certified physicians prepared the manuals, a system to prepare manuals for emerging infectious disease outbreaks is necessary for hospitals even without jaid-certified physicians. the australasian college for emergency medicine established the emergency department design guidelines, 10 which mention that "isolation rooms are needed for potentially infectious patients in emergency departments," "each emergency department should ideally have at least one isolation room," and "respiratory isolation rooms for patients who require airborne droplet nuclei isolation should have negative ventilation." however, this survey found that 30% of hospitals did not have any negative-pressure isolation rooms, and 15% of hospitals did not have isolation rooms in emergency departments. it is costly to build new isolation rooms in existing hospitals. however, this does not excuse the need for guidelines on having isolation rooms in newly built or rebuilt emergency departments. as physicians, nurses, and other staff are often busy in treating many patients in the emergency department, infection control should also be undertaken simultaneously, especially with severe patients needing resuscitation, emergency, or urgent care. 10 successful infection control in the emergency department thus requires various specialists, including emergency physicians and nurses, an infection control team, and the cooperation of administrative staff. these requirements make it difficult for hospitals to carry out strict infection control. our findings suggest that jaid-certified physicians play an important role in controlling infectious diseases. the jaid-certified physicians mostly contributed in preparing manuals regarding image examination rooms and the ebola virus outbreak in 2014. however, there is a limited number of jaid-certified physicians in japan. 11, 12 therefore, to cover all essential content in manuals, which include transmission-based precautions, disinfection and sterilization of imaging examination rooms, contacting the ems, specific manuals for emerging infectious disease, and isolation rooms, a system that allows knowledge-sharing between hospitals and jaid-certified physicians is needed. moreover, although guidelines are desirable, there is no sufficient evidence regarding infection control in the emergency department; 6,13 thus, a checklist of essential content for infection control manuals in emergency departments could be helpful. this survey did not investigate several other elements of infection control, such as screening at admission, isolation of suspected patients, standard precautions, transmissionbased precautions, disinfection and sterilization of medical instruments, disinfection of medical devices and patient rooms, surveillance culture, environmental controls, control for multidrug-resistant organisms, or vaccination of healthcare providers and all staff in the hospital. [14] [15] [16] [17] in addition, the results do not reflect the situation of all jaam-certified hospitals in japan (valid responses, 60%). in emergency departments were not sufficiently met in the hospitals studied. such elements are required to prevent secondary infection among health-care providers and staff, ems personnel, and other patients. therefore, education, information sharing, and a checklist for preparing manuals are needed to establish better infection control systems in emergency departments. global mortality of 2009 pandemic influenza a h1n1 current control and treatment of multidrug-resistant acinetobacter baumannii infections ebola in africa: beyond epidemics, reproductive health in crisis mers-cov outbreak following a single patient exposure in an emergency room in south korea: an epidemiological outbreak study infection prevention in the emergency department ebola virus disease: radiology preparedness association for professionals in infection control and epidemiology. guide to infection prevention in emergency medical services c2013 texas healthcare worker is diagnosed with ebola emergency department design guidelines ver. 3.0 c1998 the japanese association for infectious disease japanese board of medical specialties. present number of medical specialties. c2017 common infection control practices in the emergency department: a literature review apsic guidelines for environmental cleaning and decontamination world health organization. hospital preparedness for epidemics guide to infection prevention for outpatient settings health care infection control practices advisory committee guideline for isolation precautions: preventing transmission of infectious agents in health care settings t his manuscript was edited by a native english speaker associated with editage, tokyo, japan. the following members are all based in japan. chairman of the committee, the japanese association for acute medi members of the committee for infection control for the emergency department, the japanese association for acute medicine, and the joint working group additional supporting information may be found online in the supporting information section at the end of the article: table s1 . questionnaire to hospitals certified as educational institutions for board-certified acute care physicians in japan, regarding infection control in the emergency department. table s2 . number of physicians with board certification in tertiary care emergency centers and general emergency departments in japan. key: cord-333209-f6xja3v2 authors: castner, jessica title: special disaster issue date: 2020-08-19 journal: j emerg nurs doi: 10.1016/j.jen.2020.06.012 sha: doc_id: 333209 cord_uid: f6xja3v2 nan control and prevention report that more than 590 health care personnel have died from covid-19 in the united states alone, and there are likely many more owing to missing data. 1 as a professional community, we deeply grieve these tremendous losses of our valued and beloved colleagues and lift up their families in the us and around the globe. we pause to honor their lives, commitment, and sacrifice ( figure 1 ). in addition to offering a sincere and heartfelt tribute to emergency nurses and other health care personnel who have lost their lives to covid-19, the purpose of this editorial is to briefly relay a surge planning model 2 and the collection of all-hazard disaster manuscripts published in this issue of jen. as the number of covid-19 cases continues to rise with no approved or effective vaccine, we face unprecedented uncertainty on the continued impact of covid-19 on our health care systems. respiratory virus transmission and health care surges frequently occur in the fall after school-aged children typically return to classrooms and weather pattern changes result in more time congregated together indoors. 3, 4 although extensive preventative measures for the general public such as face masks, physical distancing, and limiting the number of individuals congregated together can limit virus transmission, it is prudent and reasonable to prepare for continued surges in covid-19 infection presentations to the emergency department. effective continued ed pandemic disaster response depends on the preparedness and competency of every member of the team at every level and in every role as we care for patients and for each other. anesi et al 2 published the framework entitled "an adaptable model for hospital preparedness and surge planning for emerging infectious diseases" in 2020 ( figure 2 ). the framework is briefly summarized here in this editorial, and the original manuscript is available as an open access publication for readers who wish to have more detail. 2 the figure is reprinted here as an important and timely tool for every member of the emergency care team to incorporate into their own professional preparedness, habits, teamwork, and mental or physical drills and reminders. because patient crowding is a major and protracted problem in the emergency care specialty, emergency nurses are extensively familiar with the causes of health care capacity strain depicted in the framework as one or more of the following: increased patient volume, increased acuity, special care requirements, and resource reduction. 2, 5 the framework provides a clever and easily memorized "4 ss" of surge preparation for (1) space, (2) staff, (3) stuff, and (4) systems. specific to staff, one of the key components of preparedness requires that staff are appropriately trained and have the needed competencies. the major theme of this jen special disaster issue is all-hazard disaster competency and training for emergency nurses around the globe. imagine how preparedness would increase if every member of the emergency care team, at every level and in every role, reviewed the domains of focus ( figure 2 , right column) and contributed to or felt ownership of disaster preparedness problemsolving ideas and actions within their scope of practice: case definitions, testing capability and logistics, personal protective equipment and isolation precautions, triage and cohorting, clinical protocols, staff health concerns and optout, clinician well-being, communication/coordination, surge planning, and scarce resource allocation. 2 the framework provides a useful mental model to address all of the listed domains of focus during acute surge (right column of figure 2 ) to effectively respond to a patient volume surge of covid-19 or other emerging infectious diseases. the editorial team is honored to contribute to supporting and elevating the specialty of emergency nursing in the midst of the covid-19 pandemic with a special collection of all-hazard disaster content. this issue also contains a broad range of nondisaster manuscript topics. here, i'd like to call the reader's attention to the manuscripts that address frontline nursing staff disaster preparedness and disaster competencies. amberson et al 6 successfully delivered a 9-module ed-specific disaster preparedness curriculum. rather than a didactic classroom approach alone, the authors used a creative, flexible, and pragmatic approach to deliver the educational material integrated into clinical workflow through daily huddles, staff meetings, staff emails, and a designated education board. the authors generously provided the curriculum and materials as online supplemental material for use in other settings. disaster response in the emergency setting includes stressful incidents that can threaten mental health and well-being. addressing a low-frequency, high-impact event in the trauma notebook section, mccall 7 explored the experiences of emergency nurses who cared for victims of a multiple casualty school shooting, psychosocial aftereffects, and lessons learned. pallas 8 provided a new idea for professional peer social support by combining technical team debriefing and after-action with psychosocial peer support and referral interventions. the newly developed program was well received at the author's practice site and provides a promising novel emergency clinician peer support idea for further development and rigorous testing. the program manual is included as online supplemental content for replication in other emergency departments. nicholas et al 9 refocus us on the mental health of patients and a contemporary disaster with an even broader scope and scale than the current pandemic-climate change. the authors provided an overview of the key concepts for mental health impacts of climate change as an update for emergency nursing practice. patient and clinician mental health and well-being are also major considerations in preparedness for infectious disease surges, and we welcome emergency clinician psychosocial intervention testing manuscripts in jen. an accurate baseline assessment of nurse disaster competency is essential to planning interventions that improve knowledge, skills, and perceptions on the topic. marin et al 10 developed and tested a survey tool to measure general nursing disaster response competency. readers can find references to 8 pre-existing surveys to measure nurses' knowledge, attitudes, and training in the manuscript's introduction. the newly developed survey was tested with nurses in southern brazil on the basis of the international council of nursing's framework of disaster nursing competencies. 11 further research and development are needed to address the limited perceptions of the disaster nurse's role in providing psychosocial support in addition to physical care. extending our global perspective on disaster preparedness, setyawati et al 12 assessed the knowledge, skills, and preparedness in 130 nurses in indonesia. their results replicated findings from similar studies around the globe, demonstrating only moderate disaster preparedness and a need for further preparation. the study by setyawati et al 12 provides a special insight about the implications for interspecialty disaster preparedness professional development as the authors found no difference in preparedness among emergency, intensive care, and surgical unit nurses. nursing competency to respond to radiological or nuclear incidents includes distinct knowledge of disaster case identification, countermeasures, clinical protocols, infection control, decontamination, and further irradiation and contamination prevention. a study of emergency nurses by bowen et al 13 reveals sobering knowledge gaps and a demonstrated need for specialty-wide professional development and training in radiological and nuclear incident response. the authors have provided the test they used in the study as part of the manuscript for readers to review, as well as a table of resources and links for independent professional development. one of the coauthors of this manuscript, dr goodwin veenema, has also authored and edited the definitive textbook for disaster nursing, which provides an excellent educational resource for nurse educators and emergency nurses seeking further information. 14 as emergency clinicians prioritize developing and improving their own preparedness for nuclear and radiologic events, there is also a need for injury prevention and discharge education to address the lack of household preparedness. in an annual survey conducted by the us federal emergency management agency in 2018, nuclear explosive events were listed as the lowest levels of household emergency planning (42%), followed by earthquake (43%) and flood (47%). 15 emergency nurses are well poised to address this planning and knowledge deficit through injury prevention programs, community outreach work, and patient education. only 12% of us households have all recommended supplies, evacuation plans, and communication modalities recommended for all-hazard disaster preparedness. 16 ready.gov, a us homeland security website provides allhazard education and household disaster plans that can be provided to patients as part of patient education. the information is also useful for emergency clinicians to develop their personal household readiness plans and obtain supplies. the covid-19 pandemic resulted in rapid adoption and expansion of telehealth to improve social distancing figure 2 a conceptual and adaptable approach to hospital preparedness for acute surge events caused by emerging infectious diseases. 2 health care capacity strain occurs owing to increased patient volume, increased patient acuity, special patient care demands, and/or resource reduction. preparedness and response strategies to combat acute surge events must address the "4 ss": space (beds), staff (clinicians and operations), stuff (physical equipment), and system (coordination). icu, intensive care unit; pui, patient under investigation; ppe, personal protective equipment. reprinted with permission from wolters kluwer. and reduce viral transmission risks for nonurgent patients. a systematic review of the published literature by nejadshafiee et al 17 reveals a surprising gap in evidence about telenursing in incidents and disasters. the authors highlight the priority need to disseminate novel telenursing models and feasibility, as well as research the efficacy and comparative effectiveness of telenursing compared with usual emergency care. jen continues to welcome manuscripts on general telehealth and telenursing interventions. furthermore, pandemic planning must include the potential to administer covid-19 vaccines in the emergency department, once a vaccine is available. although ozog et al 18 did not study attitudes toward covid vaccination, their study on health care provider attitudes toward an influenza vaccination in the emergency department has important and timely implications for the current pandemic. most clinicians supported nurse-initiated protocols to enhance the efficiency of vaccine administration, as most were vaccinated themselves (91%) and were in favor of providing vaccination interventions (86%) when staffing and resources were sufficient for overall ed flow and function. in summary, i wrote this editorial to honor the lives of our health care provider colleagues who have, sadly, succumbed to covid-19, provide a brief overview of a surge planning framework with immediate clinical implications, and briefly introduce the collection of all-hazard disaster manuscripts in this issue of jen. in addition to individual household preparedness resources at ready.gov, several of the manuscripts and online supplemental content include resources that can be immediately translated into education and practice. 6, 14 it is a distinct privilege to disseminate this and all the material in this issue to support and lift up the specialty of emergency nursing as we confront, draw together, and overcome in these challenging pandemic times. centers for disease control and prevention. coronavirus disease 2019: cases in the u.s a conceptual and adaptable approach to hospital preparedness for acute surge events due to emerging infectious diseases ambient air pollution and emergency department visits for asthma in erie county respiratory virus transmission dynamics determine timing of asthma exacerbation peaks: evidence from a population-level model ena position statement committee. crowding, boarding, and patient throughput increasing disaster preparedness in emergency nurses: a quality improvement initiative caring for patients from a school shooting: a qualitative case series in emergency nursing the acute incident response program: a framework guiding multidisciplinary responses to acutely traumatic or stress-inducing incidents in the ed setting mental health impacts of climate change: perspectives for the ed clinician development and psychometric testing of a tool measuring nurses' competence for disaster response world health organization, international council of nurses. icn framework of disaster nursing competencies disaster knowledge, skills, and preparedness among nurses in bengkulu, indonesia: a descriptive correlational study exploring national nursing readiness for radiological or nuclear incident: a crosssectional study disaster nursing and emergency preparedness for chemical, biological, and radiological terrorism, and other hazards preparedness perceptions, sociodemographic characteristics, and level of household preparedness for public health emergencies: behavioral risk factor surveillance system telenursing in incidents and disasters: a systematic review of the literature attitudes toward influenza vaccination administration in the emergency department among health care providers: a cross-sectional survey key: cord-319859-6mt34av6 authors: zhou, min; yuan, fei; zhao, xiaolong; xi, fanjie; wen, xianxiu; zeng, li; zeng, wenbo; wu, haiyan; zeng, hui; zhao, ziyu title: research on the individualized short‐term training model of nurses in emergency isolation wards during the outbreak of covid‐19 date: 2020-08-04 journal: nurs open doi: 10.1002/nop2.580 sha: doc_id: 319859 cord_uid: 6mt34av6 aim: to explore an effective personalized training model for nurses working in emergency isolation wards of covid‐19 in a short period. design: this study is a longitudinal study from 24 january 2020 to 28 february 2020. methods: there are 71 nursing staff working in the emergency isolation wards of sichuan provincial people's hospital that participated in this study. the questionnaires were conducted with likert scale. the operation assessment teachers have received standardized training. the self‐rating anxiety scale (sas) and self‐rating depression scale (sds) were applied to assess the mental state of nurses. results: after short‐term training, these nurses can handle the emergency tasks in a timely manner. the pass rate of nurse theory and operation assessment is 100%. the 111 suspected patients admitted to the emergency isolation ward have been scientifically diagnosed and treated, the three confirmed patients have received appropriate treatment. no nurses have been infected. conclusions: in this study, the personalized emergency training mode was feasible in the emergency isolation ward during the covid‐19 epidemic, which rapidly improved the rescue ability of nurses and effectively avoid the occurrence of cross‐infection. this mode can provide a valuable reference for the emergency training of nurses in the future. transmission routes (national health commission of china). covid-19 broke out in wuhan in december 2019, and then, the epidemic spread globally (who, 2020) . the whole world should pay attention to how to deal with the outbreak (kickbusch & leung, 2020) . to stop the spread of the epidemic as soon as possible, all of provinces and cities in china have taken strong measures. although various industries have resumed production in china, the current international covid-19 epidemic is still grim. under this circumstance, how to control the epidemic situation and prevent the recurrence of the covid-19 epidemic is worthy of attention (wu, guo, & chao, 2020) . through literature review, there are many studies on covid-19 in various countries; however, there are few reports about the training content of the nurses in the emergency isolation ward. our training methods follows the model: training → assessment → feedback → evaluation → retraining → reassessment. hopefully, this study could provide theoretical basis for training nurses under emergency assistance of covid-19 and we also hope to work with nursing colleagues around the world with an open attitude to save more patients. the sichuan provincial people's hospital has temporarily established an emergency isolation ward during the outbreak of covid-19. to seek efficient nursing training mode under the epidemic situation and improve the nurses' knowledge reserve on emergency handling and control capabilities, a combination of on-site training and online training was implemented to provide covid-19 related knowledge on nursing operation skills and hospital infections to the nursing team in a short term. the medical department, the infection control department and the nursing department trained the nursing staff through online social media (wechat or oa system) and on-site training. the nursing operations are mainly conducted through onsite training. all nursing staff need to pass the assessment before they start to work in the emergency isolation ward. the electronic questionnaire was filled in after the nursing staff worked in the ward for 2 weeks to assess the nurses' need for training. then, targeted training was conducted and the training results were evaluated by trainers. to control the spread of the epidemic, cut-off the route of transmission and protect susceptible cases effectively, sichuan provincial people's hospital reconstructed emergency isolation ward within three days. there are 32 open beds in this ward. by the end of 28 february (2020), a total of 111 suspected patients were treated in the emergency isolation ward, including three patients who were diagnosed with covid-19. they are mainly middle-aged and elderly patients. during the preparation of the emergency isolation ward, the nursing department established the logistics team, professional team and management team immediately. the logistics team is responsible for participating in ward reconstruction and material preparation; the professional team is responsible for personnel training and supervision; and the management team is responsible for nursing staff management, including communication and coordination among various departments. firstly, the management team established a human resource database for emergency isolation ward. all nurses in the hospital are encouraged to apply online to the human resources database. then, 71 nurses were selected by the nursing department from the human resources database. to avoid excessive fatigue, the selected nurses are divided into three echelons and work in turns on a flexible schedule. nursing positions included clinical nurses, supervisors, trainers and head nurses. the training process adopts training → assessment → feedback → evaluation → retraining → reassessment. a scenario drill is added in the first operation training section. the training forms and content are shown in table 1 . the forms are including online training and on-site training. the training contents include basic diagnosis, hospital infection, operation and psychological support. previous studies have already shown that nursing staff working in the emergency isolation wards might face tremendous psychological pressures (oh et al., 2017) . the anxiety self-rating scale (sas) and depression self-rating scale (sds) were implemented by head nurses to evaluate the psychological status of nursing staff. psychologists provide psychological support and guidance to medical staff based on individual circumstances, including online and on-site psychological counselling (zhou, 2020) . in addition, experts from the psychological workshop were invited to perform mindfulness decompression. psychological intervention based on mindfulness meditation has become an increasingly obvious part of the healthcare field (demarzo, cebolla, & garcia-campayo, 2015) . evaluation indicators include the following: nurses' grasp of training content, choice of training methods and improvement of psychological conditions before and after training. a self-made online questionnaire "nursing staff emergency training mode approval feedback questionnaire" was used to access nursing staff's feedback on the emergency isolation ward's training mode. the questionnaire is divided into four parts and 20 items which mainly includes basic information, feedback on theory, operation training methods and content. in order to evaluate the degree of recognition, the training content evaluation is divided into three angles: text, graphics and video. the knowledge level of the covid-19 is based on the national health and health commission's diagnosis and treatment plan and the hospital's sense prevention and control requirements, including theory and operation. the "nursing staff covid-19 emergency training theory assessment test questions" is prepared for online assessment. the operation technology is on-site assessment. then, comparing the pre-training and post-training, nursing theory and operation score are proportional to the degree of knowledge mastery. the improvement of nursing staff's psychological construction level before and after the training adopts zung's (1971) self-rating anxiety scale (sras) and zung's (1965) self-rating depression scale (srds). zung's sras and srds consist of 20 questions, each of which has answers in likert scale format from levels 1-4. the original score is converted to 100 points and psychological evaluation of the nursing staff is performed. the higher the score, the greater the degree of anxiety and depression. comparison was made before and after training. statistical analysis was performed by spss13.0 software. normal continuous variables were expressed as mean ± standard deviation, non-normal continuous variables were expressed as median values (interquartile range) and categorical variables were expressed as percentages. the comparison between groups was based on whether they met the normal distribution using the mann-whitney u test or t test and the categorical variables used the chi-square test or fisher's exact test. before and after the training, paired t test is mainly used; p < .05 was considered statistically significant. the study was previously explained to the head nurse of the selected hospital, with official permission. the purpose of the study was explained to all study participants, and their informed consent was subsequently obtained. all answers are confidential and used for this study only. basic information of nursing staff. it is shown in table 2 and there were also nine staff whose working experience was under 5 years (12.68%). there were 36 internal nurses, accounting for 50.7%, 23 surgical nurses, accounting for 32.39% and six paediatric and obstetrics nurses, accounting for 8.45%. the mean age of nurses was 31.31 (sd 4.85), their working years ranged from 2 to 20 years. through the scale survey of nurses' degree of recognition of training methods, the results have shown that theoretical training, environmental and process training using online and offline combination (online + on-site training) method is better statistical significance (p = .042, p = .002); while the operation training adopts on-site and on-site + network training methods, the difference is not significant. (p = .081; table 3 ). nursing staff recognized and evaluated the training content in the form of questionnaires in terms of text, graphics and video. it is indicated that the operation training content with partial text and video was better (p = .042, p = .040). there is no difference in the training effect of the three types of network training content, theoretical training, environment and process training (table 4) . compared with pre-training and post-training, the improvement of the covid-19 theory knowledge, operation skills and psychological conditions was significantly improved by paired t test, the mean value is >0 and the p value is <.01. the sas score decreased after training, with statistical difference (p = .019). the difference in sds before and after training was not statistically significant, with a pvalue equal to .306 (table 5) . this study has shown that compared with the pre-training, the difin terms of the degree of recognition of the training content, the results of this study have shown that the order of online training scoring is as follows: online video, online text and online graphics. it illustrates that dynamic visualization training works best. and dynamic visualization training, such as animation and video, has been proved as a particularly effective teaching programme (bernay & betrancourt, 2016; betrancourt & tversky, 2000; marcus, cleary, wong, & ayres, 2013) . regarding the selection of training methods, the results of the study have revealed that the on-site training method is effective for the nursing staff to improve their ability in emergencies, and the combination of network and on-site training methods is the best. supported by research, the comparison between online and faceto-face training, well-designed online training shows more advantages in terms of time efficiency and memory effect (kalyuga, 2007 ; ta b l e 5 before and after training, the nursing staff improved the covid-19 theory knowledge, operation skills and psychological conditions kalyuga & sweller, 2005) , which is consistent with the results of this study. but it is less effective at changing behaviours (aspegren, 1999; mansouri & lockyer, 2007) and face-to-face training seems to be more effective than online training. the reason for analysis may be related to the knowledge and skills provided by online training, and the on-site training can improve the self-confidence of nursing staff. the psychological status of nursing staff before and after working in the emergency isolation ward. the results of this study showed that the sas score of nursing staff after standardized training was lower than before training (p < .05). it indicates that through training and psychological intervention (mindfulness, group) related to the covid-19, the nurses in the emergency ward can be guided to scientifically treat the infection and control of the covid-19, thereby reducing the level of anxiety. the sds level did not change much before and after, one of the possible reasons could be the short-term trainees did not reach the level of depression. however, although the training involves psychological aspect, the need for psychological support is repeatedly mentioned in the questionnaire, indicating that when the medical staff first contacted the patient at the beginning of the outbreak and faced a large number of patients (suwantarat & apisarnthanarack, 2015) , the nurse's level of occupational stress is increasing. (wheeler, 1997) . due to the short-term emergency training and the high risk of infection, it is a huge challenge work for nursing staff. the survey shows that psychological problems are repeatedly mentioned, indicating that nurses have a greater need for psychological support, which seemingly suggests that future psychological support for front-line nurses needs to be strengthened in many ways (zhou, 2020) . selecting the nursing staff of the emergency ward of a hospital may have certain geographical restrictions, or the sample size may not be large enough. more samples from different regions can be researched in the future. the theory of planned behaviour holds that past experience is one of the determinants of a person's beliefs (ajzen, 1991; oh et al., 2017) . the planned selection of experienced nursing staff to participate in the rescue incident is more conducive to the rescue work. this training did not involve the problems of personnel's previous rescue experience. in future emergency rescue work, it is preferable to choose personnel with rescue experience in the human resources database. emergency training of nursing staff is crucial on preventing the spread of the covid-19 epidemic effectively and ensuring the operation of emergency isolation ward orderly. the training content of this study is based on the covid-19 theory operating materials of the chinese health commission and the us guidelines for disease prevention. the training form is a combination of online and offline. in order to form the best training content and provide an optimized training model for the next epidemic prevention and control, the effectiveness of the training form was analysed. at the same time, this study pays particular attention to the psychological problems of nursing staff. carrying out the prevention and intervention of psychological problems to the nursing staff in a timely manner will ensure the staff positively faces the epidemic situation. in short, the value of nursing staff in the prevention and control of the covid-19 epidemic cannot be replaced. how to ensure the safety of nursing staff and patients through training is a significant issue that worth to be discussed. the theory of planned behavior children & disasters: pediatric disaster preparedness and response topical collection children & disasters: educational tools beme guide no. 2: teaching and learning communication skills in medicine-a review with quality grading of articles does animation enhance learning? a meta-analysis effects of computer animation on users' performance: a review emergency preparedness and response: resources for emergency response professionals exploration of preparations for constructing emergency-oriented hospitals under covid-19 pandemic a42) disaster nurses in developing countries: strengthening disaster nurses' competencies through training and disaster drills expertise reversal effect and its implications for learner-tailored instruction rapid dynamic assessment of expertise to improve the efficiency of adaptive e-learning response to the emerging novel coronavirus outbreak a meta-analysis of continuing medical education effectiveness should hand actions be observed when learning hand motor skills from instructional animations? a systematic review evaluating the impact of online or blended learning vs. face-to-face learning of clinical skills in undergraduate nurse education announcement of the national health and health commission of the people's republic of china exploring nursing intention, stress and professionalism in response to infectious disease emergencies: the experience of local public hospital nurses during the 2015 mers outbreak in south korea risks to healthcare workers with emerging diseases: lessons from mers-cov, ebola, sars and avian flu face-to-face instruction combined with online resources improves retention of clinical skills among undergraduate nursing students office of the assistant secretary for preparedness and response office of the assistant secretary for preparedness and response a review of nurse occupational stress reasearch: 1 director-general's opening remarks at the media briefing on covid-19-9 formulation and implementation of standardized training program on nosocomial infection prevention and control in covid-19 general hospital construction of nursing emergency training system for covid-19 psychological intervention and self-help manual for 11 groups of patients with pneumonia a self rating depression scale a rating instrument for anxiety disorder research on the individualized short-term training model of nurses in emergency isolation wards during the outbreak of covid-19 key: cord-331452-y5lhawqo authors: lentz, skyler; grossman, alexandra; koyfman, alex; long, brit title: high-risk airway management in the emergency department: diseases and approaches part i date: 2020-05-12 journal: j emerg med doi: 10.1016/j.jemermed.2020.05.008 sha: doc_id: 331452 cord_uid: y5lhawqo abstract background successful airway management is critical to the practice of emergency medicine. thus, emergency physicians must be ready to optimize and prepare for airway management in critically ill patients with a wide range of physiologic challenges. challenges in airway management commonly encountered in the emergency department are discussed using a pearl and pitfall discussion in this first part of a two-part series. objective this narrative review presents an evidence-based approach to airway and patient management during endotracheal intubation in challenging cases commonly encountered in the emergency department. discussion adverse events during emergent airway management are common with post-intubation cardiac arrest reported in as many as 1 in 25 intubations. many of these adverse events can be avoided by proper identification and understanding the underlying physiology, preparation, and post intubation management. those with high risk features including severe metabolic acidosis; shock and hypotension; obstructive lung disease; pulmonary hypertension, right ventricle failure, and pulmonary embolism; and severe hypoxemia must be managed with airway expertise. conclusions this narrative review discusses the pearls and pitfalls of commonly encountered physiologic high-risk intubations with a focus on the emergency clinician. successful airway management is a critical skill in emergency medicine. 1, 2 the majority of 26 emergent and unplanned intubations in emergency departments (ed) are managed by emergency 27 physicians using rapid-sequence intubation, with success rates as high as 99%. 2-4 however, 28 emergency physicians must be able to prepare for and manage critically ill patients with a wide 29 range of physiologic challenges in the peri-intubation setting. 30 31 first pass success is a priority in any attempt at endotracheal intubation, but especially in 32 physiologically challenging airways, as multiple attempts are associated with an increase in 33 adverse events. 5,6 difficult visualization and intubation, generally defined as 3 or more attempts, 34 occur as often as 6.6-12% in critically ill patients. [6] [7] [8] [9] this rate may be decreasing in the ed 35 population, potentially because of video laryngoscopy or improved techniques, as shown by a 36 decreased rate of multiple attempts of 1.5% in a more recent study of ed intubations. 4 severe 37 complications occur as frequently as 24-28% of endotracheal intubation in critically ill patients, 38 most commonly hypoxemia and hypotension. 6, 8 patients with high risk comorbid disease and 39 pre-intubation factors such as hypoxemia, hypotension, and severe acidosis are at high risk for 40 peri-intubation hemodynamic collapse and resultant worse outcomes. 8,10-13 the incidence of 41 peri-intubation cardiac arrest is as high as 1 in 25 emergency airways in one series. 10 post-42 intubation hypotension is more common, occurring as frequently as 25% of emergency 43 intubations and is associated with increased mortality. 11 many of the pre-intubation risks for 44 decompensation can be recognized and prevented with proper preparation and evaluation. 8,10,14-18 45 46 this first part of a two-part series will focus on the latest literature, recommendations, and 47 tidal volume of 8 ml/kg predicted body weight (pbw) or higher may be needed. a blood gas 120 should be assessed within 15 minutes of intubation to make sure the ph has not significantly 121 worsened. continuous etco 2 may be used to follow paco 2 once intubated; in the patient with 122 normal lung function the etco 2 value is 2-5 mm hg lower than paco 2 . 20,31 123 124 there are many different mechanical ventilator strategies post intubation. 12,24 when the sedation 125 and neuromuscular blockade medications are metabolized some advocate for spontaneous 126 ventilatory modes such as pressure support ventilation so the patient can set the respiratory rate, 127 tidal volume, and inspiratory time. 12 alternatively, adequate sedation and assist control modes of 128 ventilation with a prescribed tidal volume (e.g. vc-ac) or pressure (pc-ac) and respiratory rate 129 may be used, but the patient should be monitored for patient-ventilator dyssynchrony with the 130 increased respiratory drive stimulated by the acidosis. 12,24 the recommended approach is to 131 deliver a guaranteed minute ventilation by setting the respiratory rate and a starting tidal volume 132 of 8 ml/kg pbw in an assist control type mode. patients with shock and hypotension requiring intubation and mechanical ventilation are at high 144 risk for peri-intubation cardiovascular collapse. 7,8,10,17,32 post intubation hypotension (pih) is 145 common and occurs in up to 25% of emergently intubated patients, is associated with adverse 146 outcomes, and should be aggressively avoided and treated. 8,11,12,33 studies suggest pre-intubation 147 hypotension and shock index >0.8-0.9 (heart rate/systolic blood pressure [bp] ) are the best 148 predictors of post-intubation cardiac arrest and pih. 7,10,12,17,32 the shock index is associated with 149 severity of illness and suggests impending instability. 17 post-intubation cardiac arrest occurs in 150 approximately 2%, though one series reported a higher rate of 4.2% in emergency intubations. 10 151 the reported incidence of cardiac arrest in those with pre-intubation hypotension is even higher 152 at 12-15% of emergency intubations. 7,10 post intubation cardiac arrest is unsurprisingly 153 associated with increased mortality. 8 in those with anticipated hemodynamic instability, the dosing and familiarity of the induction respiratory failure from obstructive lung disease, such as asthma and chronic obstructive 214 and a respiratory acidosis with a ph of > 7.20 can be tolerated in most patients aside from those 264 with a potential contraindication to a respiratory acidosis such as those with pulmonary 265 hypertension, brain injuries at risk for increased intracranial pressure (icp), severe right sided 266 heart failure, pregnancy, and certain toxic ingestions. 49 267 table 3 obstructive lung disease likely indicates hyperinflation from auto-peep. 53 the peak pressure will be elevated due to airway resistance, but this pressure is less important, and can be tolerated, if 282 the plateau pressure remains < 30 cm h 2 o, since the peak pressure is not transmitted to the 283 alveoli of lung parenchyma. 24,28,53 an example of a pressure waveform in a mechanically 284 ventilated patient with high airway resistance is demonstrated in figure 2 . requiring emergent intubation in the icu, preoxygenation with nippv compared to non-408 rebreather mask resulted in an increased spo 2 after preoxygenation as well as during and after 409 intubation. 67 episodes of severe desaturation to spo 2 < 80% were significantly less common in 410 the nippv group than the control group (2/27 compared to 12/26). 67 the florali-2 trial 411 compared preoxygenation with hfnc to nippv in 322 icu patients with acute hypoxemic 412 respiratory failure. 68 it found no significant difference in the incidence of severe hypoxemia or 413 serious adverse events between groups. however, in the subgroup of patients with pre-intubation 414 moderate-to-severe hypoxemia (pa0 2 /fio 2 < 200), nippv resulted in a statistically significant 415 decrease in incidence of severe hypoxemia. 68 of note, the lack of difference may be confounded 416 by the fact that nippv ventilation group received no apneic oxygenation while the hfnc group 417 continued to receive apneic oxygenation via hfnc. nippv may be beneficial in those with 418 severe hypoxemia for preoxygenation, as this group had equivalent overall outcomes and 419 reduced hypoxemia despite not receiving apneic oxygenation. 68 the benefit of hfnc for preoxygenation and apneic oxygenation compared to conventional 428 oxygen therapy is unclear. several small randomized controlled trials comparing hfnc to bvm 429 or face mask in hypoxemic patients found no statistically significant difference in mean lowest 430 spo 2 between groups. [70] [71] [72] recently, the optiniv trial compared the combination of hfnc 431 and nippv to nippv alone for preoxygenation in icu patients requiring intubation for 432 hypoxemic respiratory failure. 73 the intervention group (hfnc + nippv) continued to receive 433 apneic oxygenation via hfnc while the nippv group alone received no further oxygenation 434 after the standardized 4-minute preoxygenation period. authors found that the intervention 435 groups had higher minimum spo 2 during intubation (100% vs 96%) and fewer episodes of 436 desaturation spo 2 <80% (0% vs 21%) than the control group. 73 it is important to note that these preoxygenation strategies are effective in those requiring 443 intubation due to respiratory infections. in the study by baillard et al, 65-70% of included 444 patients had a diagnosis of pneumonia. 67 additionally, 35% of study participants in the 445 florali-2 trial had primary respiratory failure due to infection. 68 though discussion of airway 446 management for patients with novel covid-19 is beyond the scope of this paper, in the midst of 447 a respiratory illness pandemic appropriate personal protective equipment (ppe) with airborne 448 precautions, careful donning and doffing of ppe, and use of negative pressure rooms should be 449 employed to reduce the risk of disease transmission. if a negative pressure room is not available, 450 a private room with a closed door is recommended. if covid-19 is suspected, video 451 laryngoscopy is recommended. viral filters must also be appropriately utilized. emergency clinicians are experts in airway management and routinely encounter critically ill 457 patients with pre-and post-intubation physiologic challenges associated with adverse events. those with a severe metabolic acidosis require maintenance of the minute ventilation to prevent 459 a sudden deterioration in ph. in the case of shock and hypotension, resuscitation prior to 460 induction is the goal, and a shock index of >0.8-0.9 predicts post intubation hypotension. 461 preceding hypoxemia should be aggressively preoxygenated using nippv. pulmonary 462 hypertension and right ventricle failure present complex physiologic challenges; the major goal 463 is to avoid systemic hypotension or a sudden increase in pvr from hypercapnia or hypoxemia. 464 obstructive lung disease presents a risk of hemodynamic collapse from high intrathoracic 465 pressure caused by air-trapping, and patients require prolonged expiratory times with slow 466 respiratory rate while mechanically ventilated. these considerations can assist emergency 467 clinicians in optimizing the patient during and after intubation attempts. 468 469 470 table 1 . pearls and pitfalls in the management of high-risk airways. high-risk airway airway management by us and canadian 472 emergency medicine residents: a multicenter analysis of more than 6,000 endotracheal 473 intubation attempts emergency airway management: a multi-476 center report of 8937 emergency department intubations airway management in the emergency 479 department: a one-year study of 610 tracheal intubations techniques, success, and adverse events of 482 emergency department adult intubations the importance of first pass success when 485 performing orotracheal intubation in the emergency department complications of endotracheal 488 intubation in the critically ill death and other complications of emergency 491 airway management in critically ill adults a prospective investigation of 297 tracheal 492 intubations clinical practice and risk factors for immediate 494 complications of endotracheal intubation in the intensive care unit: a prospective, multiple-495 center study* the who, where, and what of rapid sequence intubation: 498 prospective observational study of emergency rsi outside the operating theatre incidence and factors associated with cardiac 501 arrest complicating emergency airway management the frequency and significance of 504 postintubation hypotension during emergency airway management the physiologically 507 difficult airway cardiac arrest and mortality related to intubation 510 procedure in critically ill adult patients: a multicenter cohort study delayed sequence 513 intubation: a prospective observational study preoxygenation, reoxygenation, and delayed sequence intubation in the 516 emergency department effectiveness of apneic oxygenation 519 during intubation: a systematic review and meta-analysis predictors of the complication 522 of postintubation hypotension during emergency airway management physiologically difficult airway in critically ill patients: winning the race 525 between haemoglobin desaturation and tracheal intubation ventilatory failure: can you sustain what you need? 530 comparison of end-tidal carbon dioxide and arterial blood bicarbonate levels in patients with 531 metabolic acidosis referred to emergency medicine treatment of metabolic acidosis sodium bicarbonate therapy in patients with metabolic acidosis sodium bicarbonate therapy for patients with severe 540 metabolic acidaemia in the intensive care unit (bicar-icu): a multicentre, open-label, 541 randomised controlled, phase 3 trial avoiding circulatory complications during endotracheal intubation and 544 initiation of positive pressure ventilation alternatives to rapid sequence intubation: 547 contemporary airway management with ketamine difficult airway society guidelines for awake 550 tracheal intubation (ati) in adults. anaesthesia bag-mask ventilation during tracheal intubation of 552 weingart sd. managing initial mechanical ventilation in the emergency department lung-protective ventilation initiated in the 556 emergency department (lov-ed): a quasi-experimental, before-after trial physiological approach to assessment of acid-base 559 disturbances capnography in the emergency department evaluation of the incidence, risk factors, and 563 impact on patient outcomes of postintubation hemodynamic instability postintubation hypotension in intensive care unit 566 patients: a multicenter cohort study the incidence and risk factors for cardiac arrest during emergency tracheal 569 intubation: a justification for incorporating the asa guidelines in the remote location co-induction with a vasopressor "chaser" to mitigate propofol-572 induced hypotension when intubating critically ill/frail patients-a questionable practice timing resuscitation sequence intubation for critically ill patients effect of a fluid bolus on cardiovascular collapse 579 among critically ill adults undergoing tracheal intubation (prepare): a randomised 580 controlled trial pharmacotherapy update on the use of 583 vasopressors and inotropes in the intensive care unit influence of 586 phenylephrine bolus administration on left ventricular filling dynamics in patients with 587 coronary artery disease and patients with valvular aortic stenosis safety considerations and guideline-based 590 safe use recommendations for "bolus-dose" vasopressors in the emergency department hemodynamic response after rapid sequence 593 induction with ketamine in out-of-hospital patients at risk of shock as defined by the 594 shock index assessment and resuscitation in trauma management airway management in trauma airway management in critically ill patients rapid sequence induction in the emergency 603 department: induction drug and outcome of patients admitted to the intensive care unit increased incidence of clinical hypotension 606 with etomidate compared to ketamine for intubation in septic patients: a propensity matched 607 analysis etomidate versus ketamine for rapid sequence 609 intubation in acutely ill patients: a multicentre randomised controlled trial cardiovascular effects of anesthetic induction 612 with ketamine ventilator strategies 614 and rescue therapies for management of acute respiratory failure in the emergency 615 non invasive ventilation for the management of acute hypercapnic respiratory failure due to 618 exacerbation of chronic obstructive pulmonary disease. cochrane database syst rev management of copd exacerbations: 621 a outcomes of noninvasive and invasive ventilation 624 in patients hospitalized with asthma exacerbation mechanical ventilation for severe asthma inflation pressure, gastric insufflation and rapid sequence 629 induction ketamine in status asthmaticus: a review ketamine in the treatment of bronchospasm during 634 mechanical ventilation right ventricular function in cardiovascular 637 clinical importance, and management of right 638 ventricular failure pulmonary hypertension and right ventricular 641 failure in emergency medicine right ventricular function in 644 anatomy, physiology, aging, and functional assessment of 645 the right ventricle ventricular interdependence: significant left ventricular 648 contributions to right ventricular systolic function physiologic approach to mechanical 651 ventilation in right ventricular failure diagnosis, treatment and follow up of 654 acute pulmonary embolism: consensus practice from the pert consortium risk factors for and prediction of hypoxemia 657 during tracheal intubation of critically ill adults preoxygenation is more effective in the 25 degrees 660 head-up position than in the supine position in severely obese patients: a randomized 661 controlled study pre-oxygenation in the obese patient: 664 effects of position on tolerance to apnoea optimizing preoxygenation in adults noninvasive ventilation improves preoxygenation 669 before intubation of hypoxic patients non-invasive ventilation versus high-flow nasal 672 cannula oxygen therapy with apnoeic oxygenation for preoxygenation before intubation of 673 patients with acute hypoxaemic respiratory failure: a randomised, multicentre, open-label 674 trial preoxygenation before intubation in adult patients with acute 676 hypoxemic respiratory failure: a network meta-analysis of randomized trials high-flow nasal cannula oxygen during endotracheal 679 intubation in hypoxemic patients: a randomized controlled clinical trial high-flow nasal cannula 682 versus bag-valve-mask for preoxygenation before intubation in subjects with hypoxemic 683 respiratory failure apnoeic oxygenation via high-flow nasal cannula 688 oxygen combined with non-invasive ventilation preoxygenation for intubation in 689 hypoxaemic patients in the intensive care unit: the single-centre, blinded, randomised 690 controlled optiniv trial why is this topic important? critically ill patients present several physiologic challenges 696 to emergency clinicians what does this review attempt to show? this review provides an evidence-based approach 698 to management of the physiologically-challenging airway what are the key findings? peri-intubation complications can occur in emergent airways high risk scenarios including severe metabolic acidosis; shock and hypotension; obstructive 701 lung disease; pulmonary hypertension, right ventricle failure, and pulmonary embolism; and 702 severe hypoxemia require consideration of several factors to optimize patient outcomes how is patient care impacted? knowledge of these scenarios can improve management of 704 challenging physiologic scenarios metabolic acidosis key: cord-337665-roelk7i5 authors: bhattacharjee, hemanga k.; chaliyadan, shafneed; verma, eshan; kumaran, keerthi; bhargava, priyank; singh, abhishek; maitra, souvik; parshad, rajinder title: emergency surgery during covid-19: lessons learned date: 2020-09-30 journal: surg j (n y) doi: 10.1055/s-0040-1716335 sha: doc_id: 337665 cord_uid: roelk7i5 introduction the ongoing coronavirus disease-2019 (covid-19) pandemic has disrupted health services throughout the world. it has brought in several new challenges to deal with surgical emergencies. herein, we report two suspected cases of covid-19 that were operated during this “lockdown” period and highlight the protocols we followed and lessons we learned from this situation. result two patients from “red zones” for covid-19 pandemic presented with acute abdomen, one a 64-year male, who presented with perforation peritonitis and another, a 57-year male with acute intestinal obstruction due to sigmoid volvulus. they also had associated covid-19 symptoms. covid-19 test could not be done at the time of their presentation to the hospital. patients underwent emergency exploratory laparotomy assuming them to be positive for the infection. surgical team was donned with full coverall personal protective equipment. sudden and uncontrolled egression intraperitoneal free gas was avoided, echelon flex 60 staplers were used to resect the volvulus without allowing the gas from the volvulus to escape; mesocolon was divided using vascular reload of the stapler, no electrosurgical devices were used to avoid the aerosolization of viral particles. colostomy was done in both the patients. both the patients turned out to be negative for covid-19 subsequently and discharged from hospital in stable condition. conclusion surgeons need to adapt to safely execute emergency surgical procedures during this period of covid-19 pandemic. preparedness is of paramount importance. full precautionary measures should be taken when dealing with any suspected case. introduction the ongoing coronavirus disease-2019 (covid-19) pandemic has disrupted health services throughout the world. it has brought in several new challenges to deal with surgical emergencies. herein, we report two suspected cases of covid-19 that were operated during this "lockdown" period and highlight the protocols we followed and lessons we learned from this situation. result two patients from "red zones" for covid-19 pandemic presented with acute abdomen, one a 64-year male, who presented with perforation peritonitis and another, a 57-year male with acute intestinal obstruction due to sigmoid volvulus. they also had associated covid-19 symptoms. covid-19 test could not be done at the time of their presentation to the hospital. patients underwent emergency exploratory laparotomy assuming them to be positive for the infection. surgical team was donned with full coverall personal protective equipment. sudden and uncontrolled egression intraperitoneal free gas was avoided, echelon flex 60 staplers were used to resect the volvulus without allowing the gas from the volvulus to escape; mesocolon was divided using vascular reload of the stapler, no electrosurgical devices were used to avoid the aerosolization of viral particles. colostomy was done in both the patients. both the patients turned out to be negative for covid-19 subsequently and discharged from hospital in stable condition. conclusion surgeons need to adapt to safely execute emergency surgical procedures during this period of covid-19 pandemic. preparedness is of paramount importance. full precautionary measures should be taken when dealing with any suspected case. our hospital also has adopted the policy to defer all elective surgeries and only to perform emergency procedures. emergency surgical procedures are time sensitive and require prompt decisions, but during this pandemic, the decision making becomes more difficult as the symptoms can overlap with potential sars-cov-2 (severe acute respiratory syndrome coronavirus-2) infection and there is a potential community spread of the infection. waiting for covid-19 test result leads to delay in undertaking the procedure, while immediate surgery can compromise the safety of staff and other patients in the event that the patient tests positive for infection subsequently. other option is to consider all patients as potentially positive for the infection, unless proven otherwise. operating upon covid-19 patients is both resource consuming and stressful for the surgeons. we report, herein, two patients requiring emergency surgical procedures during this lockdown period, highlighting the protocol we followed, and lessons learned from this unique situation. a 64-year-old male presented with complaints of abdominal pain and distention for 1 day. he had history of fever and loose stool 2 days back. he was tachycardic, tachypneic, and hypotensive on presentation. his abdomen was distended, tender, and rigid. an abdominal radiograph showed air under the diaphragm. he was resuscitated in the emergency and started on low-dose inotropic support. he came from an area having high concentration of covid-19 positive cases ("red zone"). although he had no known contact with covid-19 patients but a few of his symptoms resembled that of covid-19. he came to the hospital in the evening; there was no provision of covid-19 testing at that time and report could only be available by next day evening at the earliest. in view of deteriorating patient condition, the decision was taken to operate the patient as "covid suspect" with all precautions with the assumption that the patient is covid-19 positive. our institution has earmarked wards and operation room (or) for covid-19 suspected patients. the designated or area for covid-19 suspected patients has anterooms for donning (unsterile and sterile areas) and doffing. patient was brought from the designated ward to the or through a separate corridor and an elevator, which was earmarked for the transport of "covid-19 suspect" patients. the corridor through which the patient would enter and exit or was also predefined and was separate from that of the hospital staff. patient was accompanied by a hospital assistant and a physician wearing coverall personal protective equipment (ppe). the operating team entered through a different corridor of the or and team had only minimum number of staffs. the detailed steps for donning with ppe with coverall gowns, n95 mask, eye wear, face shield, gum boots, shoe covers, were illustrated on an ot board and were supervised by a senior nursing staff. after donning, identification of the patient was performed by the surgeon who had earlier seen the patient in the emergency department. anesthetists intubated the patient while rest of the team remained outside. a rapid sequence induction technique was used without any mask ventilation to reduce aerosol generation. senior most member of the anesthesia team performed intubation by a video laryngoscope to reduce intubation time. surgeons and scrub nurse did hand hygiene using alcohol-based solution on already donned "coverall" ppe and wore impervious sterile gown and gloves in the sterile donning area. once the anesthesia team gave go ahead, the fully donned surgeons and nursing staff (a scrub nurse and a floor nurse) entered the ot and prepared the patient. a midline incision was made, extended deep and peritoneum was opened slowly using scalpel. free peritoneal gas and contaminated fluid were readily sucked from the operating field using two sets of suction apparatus. a large slough out area with perforation was identified in the sigmoid colon. bowel above and below the perforation was unhealthy. sigmoid colon was transected using echelon flex endopath staplers (ethicon endo-surgery, llc, pr) above and below the perforated segment and the segment was excised. to avoid aerosol generation electrosurgery devices were not used. sigmoid mesocolon was divided using a vascular reload of the stapler (white cartridge). proximal end of the colon was brought out as stoma and stoma bag applied immediately. patient was not extubated inside the or and shifted to the designated covid-19 suspect ward. the surgical team did doffing under supervision of an experienced staff in the designated area and took shower before coming out of or complex. the patient was shifted to general ward on the next day evening after his covid-19 test report came out as negative. in view of his persistent tachypnea, cect thorax was done on postoperative day two, which revealed pulmonary embolism and was managed conservatively. patient was discharged from hospital on 12th postoperative day. a 57-year-old male, presented with abdominal distension, nausea, and vomiting for 7 days. he had obstipation since past 5 days. he was a known patient of bronchial asthma, hypertension, and vascular dementia. his pulse was 96/min, blood pressure was 110/60 mm hg, and respiratory rate was 26/min. the abdomen was distended, tender with features of peritonism. there were bilateral infra-axillary crepitations on chest auscultation. his abdominal plain radiograph showed features of sigmoid volvulus and chest radiograph showed right lower zone opacities. cect abdomen and thorax confirmed those findings. although he had no history of contact with covid-19 patient, he came from a "red zone" area and a few of his symptoms resembled that of covid-19. covid-19 testing could not be done at the time of presentation. he was taken up to or as a "covid suspect" assuming a positive status. exploratory laparotomy was performed. there was a sigmoid volvulus with dusky sigmoid colon. volvulus was derotated; colon was transected proximal and distal to the volvulus using echelon flex endopath staplers. sigmoid mesocolon was divided with vascular reloads of the stapler (white cartridges). proximal end was brought out of the surgery journal vol. 6 no. 3/2020 the abdomen as stoma and stoma bag was applied immediately. no energy devices were used during the entire procedure. patient was not extubated inside the or and was shifted to covid suspect ward. he was transferred to general ward after his covid-19 test report came negative on the next day. he made an uneventful recovery and was discharged on eighth postoperative day. covid-19 pandemic has brought in several new challenges to deal with surgical emergencies. international and national societies have published guidelines to address this situation. [5] [6] [7] [8] [9] however, local situation may vary from hospital to hospital and health care personnel need to adapt and improvise to deliver safe and effective health care. waiting period for confirmatory test may take from 24 hours to 5 days. 9,10 our hospital has in-house severe acute respiratory syndrome coronavirus-2 (sars-cov-2) reverse transcription polymerase chain reaction testing and performs it twice a day, once in the morning 10.00 am and the other at 3:00 pm. reports are usually available by approximately 7 hours. all positive cases are sent to another designated building for further care. emergency surgical patients who come during odd hours of the day pose a special concern. both of our patients came in afternoon hours and required urgent surgical intervention. they came from high alert area of covid-19. the government of india has divided country into zones based on the number of cases, the recovery rate, the doubling rate, etc. 11 red zone districts account for more than 80% cases in the state or have a doubling rate of less than 4 days. patients had few suspicious features of covid-19 making them "covid-19 suspects." waiting for confirmatory test result would have delayed interventions by at least 24 hours. so, we decided not to wait for results and performed the procedures assuming patients are covid-19 positive. in both the cases, our surgical target region was the gastrointestinal tract. presence of sars-cov-2 ribonucleic acid virus has been detected in enteric content, peritoneal fluid, and feces of the positive patients. 12, 13 it has been shown that virus was detectable in stool of positive patients regardless of the severity of illness and for a longer duration than any other body fluids. 13 in the first case, there was free intraperitoneal gas, which may be infectious in nature. to reduce the sudden and uncontrolled egression of free intraperitoneal gas, we made a small hole on the peritoneum and one suction canula was inserted to the peritoneal cavity and the other kept around the entry. this helped us in gradual evacuation of intraperitoneal contents. a closed system with attached filters would have been ideal for the evacuation. in absence of that, we kept the suction apparatus, which collected the contents far away as possible from the health care worker. in our second case, the sigmoid colon was hugely distended and tensed with gas. application of staplers to divide the colon proximal and distal to the volvulus helped us to minimize any escape of colonic gas and to deliver the volvulus intact. electrosurgical devices used during surgery have been found to be associated with the production of aerosolized viral particles in some blood-borne viruses. [14] [15] [16] as such, with the use of electrocautery, surgery becomes an "aerosol generating procedure." 17 due to the potential infectious nature of this aerosol, use of electrosurgical devices (monopolar electrocautery or ultrasonic device) has been cautioned in covid-19 patients. 18 a monopolar device when needs to be used, should be kept in lowest energy setting and to be used in combination with a smoke evacuation system. 18, 19 however, we did not have a smoke evacuation system in our or. although, the monopolar electrocautery was kept standby, we were able to completely avoid their use. in both cases, dissection and tissue division were done using scissors and blade. hemostasis was achieved by suture ligation or warm compression. we used vascular stapler to divide the mesocolon. due to their regular application in our non-covid-19 practice, our team was well versed with their application. we believe and have experienced that, operating with full personal protective gear causes immense physical and mental stress. disturbances caused by the mist on the goggles and face shield adds to the misery. all measures should be taken to execute surgery safely without any undue prolongation. the indication and type of emergency procedure may also vary in pandemic. conditions where nonoperative management is feasible should be practiced. these include conservative management in conditions like uncomplicated appendicitis, acute cholecystitis, and diverticulitis. 8 however, some authors have opined that for hospitals with limited resources, emergency appendicectomy might be favored over conservative management, 20 as the former is associated with earlier hospital discharge. 21 this can potentially save the health care resources that could be used for the ongoing pandemic. there are differences of opinion in regard to certain clinical practices. the spanish society of surgeons guidelines recommend caution on creating stoma, as it is a possible focus of transmission of infection to hospital personnel and patient relatives. 7 the italian group on colorectal surgery has, however, recommended hartmann's procedure over anastomosis, because the latter in emergency setting is associated with higher risk of complications (e.g., anastomotic leak, intra-abdominal collection), that can result in consumption of more hospital resources and can be complicated further by co-existing covid-19 infection status. 13 in our first case, the patient merited a stoma. in the second case, anastomosis was also a possibility, but we chose to perform stoma to reduce the possible postoperative complications. another contentious issue is the use of laparoscopy during covid-19 pandemic. due to pneumoperitoneum and low gas movement, aerosols created during laparoscopic surgery tend to get concentrated inside the abdomen. during the release of trocar valves or nonair-tight exchange of instrument, there is sudden egression of aerosols through these ports. due to these potential risks of increased aerosolization and possible viral transmission to health care workers, laparoscopic approach is discouraged. 19, 22 on the other hand, laparoscopic surgery in most cases is associated with early recovery, reduced hospital the surgery journal vol. 6 no. 3/2020 emergency surgery during covid-19 bhattacharjee et al. e169 stay, and reduction in complications minimizing the consumption of hospital resources that have already been strained due to the ongoing pandemic. furthermore, other advantages of laparoscopic approach such as inherent physical barrier between patient and surgical team and more controlled and safer way of releasing surgical smoke and aerosol make laparoscopic approach an attractive option in pandemic setting. the society of american gastrointestinal and endoscopic surgeons (sages) and european association of endoscopic surgery (eaes) guidelines therefore recommend laparoscopy, with strong suggestion to consider the use of devices to filter released co 2 for aerosolized particles. 6 surgeons might need to modify their approaches even for common surgical procedures during the pandemic so that timely intervention can be done. careful planning and logistical preparedness to address such unprecedented situation are of paramount importance for safety of the patients as well as the health care worker. none. covid-19 map. johns hopkins coronavirus resource center. available at understanding pathways to death in patients with covid-19 covid-19: gastrointestinal manifestations and potential fecal-oral transmission india under covid-19 lockdown emergency surgery during the covid-19 pandemic: what you need to know for practice accessed may 3, 2020 7 recommendations from the spanish society of surgery (aec) | aecirujanos.es. available at coronavirus pandemic and colorectal surgery: practical advice based on the italian experience precautions for operating room team members during the covid-19 pandemic perioperative considerations during emergency general surgery in the era of covid-19: a u.s. experience /sites/default/files/mha%20order%20dt.%201.5 .2020%20to%20extend%20lockdown%20period%20for%202%20 weeks%20w.e.f.%204.5.2020%20with%20new%20guidelines.pdf. accessed sars-cov-2 is present in peritoneal fluid in covid-19 patients. available at: https:// journals.lww.com/annalsofsurgery/documents/sarscov-2%20is% 20present%20in%20peritoneal%20fluid%20in%20covid-19%20 patients fecal specimen diagnosis 2019 novel coronavirus-infected pneumonia detecting hepatitis b virus in surgical smoke emitted during laparoscopic surgery human papillomavirus dna in co2 laser-generated plume of smoke and its consequences to the surgeon low risk of contamination with human papilloma virus during treatment of condylomata acuminata with multilayer argon plasma coagulation and co 2 laser ablation protecting surgical teams during the covid-19 outbreak: a narrative review and clinical considerations what is the appropriate use of laparoscopy over open procedures in the current covid-19 climate? updated intercollegiate general surgery guidance on covid-19. royal college of surgeons perspectives on pediatric appendicitis and appendectomy during the severe acute respiratory syndrome coronavirus 2 pandemic a prospective study of safety and satisfaction with same-day discharge after laparoscopic appendectomy for acute appendicitis considerations for optimum surgeon protection before, during, and after operation none. key: cord-257680-ds1y3ks9 authors: schiller, marcus; pilette, marijatta; rahlf, björn; von see, constantin; gellrich, n.-c. title: management of pandemic or large-scale emergencies in germany with a focus on the current and potential role of university schools of dentistry: can it help in covid-19 time? date: 2020-10-02 journal: bull natl res cent doi: 10.1186/s42269-020-00427-4 sha: doc_id: 257680 cord_uid: ds1y3ks9 background: the study presented here systematically examines the potential involvement of dental, oral and maxillofacial centres (zmk) in the management of pandemia or in large-scale emergencies. it looks at available material and infrastructural resources and how they can be brought to bear in such incidents or situations. the aim was to gain an initial scientific overview of how zmk can potentially contribute to the handling of a pandemia or mass casualty (mascal) situation in terms of available resources as well as their location within the hospital as a whole and their integration into the existing infrastructure. the study was conducted on the basis of a questionnaire consisting of 70 individual questions, which was sent to all universities in germany that offer a course of study in dental medicine. the responses were then statistically evaluated. results: the study outlines the current status of zmk and discusses what could be an important component of emergency medical care in the overall hospital context. conclusion: the involvement of zmk—with their own resources and existing infrastructural links to the hospital as a whole—could lead to faster and more effective patient treatment in the event of a pandemic or mascal situation. the increasing threat of international terrorism has shifted public focus in germany onto the question of how large-scale emergencies can be managed. after the 9/11 terrorist attacks in new york, the standing conference of federal and state ministers and senators of the interior decided to critically review civil protection and disaster control policies (simon and tepermann 2001; cook 2001) . 1 as a result, hospitals were also forced to take a closer look at this issue and to reevaluate existing emergency response plans, especially after the recent terrorist attack on a christmas market in berlin. one question that needs to be answered is how to sensibly involve dental medical centres in existing emergency concepts. so far, there have been widely differing views on this subject at the various hospitals, although there already page 2 of 8 schiller et al. bull natl res cent (2020) 44:174 are several german and international studies available on the potential integration of such centres (pahor 1992; sakr 2000; mitchell 2008) . that is because in general, each dental treatment unit (i.e. dentist's chair) could be considered a small operating table in its own right. after all, it provides an opportunity for surgical hand disinfection, a small surgical light, a suction device, monopolar electrocoagulation and, above all, various ways to position the patient, including the shock position. examinations and surgical treatments such as wound care, splinting or other emergency treatments are possible. taking into account previous studies, the aim of this study was thus to systematically investigate the current rate and potential increase in integration of dental medical centres at university hospitals in the emergency response plan of the hospital as a whole. for this purpose, a specifically developed questionnaire was used to survey the structures and resources of the dental medical centres at german university hospitals. their potential involvement in providing emergency medical treatment in case of large-scale emergencies is illustrated using hannover medical school (mhh) as an example. previous contingency plans for a mass casualty scenario had foreseen the fire service, germany's federal disaster relief agency (thw) and the red cross setting up and operating treatment stations at the outpatient clinic of the mhh to support the hospital. the option of falling back on the dental treatment stations of the dental medical centre is currently not included. emergency medicine as we know it today is a relatively new medical discipline. its history can be traced back to lessons learned in military campaigns that were translated into principles for the rescue and evacuation of casualties. it was not until after world war ii that civilian emergency medicine became truly established (ambulances, triage, etc.). 2 härtel stated in 1920 that physicians who worked in other specialties during times of peace had to get used to thinking and acting as surgeons in times of war (robertis et al. (2017)). the way ambulance services in germany are organised today is a result of the adaptation of military principles, the further development of medical knowledge and increasing regulation (skandalakis et al. 2006) . during world war i, emergency rescue was the responsibility of the red cross and the fire services. after world war ii, the emergency rescue services were shaped by the occupying powers and the different occupation zones. rutherford suggested that the order of evacuation should depend on the pattern of injury in the different triage categories. 3 on the federal level, civil disaster control tasks fall into the remit of the federal ministry of the interior and are allocated to the federal office of civil protection and disaster assistance. this office is a higher federal authority and supports the supreme federal authorities in uniform civil defence planning. in case of a hazard or emergency situation, crisis staffs at the federal ministry of the interior assume coordination tasks (niska and shimizu 2011) . in germany, 95% of medical assistance delivered in an emergency situation is provided by nongovernmental organisations. 4,5 a system of fast response units has been established, which are mainly employed for preclinical tasks (sakr 2000) . 6, 7 the länder (german federal states) disaster control in germany reflects the german federal system as federal law assigns certain tasks to the länder [article 73 (1) of the basic law]. however, the federation also makes recommendations and cooperates with the länder [article18 (1) of the civil protection and disaster management law]. this is especially the case in largescale emergency situations or emergency situations of national significance (niska and shimizu 2011) . in order to improve joint coordination and practice, the federal minister of the interior and the ministers of the interior of the länder decided in 2002 to conduct a national crisis management exercise. over 180 hospitals in lower saxony provide medical care for the state's population. in the event of an emergency, the number of patients they will treat will exceed normal capacity. in this context, a contingency plan may be important to facilitate an appropriate response. according to sefrin et al., a working emergency response plan is a prerequisite for extending the treatment capacities of every hospital in an emergency (schenk 2008) . page 3 of 8 schiller et al. bull natl res cent (2020) 44:174 allocating patients in successive waves may counter clinical overload (adams and tecklenburg 2007) . this plan of admitting patients in "waves" makes it possible to maintain the hospitals' ability to act, even though requests for treatment capacity can no longer be accommodated. the tool used by the länder for adapting to actual needs is the so-called hospital plan. this plan provides the basis for ensuring requirement-oriented support of the population with respect to the hospitals needed according to their location, specialties, number of beds and functional units (niska and shimizu 2011; mistovich et al. 2013) . the state of lower saxony has such an emergency response plan in place. the hannover medical school (mhh) is a well-established university hospital and a supramaximal care hospital. with a capacity of about 1500 beds (as of 2013), the mhh is one of the largest hospitals in lower saxony. together with the university medical centre göttingen, the mhh is one of two hospitals in lower saxony to feature a university dental medical centre and offer a course of study in dental medicine. the 2015 hospital plan of lower saxony states that the number of beds assigned to oral and maxillofacial surgery is equivalent to 0.3 inpatient beds per 10,000 inhabitants (adams and tecklenburg 2007) . a credo of emergency medicine is that each patient should be provided with individual care as quickly as possible, but not past the point where, in the case of a large number of casualties, the treatment of that individual patient would have a disproportionate negative effect on the prognosis of others. forecasts about the type of patients admitted to hospital as well as their patterns of injury and time of arrival are mostly based on the nominal analysis of patient numbers. the population of the study consisted of 28 hospitals. questionnaires were sent out to the following university hospitals with dental medical centres and/or dental student training (fig. 1 in the run-up to the study, ethics commission at the hanover medical school was asked. this study does not require an ethics vote, as the study is purely anonymous. of the 28 university hospitals-based dental medical centres that were invited to participate in the study, 71.4% returned the questionnaire. most dental medical centres feature instruction rooms (88.0%). in 14 (60.9%) of these centres, such rooms have separate entrances with direct access to the outside. only 30.4% of them lack access to the outside area. sterile processing is carried out in three different places: at the central sterile processing department of the entire hospital, at the central sterile processing unit of the dental medical centre or locally, i.e. at the individual departments of the dental medical centre. if only the central sterile processing department (n = 4) or a combination of that department and the central sterile processing unit at the dental medical centre (n = 4) is used, transportation/supply of sterile items is possible 24 h a day. if the hospital provides transportation services for patients on a 24-h basis all year round, sterile material will also always be transported/supplied 24 h a day (n = 18). of the hospitals that do not provide 24-h transportation/supply of sterile items, 50% did not provide a patient transportation service either. on average, the dental medical centres feature a total of 82.5 dental treatment units and 4.9 surgical rooms, which fall into the categories of minor surgery rooms, emergency operating theatres and operating theatres. in dental treatment centres equipped with dental treatment units, the numbers are: (fig. 2) . the number of minor surgery rooms, operating theatres and emergency operating theatres was also determined. the graph illustrates the results (fig. 3) . four dental medical centres are equipped with intensive care capacities. a maximum of three intensive care beds are available in 4.5% of all dental medical centres. two such beds are available in 13.0% of the centres. this results in an average capacity of 0.4 intensive care beds at dental medical centres. the ratio of surgical room capacities to bed capacities is 1:7 (one operating theatre per seven ward beds). the ratio between operating theatre capacity (4.9) and recovery room places (2.35) is approximately 1:2. schiller et al. bull natl res cent (2020) 44:174 digital networking upon investigating the dependency on information technology (it), we found that a digital record exists in 36.0% of all hospitals, including dental medical centres. the number of patients to be treated in a mass casualty event is always difficult to estimate (mistovich et al. 2013; rutherford 1989) . it depends not only on the total number of people affected by the event but particularly on the number of people with injuries that see them classified as triage categories i-iii. a comparison of the german eschede train disaster with the terrorist attacks in madrid in terms of victims shows that the number of injured who reach a hospital does not have a linear correlation with the overall number of people affected. in eschede, only 50% of casualties were alive upon arriving at a hospital for treatment, compared with 90% of victims in madrid (turégano-fuentes et al. 2008) . insufflation anaesthesia is required for almost all patients of triage categories i and ii. of the total number of patients to be expected, 60% will fall into these two categories. at least 20% of trauma patients classified as "category red" are in need of life-saving emergency surgery. for critically injured patients, surgical capacity is one of the decisive bottlenecks. analyses of the surgeries performed after the madrid bombings have shown that out of the 124 operations carried out within the first 24 h, 17 were maxillofacial surgeries. about 10% of these injuries were pure fractures of the jaw and facial bones, while around 66% affected the face, head and neck area. of all seriously injured category i patients, approximately 26% require surgical interventions in the region of the head and neck. patients with minor injuries can be expected to make up a proportion of 40%. adams has in different publications already suggested having these patients treated at a dental, oral and maxillofacial clinic by staff of the dental medical centre. triage category iii patients can usually be treated under local anaesthetic. treatment under local anaesthetic is part of the standard treatments routinely performed by dentists (pahor 1992; daubländer 2012) . they have the required facilities and equipment at their disposal, and treating their patients in a dentist's chair is common practice for them. this resource, which is available in relatively large numbers, should thus be considered for use in major emergency situations. in that case, such facilities and the dental treatment units would mainly be used for the treatment of triage category iii patients. this would involve the organisational integration of the staff and in some cases the students at dental medical centres, who would cooperate with doctors and assistant personnel in a multidisciplinary approach. a dentist's chair can fig. 2 numbers of available minor surgery rooms, operating theatres, emergency operating theatres page 6 of 8 schiller et al. bull natl res cent (2020) 44:174 generally also be used for the treatment of regions other than the head and neck area. an average of 86 dental treatment units are available, which means that 86 treatment stations are available for triage category iii patients. these units are spread all over germany according to the distribution of universities for dental, oral and maxillofacial medicine. in addition, dental medical centres lend themselves to providing rooms for crisis staffs or families as well as for pastoral care, etc. this workload sharing within hospitals equipped with a dental medical centre would make it possible to more efficiently use the resources for triage categories i and ii at the main hospital. if the condition of a triage category iii patient deteriorates during treatment and a more severe triage category needs to be assigned, the traditional surgical and monitoring facilities within the dental medical centres can be incorporated across the specialties. the objective of this study was to investigate the existing and future potential integration of dental, oral and maxillofacial clinics into the emergency concepts of hospitals as a whole. the data obtained were statistically evaluated and analysed. the majority of dental medical centres in the area surveyed were found to not be included in the emergency concepts of university hospitals. of the 18 dental medical centres that are in fact included in emergency concepts, only two-thirds were able to provide details on the exact nature and extent of this involvement. we thus conclude that resources for patient examination, treatment and admission are generally available but not used to their full extent. in terms of these resources, we were able to establish the numbers of dental treatment units (average 82.5), minor surgery rooms (average 2.8), operating theatres (average 3.0) and ward beds (average 25.1). we further conclude that dental medical capabilities in germany are insufficiently used as a potential resource in case of an emergency. there are doubts about the integration of dental (assistant) personnel. however, the geographical distribution of existing dental medical centres is an additional positive aspect in terms of their potential involvement in case of large-scale emergencies. in the current situation, hospitals are flooded with a large number of patients. the focus of the hospitals is on the treatment of emergencies and especially on the treatment of covid-19 patients. additional places are being created for triage, either by setting up additional treatment places or by putting up tents. the use of the resources of dental medical centres to relieve the main clinics should be included in the considerations. dental medical centres offer a large number of possibilities for the initial treatment and/or treatment of patients with mild to severe diseases. the integration of dental medical centres, with their own resources and existing infrastructure connections to the hospital compound, could facilitate quicker and more efficient treatment in a mass casualty event. in such emergency situations, physicians and other non-dental medical personnel could take up work at the dental medical centres, and their dentist colleagues who work in hospitals and in outpatients setting could also be involved. the necessary statutory provisions would first have to be established, however. the usa sets a positive example in this regard. constant further development of the task spectrum of dentists as part of mass casualty planning and the creation of a clear statutory framework ensure that all capabilities are exploited to their full potential. through extended training in the field of emergency medicine as students, dentists are thoroughly prepared for their future tasks and thus able to provide a real contribution to casualty care in large-scale emergencies. der notfallplan des krankenhauses the world trade center attack. the paramedic response: an insider's view neue notfallfolge trainieren für den tag x. zahnärztl mitteil the monopolisation of emergency medicine in europe: the flipside of the medal prehospital emergency care a brief history of triage hospital preparedness for emergency response: united states historical article: ear, nose and throat in ancient egypt triage for simple compensated disasters casualty, accident and emergency, or emergency medicine, the evolution krankenhaus-alarm-und -einsatzplan (kaep) -niedersächsisches muster the world trade center attack. lessons for disaster management to afford the wounded speedy assistance": dominique jean larrey and napoleon injury patterns from major urban terrorist bombings in trains : the madrid experience publisher's note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations not applicable. authors' contributions mp, ms, br, cs and ncg conceived the study and participated in its design and coordination. mp and ms made substantial contributions to data acquisition and conception of manuscript. ms, br and cs drafted and designed the manuscript and contributed equally to this work. ms and ncg were involved in revising the manuscript. all authors read and approved the final manuscript. not applicable. the datasets used and/or analysed during the current study are available from the corresponding author on reasonable request. not applicable. yes. the authors declare that they have no competing interests. key: cord-332110-6fmc5mbs authors: drury, john; reicher, stephen; stott, clifford title: covid‐19 in context: why do people die in emergencies? it’s probably not because of collective psychology date: 2020-06-16 journal: br j soc psychol doi: 10.1111/bjso.12393 sha: doc_id: 332110 cord_uid: 6fmc5mbs notions of psychological frailty have been at the forefront of debates around the public response to the covid‐19 pandemic. in particular, there is the argument that collective selfishness, thoughtless behaviour, and over‐reaction would make the effects of covid‐19 much worse. the same kinds of claims have been made in relation to other kinds of emergencies, such as fires, earthquakes, and sinking ships. we argue that in these cases as well as in the case of the covid‐19 pandemic, other factors are better explanations for fatalities – namely under‐reaction to threat, systemic or structural factors, and mismanagement. psychologizing disasters serves to distract from the real causes and thus from who might be held responsible. far from being the problem, collective behaviour in emergencies – including the solidarity and cooperation so commonly witnessed among survivors – is the solution, one that should be harnessed more effectively in policy and practice. but is this really the case? exactly the same claim about the role of public 'panic' has historically been made in relation to many other kinds of emergencies, including fires, terrorist attacks, sinking ships, and crowd crushes. was it really selfishness, over-reaction, and general bad behaviour that caused so many deaths in these cases? or was it something else? take the sinking of the m/v estonia in 1994, for example. over 800 people died. prima facie, the greater survival rates of men over women and crew over passengers might suggest that the strongest individuals selfishly neglected others in order to save themselves. but analysis of the survivorship records and eyewitness testimonies illustrates the danger of psychologizing physical constraints (cornwell et al., 2001) . the extreme listing of the ship was very sudden. there were attempts among passengers to help each other, but most did not have the strength to get to the exits themselves, let alone assist others. examining the evidence in emergencies suggests three main reasons why there are avoidable fatalities: (1) under-reaction to threat, (2) systemic factors, and (3) mismanagement. here, we briefly describe these alternative explanations for deaths in disasters. we then examine how far they help us understand what has happened in the case of covid-19 in the uk context, before discussing the real collective psychology of emergencies. why did they die? rather than over-reaction, the first factor that turns an emergency into a disaster is underreaction. people often underestimate risk and disregard possible signals of danger (tierney, lindell, & perry, 2001) . during 9/11, people inside the world trade center who saw objects falling from the sky outside did not initially recognize these as pieces of the plane that had struck their building. slowness to comprehend the threat means delay in attempts to escape. some people even took time to close down their computers before they sought to leave the building. the second reason for deaths in emergencies is systemic. disasters do not affect everyone in the same way; those already disadvantaged suffer disproportionately. 6 in the grenfell tower firethe worst fire in the united kingdom since the second world warneglect and cost-saving by the authorities and manufacturers were behind the fatal decision to clad the block in flammable material. poorer sections of society also have fewer resources to help them cope when disaster strikes and less power to demand adequate aftercare. a third reason why emergencies often end so badly is mismanagement. the cocoanut grove nightclub fire of 1942, in which 492 people died, has been presented in psychology textbooks as an embodiment of the received wisdom that 'most deaths in night-club fires are due to crowd panic'. chertkoff and kushigian's (1999) detailed re-analysis of events suggests instead failure of management of two types. first, there was mismanagement of space. the emergency exit door was locked. the windows were also nailed shut to prevent people leaving without paying their tab. second, there were failures of communication. there were no exit signs or training in emergency evacuation, so when staff tried to help lead survivors out, they could not find the fire exit. in the official investigation, the major causes of the loss of life were said to be the locked doors, the unfamiliarity and inaccessibility of normal exits, and the jamming of the revolving door. there was no implication that crowd behaviour caused the deaths. the management was subsequently prosecuted for manslaughter and neglect of building laws. a similar story of mismanagement of space can be found in the literature on fatal crowd crushes (sometimesusually erroneouslycalled 'stampedes'). 'panic' explanations once dominated, but a recent systematic review cites as the most common causes of fatalities not collective psychology but overcrowding, closure of exits, congestion at bottlenecks, deficiencies in safety barriers, and lack of coordination with local authorities (de almeida & von schreeb, 2019) . notoriously, the fatal crush at hillsborough in 1989 was initially explained by some in terms of the disorderly behaviour of fans. but it was later demonstrated that disproportionate concern among authorities with preventing football hooliganism led to neglect of crowd safetyincluding the disastrous decision to let fans into an already overcrowded terrace. 7 in short, hillsborough, like cocoanut grove, did not happen because of failings at the level of collective psychology. in relation to failures of communication, changes to information and communication practices have often improved safety and saved lives. when the world trade center was subject to a terrorist attack in 1993, the evacuation was relatively slow (aguirre, wenger, & vigo, 1998) . subsequently, regular drills were introduced so that people became familiar with the locations of emergency exits. this measure helped make the 9/11 evacuation so successful. 8 in the case of mass casualty decontamination following a chemical incident, failure of responders to communicate effectively has led to reduced public compliance with the procedure, increasing risk of fatalities (carter et al., 2015) . the solution has been to train responders with the skills to communicate to the public both why decontamination is needed and how to carry it out (drury et al., 2019) . under-reaction, system, and mismanagement in the covid-19 response in the united kingdom unlike fires, earthquakes, floods, and bombings, which tend to be short-term events which occur in one place, the effects of the current pandemic are dispersed in time and space. yet like these other emergencies, there is a mortal threat which creates collective fear. and when we examine some of the major problems in response and outcomes 9 in the covid-19 crisis, prima facie our three-fold classification above fits better than explanations in terms of public selfishness, thoughtlessness, and over-reaction. first, under-reaction: while some members of the public have not taken the pandemic seriously, the uk data show that the vast majority adhered to the social distancing and 'stay at home' regulations. 10 yet there is evidence of highly consequential political underreaction. in the united kingdom, a criticism has been that that the government did not prepare or respond in time. 11 importantly, the official advice on social distancing was only given on 16 march 2020, and the instruction to 'stay at home' only on the 23 rd . the result of this under-reaction is a death rate proportionately higher than most other countries -with over 30,000 hospital and community deaths recorded by 12 may 2020 (scally, jacobson, & abbasi, 2020) . some of this failure to prepare in time may be straightforward mismanagement. but some of it may also be due to under-estimating risk by those in authority. the world health organization warned about the risk of human-to-human transmission of covid-19 as early as 10 january 2020 and urged precautions. the first department of health and social care press release on covid-19, on 22 january, stated that the risk to the uk population was 'low'. 12 two days later, the lancet published the first article showing evidence that covid-19 was transmittable to humans; the authors recommended careful surveillance, rigorous testing, respirators, and greater use of personal protective equipment. 13 but on the same day, the uk chief medical officer still maintained that the risk to the uk public was low. the first documented transmission within the united kingdom (as opposed to from travellers from abroad) appeared on 28 february. yet the uk risk level was not raised to 'high' till 12 march. in relation to our second factor, one example where systemic factors were evident but a discourse of public bad behaviour was mobilized was in the case of so-called 'panic buying'. 14 the rapid emptying of supermarket shelves was an effect of the vulnerability of just-in-time supply chains to just a small uptick in consumer spending; and purchasing evidence suggests that, in fact, only a small proportion of the population was stockpiling in response to the expectations of 'lockdown' and shortages. 15 nevertheless, government ministers chided some of the public for their 'selfishness', psychologizing the problem. this representation of the public as selfish is highly consequential. where others in the community are seen as competitors, this can create the very individualism that is being condemned, undermining the sense of collectivity needed in these times (van bavel et al., 2020) . systemic factors have been crucial in another sense. poorer and less powerful sections of society had fewer choices about how to behave during the first phase of lockdown. despite media campaigns to vilify some people as selfish and thoughtless 'covidiots', the evidence on reasons for non-adherence shows that much of it was practical rather than psychological. many people had to cram into tube trains to go to work because they needed money to survive and government support schemes were insufficient. people were told they could go out to exercise, but those in urban areas had limited public space. and some employers failed to provide the support for social distancing and hygiene. 16 those with less income and wealth also live in more crowded homes. 17 the outcomes of these systematic inequalities are predictable: poorer people have repeatedly been shown to be more vulnerable to infection and more likely to die. 18 these inequalities have persisted into the second phase of lockdown (from may 2020), with lower income people being less able to work from home and more likely to be in jobs that bring them into contact with others. 12 https://www.gov.uk/government/news/dhsc-and-phe-statement-on-coronavirus 13 https://www.thelancet.com/journals/lancet/article/piis0140-6736(20)30183-5/fulltext 14 the use of the term 'panic' in this case illustrates why it is seen as an unhelpful concept by disaster researchers (chertkoff & kushigian, 1999) ; the judgement about whether a behaviour is an overreaction is either subjective since criteria are unclear (how much shopping does one really need?) or post hoc (and therefore not explanatory). 15 https://www.warc.com/newsandopinion/opinion/why-stockpiling-is-not-the-crazy-selfish-behaviour-that-it-seems/3483 16 https://www.bbc.co.uk/news/business-52243179 17 https://www.citylab.com/equity/2020/04/coronavirus-spread-map-city-urban-density-suburbs-rural-data/609394/ 18 https://www.health.org.uk/news-and-comment/news/deaths-from-covid-19-in-the-most-deprived-areas finally, there is evidence of a specific mismanagement in the form of failure of communication. in the uk response, one thing we observed to have changed (and which might therefore indicate recognition of an earlier error) was the way the public were addressed in the official messaging. initial government communications stressed the risk to oneself as an individual. for example: as per the current advice, the most important thing individuals can do to protect themselves remains washing their hands more often, for at least 20 seconds, with soap and water. 19 (emphasis added) the message some people therefore picked up from this was about the risk to themselves personally. such individual-focused messaging can lead people to discount the risk, especially if they consider themselves young and healthy. 20 later, there was a shift to the rationale being to 'protect the nhs', 'protect others', and a change from 'you the potential victim' to 'you the spreader' (e.g., 'act like you've got it'), which seems to have been more persuasive. 21 this last example makes the point that indeed psychology is heavily involved in the public response to covid-19. however, it is not a psychology of fixed behavioural tendencies, since the self and hence 'self-interest' (the motivations for and boundaries of concern) varies with contextual factors (in this case political leadership, which failed initially to communicate in collectivist terms). so, of course psychology matters in what happens in emergencies, but for reasons other than inevitable collective selfishness, thoughtlessness, and over-reaction. let's consider first the conditions under which behaviour is competitive vs cooperative in emergencies. there have been many reports of mutual social support by members of the public during the covid-19 crisis. 22 reviews suggest that cooperation among survivors is very common in emergencies and that members of the public save more lives than professional responders (drury et al., 2019) . but, in some emergencies, people compete, push, and even trample each other. what are the conditions for this to occur? chertkoff and kushigian's (1999) comparison of different evacuations found that there was more competition when exits were narrow and unfamiliar. we also know that people compete more and coordinate less in evacuations when they are positioned psychologically as individuals rather than as group members. as mintz (1951) shows, when an evacuating crowd blocks the exit, this can be explained in terms of the prevalence of individual competition in a collective setting (rather than in terms of excessive emotion). in these cases, then, the emergency ends badly due to the absence of collective psychology (i.e., lack of coordination and cooperation). 19 https://www.gov.uk/government/news/covid-19-government-announces-moving-out-of-contain-phase-and-into-delay 20 https://thepsychologist.bps.org.uk/dont-personalise-collectivise 21 the uk government's new slogan -'stay alert' --unveiled in early may 2020 abandoned the collectivization implicit in the previous successful messaging, with the consequence that 'only three in ten brits think that they know what the new slogan . . . is asking them to do'. https://yougov.co.uk/topics/health/articles-reports/2020/05/11/brits-split-changes-coronavirus-lockdownmeasures 22 https://www.theguardian.com/world/2020/may/03/nhs-coronavirus-crisis-volunteers-frustrated-at-lack-of-tasks?cmp=sha re_iosapp_other cooperating and giving support can also carry risks, which need to be acknowledged. in mass evacuations, the larger the group, the slower the egress, because speed is reduced through people interacting with each other (aguirre et al., 1998) . and the motivation to give support to other survivors can lead some to take risks with their personal safety; so, what is good for the collective in emergency is not always good for particular individuals (drury, cocking, & reicher, 2009). 23 in the case of covid-19, the risk to the individual from supporting the group is clear where that supportive behaviour involves physical proximity (whether delivering food or giving emotional support face-to-face). what about public under-reactionwhy does this occur? under-estimation of risk has sometimes been characterized as an 'optimistic bias' (kinsey, gwynne, kuligowski, & kinateder, 2019) . but in a context where emergency events are rare (i.e., most of the time), it is reasonable to assume that 'it won't happen to us'. this assumption can reverse when emergency events become more commonfor example, in 2017 after a spate of terrorist attacks in london, hundreds of people in oxford street fled from a noise that turned out to be harmless. in general, then, the extent to which information concerning a threat is seen as plausible is a function of the broad social context of dangers. expectations of danger are raised (and the readiness to flee or take other action is greater) in a context of recent incidents relevant to our social group. how do perceptions of risk become collective? people respond not only to 'direct' signals of risk but to other people's responses to that signal (bruder, fischer, & manstead, 2014) . we suggest that the extent to which the response of others to the possible threat is seen as conveying information is dependent on the self-relevance of these others in a particular context, which in turn is often a function of shared identity. based on what we know about social influence processes in other contexts (bruder et al., 2014) , in the case of covid-19, it is plausible to suppose that the sight of others in our community routinely observing (or ignoring) social distancing regulations, for example, is likely to send a strong signal to us around the safety of doing the sameparticularly where we identify with the community or see these exemplars as prototypes. psychological factors can interact with management failures to help explain why some emergency events end so badly. fearing public 'panic' leads the authorities to withhold information about the emergency (drury et al., 2019) . but lack of information in an emergency increases public anxiety. and when the public perceives that information is being withheld from them, this damages their relationship with the authority (carter et al., 2015) . consequently, when the authorities do release correct information, the public may mistrust and fail to act upon it. in the case of covid-19, the need to treat the public with respect in order to build trust has been part of the advice given by behavioural scientists to the uk government. 24 we do not deny that in emergencies some people behave selfishly and thoughtlessly or that some may over-react. indeed, as explained, research suggests some of the conditions for competition to prevail over cooperation. what we are questioning here is the notion that such public reactions are a default or are a major cause of problems in the covid-19 crisis. the existing literature on disasters does not support this view, and prima facie major problems in the covid-19 response and outcomes can be better understood otherwisein terms of (political) under-reaction, systemic issues, and mismanagement. collective 'panic' is referred to as a 'disaster myth' in the literature on disasters (drury et al., 2019) . rather than a neutral description of how people actually behave, it is best understood as part of a particular discourse or cultural representation, one which psychologizesand indeed pathologizespublic responses in emergencies and disasters. given what is known about under-reaction, systemic factors, and mismanagement in emergencies, to emphasize instead the role of collective 'bad behaviour' has clear ideological functions. in naturalizing fatalities, it distracts from the real causes and thus from who might be held responsible for mismanagement, instead blaming the victims. the irony, of course, is that, far from being the problem, collective psychology in emergenciesthe solidarity and cooperation so commonly witnessed among community members and strangersis usually the solution. collective psychology therefore can and should be harnessed more effectively in policy and practice in the covid-19 response (elcheroth & drury, 2020 )through framing both the threat and the solution in collective terms, and through emphasizing shared norms around collective well-being and safety (drury et al., 2019) . why do people die in emergencies? it is probably not because of collective psychology. a test of the emergent norm theory of collective behavior social appraisal as cause of collective emotions applying crowd psychology to develop recommendations for the management of mass decontamination don't panic: the psychology of emergency egress and ingress panic or situational constraints? the case of the m/v estonia human stampedes: an updated review of current literature facilitating collective psychosocial resilience in the public in emergencies: twelve recommendations based on the social identity approach the nature of collective resilience: survivor reactions to the 2005 london bombings collective resilience in times of crisis: a summary of knowledge and derived policy principles for socially effective responses to the covid-19 pandemic cognitive biases within decision making during fire evacuations non-adaptive group behaviour the uk's public health response to covid-19 facing the unexpected: disaster preparedness and response in the united states all authors declare no conflict of interest. key: cord-319890-t7tcvkd3 authors: liu, yuchen; wang, minggang; shen, yingmo; chen, jie title: analysis of operation procedure and effect for emergency surgery in general hospital during novel coronavirus pneumonia period date: 2020-08-26 journal: bmc surg doi: 10.1186/s12893-020-00852-2 sha: doc_id: 319890 cord_uid: t7tcvkd3 background: novel coronavirus pneumonia (ncp) outbreak in wuhan, china in early 2020, resulted in over 80 thousand infections in china. at present, ncp has an explosive growth in the world. surgeons could refuse selective operation during the outbreak, but they must face the emergency operation. we hope to avoid the spread of ncp while ensuring efficient treatment of emergency cases. methods: the data of patients with incarcerated hernia admitted to beijing chaoyang hospital during ncp epidemic were analyzed and compared with those in 2019. all cases were divided into ncp group and 2019 group. the operation data and inpatient protection process of emergency cases were analyzed. result during the ncp epidemic, 17 cases with incarcerated hernia were treated in our department. a total of 263 cases of the same disease were admitted in 2019. there was no significant difference in age, gender, bmi and hernia type between two groups. no significant difference was observed between the two groups in operation method and hospital stay. the waiting time for emergency operation of ncp group was significantly longer than that of 2019 group (p = 0.002). a buffer ward was set up by administrator of hospital during ncp outbreak. hospitals were divided into “red area, yellow area and green area” artificially, and strict screening consultation system was implemented. there was no case of sars-ncov-2 infection in medical staff. conclusion: it was safe and effective to carry out emergency operation on the premise of screening, protection and isolation during the ncp epidemic. the increased waiting time for operation due to ncp screening did not threaten medical safety of emergency incarcerated hernia patients. in december 2019, several cases of viral pneumonia occurred in wuhan of china, and a large-scale outbreak occurred in china in a short period of time [1] . the novel coronavirus was named by who as 2019 new coronavirus (sars-ncov-2), or novel coronavirus pneumonia (ncp) in january 2020 [2] . as of march 15th, 2020, more than 80,000 ncp cases have been confirmed, according to chinese officials. but it was gratifying that the epidemic situation in china has been fundamentally improved. the number of confirmed cases decreased significantly, and most of them were imported cases. at present, ncp outbreaks have occurred in many countries and regions around the world [3] . many countries began to use the chinese model to block the development of the epidemic. during the outbreak, most of the surgical areas in china were vacant. all elective operations were suspended within the specified time, and only patients requiring emergency operations were admitted. moreover, different regions had different treatment processes and policies, and different protective measures [4] . most of hernia surgical diseases belong to selective operation [5] . therefore, as a hernia specialist center, the treatment of elective patients was also stagnated in beijing chaoyang hospital during the epidemic. however, the emergency treatment of incarcerated hernia was still in accordance with the emergency surgery [6] , and relevant admission process (fig.1) and surgical protection management (fig.2 ) measures were formulated in order to avoid nosocomial infection, while solving emergency surgery, protect the life and health of patients and medical staffs. during the epidemic period, all patients with incarcerated hernia had no nosocomial infection after being admitted to hospital for operation, and the treatment effect was positive. the protective process and therapeutic effect of emergency hernia operation during ncp epidemic in beijing chaoyang hospital was reported. beijing municipal government launched the first level response to major public health emergencies since january 24th, 2020. the data of incarcerated hernia patients were collected from january 24th to march 15th in department of hernia and abdominal wall surgery, beijing chaoyang hospital. inclusion criteria: emergency incarcerated hernia patients who received emergency operation. at the same time, the data of the same disease cases of emergency surgery were collected in our department in 2019. the hospital was divided into "red area", "yellow area" and "green area" according to the exposure risk level, and different levels of protection were carried out according to the exposure risk of different areas. the protection level was divided into four levels: (1) general protection: wear surgical masks (including staff and patients); (2) level i protection: wear work clothes, work caps, surgical masks and gloves;(3) level ii protection: wear work clothes, isolation clothes, medical protective masks, shoe covers, work caps, goggles or protective masks; (4) level iii protection: on the basis of level ii protection, wear comprehensive respiratory protective device. "red area" was defined as high-risk exposure area, including fever clinic, emergency department, operating center, department of laboratory, pathology department, intensive care unit and other work departments that may have direct contact with pathogens. the corresponding protection level of "red area" was "level iii protection". "yellow area" was defined as buffer ward. after ncp screening, all emergency cases were admitted to the buffer ward. the ward was a separate floor in hospital, and only one emergency patient could be admitted to each room. the corresponding protection level of "yellow area" was "level ii protection". "green area" was defined as general surgical ward. emergency patients could be transferred to general ward after expiration of isolation in the buffer ward, and only one emergency patient could be admitted to each room. the corresponding protection level of "green area" was "level i protection" [7] . admission examination included ncp screening and emergency operation related examination. all emergency patients were screened by blood test and pulmonary ct before admission and completed ncp screening form [8] . after being signed by the department director and consultation by the ncp expert panel (composed of respiratory department, radiology department, intensive care unit, infection department and emergency department), emergency cases could be admitted to the buffer ward. preoperative preparations were carried out in the buffer ward. for patients with suspected ncp that cannot be excluded or with a history of close contact, the operation must be performed in a negative pressure operating room. after operation, they returned to fever observation area (red area) or negative pressure ward of icu. for patients who had passed ncp screening, the operation could be performed in the general operating room. these patients returned to the buffer ward (yellow area). open or laparoscopic surgery was selected according to the patient's condition. and a corresponding level of protection according to exposure risk was performed [7] . for the patients who return to the buffer ward after operation, blood test and pulmonary ct examination must be performed again after a week of isolation observation. the emergency patients in the buffer ward could only be transferred to general surgery ward ("yellow area" to "green area") after consultation with the "experts panel" excluding ncp. during the postoperative treatment, patients with fever should be reported twice a day, and relevant screening should be carried out according to the opinions of the expert panel. patients who had been isolated for less than one week but met the discharge standard could be discharged directly from the buffer ward. the general data of patients, waiting time for emergency operation, operation mode, operation time, intraoperative complications and postoperative complications were recorded. all emergency patients still needed to be followed up with ncp daily after discharge, such as body temperature, ncp symptoms, etc. [8] . in addition, surgical follow-up was carried out to understand recovery of operation. the follow-up time was 1 week, 1 month and 3 months after the operation [9] . spss statistics software (v 23.0) was used for data analysis. the results of descriptive analysis of continuous variables are expressed as mean ± sd and were calculated using the independent samples t-test. categorical variables are presented as number or percentage and were calculated using the χ2 test. p < 0.05 was considered to denote statistical significance. from january 24th to march 15th, data of 17 emergency patients were included in this study (tab.1). there were 9 males and 8 females, including 9 cases of incarcerated inguinal hernia, 4 cases of incarcerated umbilical hernia, 2 cases of incarcerated incisional hernia, 1 case of incarcerated parastomal hernia and 1 case of incarcerated obturator hernia. at the same time, 263 cases of emergency patients with same disease in 2019 were included, including 199 cases of incarcerated inguinal hernia, 31 cases of incarcerated umbilical hernia, 23 cases of incarcerated incisional hernia, 8 cases of incarcerated parastomal hernia and 2 cases of incarcerated obturator hernia. the age, bmi and hospital stay in ncp group and 2019 group were 68.17 ± 9.47y vs. 62.74 ± 11.25y, 22.85 ± 4.24 kg/m 2 vs. 23.41 ± 4.33 kg/m 2 and 7.52 ± 3.93d vs. 7.98 ± 4.41d, respectively. there was no significant difference in gender, age, bmi and type of incarcerated hernia between two patients (p > 0.05). the waiting time of emergency operation in the two groups was 5.53 ± 0.73 h vs. 2.78 ± 0.33 h with statistically significant difference(p = 0.002). in ncp group, laparoscopic surgery was performed in 2 cases and open surgery in 15 cases. suture was performed in 6 cases and mesh repair in 11 cases. there were 2 cases of hernia necrosis. in 2019 group, 88 cases underwent laparoscopic surgery, 175 cases underwent open surgery. the difference was statistically significant (p = 0.049). in ncp group, 7 cases were transferred to general surgery ward through buffer ward, and 10 patients were discharged directly from buffer ward. fever occurred in 2 patients with ncp screening by expert panel consultation post-operation. follow up of novel coronavirus pneumonia: ncp was excluded from 13 patients after two weeks follow-up and surgical follow-up continued; no ncp was observed in 4 cases during 1 week follow-up and observation continued. surgical follow-up: no intraoperative complications occurred; there was no infection, recurrence or intestinal obstruction in the short-term follow-up (tab. 2). hernia and abdominal wall surgery are the branches of general surgery, and types of diseases are relatively concentrated. most of the operations are elective, including some limited time operations and emergency operations [10] . during the ncp epidemic, diagnosis and treatment should be classified according to the condition. our department had stopped the treatment of all patients undergoing elective surgery since the first level response was launched in beijing. at the same time, confine operation should be postponed, but emergency operation was still needed. the emergency operation of hernia surgery is mainly incarcerated inguinal hernia, incarcerated umbilical hernia, incarcerated incisional hernia, incarcerated parastomal hernia and so on [5] . in order to save medical resources and reduce the exposure of medical staff and patients, we could suspend the treatment of patients undergoing elective surgery as a special department for hernia and abdominal wall surgery. but for incarcerated hernia emergency patients, we could only choose active surgical intervention [11] . for such cases, ncp guidelines should be done in accordance with the protection requirements of hospital and isolation to avoid hospital infection. at the same time, [7] . in terms of choice of surgical methods for emergency incarcerated hernia cases, we were faced with elderly patients, many basic diseases, long history or other characteristics. many of these patients had a high risk of general anesthesia. therefore, many emergency patients in our department chose open surgery under local anesthesia during ncp epidemic [12] . according to previous limited experience, sars-cov-2, which was mainly transmitted by droplets, was similar to the middle east respiratory syndrome (mers) coronavirus found in september 2012 [13] . seddiq reported the cases of mers after cabg in 2017, without special protection during operation. no infection was found in 40 close contacts [14] . some hospitals in south korea performed emergency operations for 4 suspected cases and 2 confirmed cases of mers under strict protection [15] . no staff infection was found. during the outbreak, a hospital in wuhan performed cesarean section for 48 pregnant women suspected and confirmed ncp, and no infection was found among the medical staff. sars-cov-2 was similar to mers coronavirus and could be transmitted through droplets and feces [16] . in contrast, sars-cov-2 may even spread through aerosols. considering the management of airway by general anesthesia intubation and the possibility of aerosol diffusion in laparoscopic surgery, most of our surgical methods were open surgery in ncp epidemic [17] . the main anesthesia was local anesthesia combined with intravenous anesthesia in order to avoid the spread of pathogens, by cutting off route of transmission. of course, there were also cases that were actually more suitable for laparoscopic surgery, such as incarcerated obturator hernia [18] , which could also be performed under premise of good protection. however, the operating room should be regarded as "red area" and the corresponding highlevel protection should be performed. during the epidemic period, proportion of laparoscopic surgery was 11.76%, and proportion of previous emergency laparoscopic surgery was 33.46%, although the difference was not statistically significant. but we preferred open surgery during ncp outbreak. during ncp epidemic, treatment process of emergency incarcerated hernia patients was more complicated than ever, and more examinations and screening work had been carried out. because in the process of admission, once it caused exposure or infection, it was fatal for the whole hospital. although we had increased admission process, resulting in a significant increase in emergency surgery waiting time compared to cases in 2019, we believed it worthy during ncp outbreak. moreover, compared with the previous emergency patients, strangulation of incarcerated hernia did not increase significantly. so we had reason to think that strict pre hospital screening process was necessary, including blood test and pulmonary ct. of course, contact history of epidemic areas and family members was also essential [19] . all the relevant examination results needed to be consulted by expert panel before entering the hospitalization process. the expert panel must be composed of specialists with rich experience. in our opinion, the expert group should be composed of senior doctors from respiratory department, infection department, radiology department, emergency department and intensive care unit. at least two groups of experts shall be equipped to ensure 24-h standby status. however, after the operation, it was not allowed to enter the "green area". it was necessary to return to the "yellow area" for at least one week of isolation observation according to the condition. if possible, we even suggested that the observation isolation time extended as much as possible. in the "yellow area", it is not allowed to visit or stay with family members. since the incubation period of ncp was about 1~14 days, mostly 3~7 days [20] , we chose to take the new ncp assessment when patients had been isolated for 7 days. in the early stage of the epidemic, patients in "yellow area" did not carry out nucleic acid monitoring 7 days after isolation instead of blood test and pulmonary ct examination. after consulting by expert panel again, patient could be transferred from buffer ward to general surgery ward ("yellow to green"). the rest of treatment continued in the general ward. in the green area, a fixed family member was allowed to stay with patient, and the family member was not allowed to leave the ward until patient discharged. at present, we suggest that ncp test kit should be included in the routine screening examination, so as to ensure the accuracy of the examination. discharge did not mean the end of isolation of patient. we still require patients to be isolated at home after discharge and did a good job of follow-up investigation. after ncp was excluded during the incubation period, surgical follow-up was continued. if ncp was suspected or diagnosed, the patients performed emergency surgery should be sent to red area for treatment. including the family members of the patients, nobody was allowed to enter yellow or green areas. it was better to transfer to a special designated hospital [7] . compared with same emergency incarcerated hernia cases in 2019, hospital stay did not increase, and there was no significant difference in repair methods in ncp group. therefore, we believed that it was safe to use mesh for emergency surgery during the epidemic. in addition, special protection did not increase the incidence of intraoperative complications. high level of protection was necessary for intraoperative protection, especially for suspected and confirmed cases. on the other hand, the emergency incarcerated hernia surgery under the epidemic situation should choose the simplest way of operation. the operation method that could achieve therapeutic effect in the shortest time was the one that should be selected during ncp epidemic [5] . so far, the number of newly confirmed ncp cases in china has declined rapidly. there have been no newly confirmed cases in wuhan for two consecutive days, and most of confirmed cases are imported ones in china. the ncp epidemic prevention and control in china has achieved phased results. we hope to summarize the experience of emergency operation during ncp epidemic and achieve the highest efficiency of treatment and the safest protection in the face of similar situations. therefore, the number of emergency surgery cases in our hospital was not enough, and data included in the study was not enough during ncp epidemic period. secondly, the follow-up time of surgical patients was very short, which did not reached long-term follow-up, so we need to continue to observe. thirdly, admission process and operation process were just our experience summary. beijing was not the area with the most severe ncp epidemic, and the infection density might be smaller than that of wuhan. it was safe and effective to carry out emergency operation on the premise of screening, protection and isolation during the ncp epidemic. the increased waiting time for operation due to ncp screening did not threaten medical safety of emergency incarcerated hernia patients. clinical features of patients infected with 2019 novel coronavirus in wuhan severe acute respiratory syndrome coronavirus 2 (sars-cov-2) and coronavirus disease-2019 (covid-19): the epidemic and the challenges first case of 2019 novel coronavirus in the united states novel coronavirus: where we are and what we know international guidelines for groin hernia management surgery for incarcerated inguinal hernia: outcomes with lichtenstein versus open preperitoneal approach expert consensus on personal protection in different regional posts of medical institutions during novel coronavirus pneumonia (covid-19) epidemic period clinical characteristics of 138 hospitalized patients with 2019 novel coronavirus-infected pneumonia in wuhan, china open preperitoneal groin hernia repair with mesh: a qualitative systematic review european hernia society guidelines on the treatment of inguinal hernia in adult patients watchful waiting versus surgery of mildly symptomatic or asymptomatic inguinal hernia in men aged 50 years and older: a randomized controlled trial biological meshes for inguinal hernia repair -review of the literature. front surg understanding the latest human coronavirus threat. viruses first confirmed case of middle east respiratory syndrome coronavirus infection in the kingdom of bahrain: in a saudi gentleman after cardiac bypass surgery infection prevention measures for surgical procedures during a middle east respiratory syndrome outbreak in a tertiary care hospital in south korea the emergence of a novel coronavirus (sars-cov-2), their biology and therapeutic options the epidemiology, diagnosis and treatment of covid-19 the feasibility of laparoscopic management of incarcerated obturator hernia early transmission dynamics in wuhan, china, of novel coronavirus-infected pneumonia understanding of covid-19 based on current evidence publisher's note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations none. not applicable. not applicable. all authors have no source of funding. the datasets used and/or analysed during the current study are available from the corresponding author on reasonable request. the datasets used and/or analysed during the current study are available from the department of hernia and abdominal wall surgery, beijing chaoyang hospital, capital medical university, on reasonable request.ethics approval and consent to participate all procedures involving human participants were in accordance to the ethical standards of the institutional research committee and with the 1964 helsinki declaration and its later amendments. the protocol was approved by beijing chaoyang hospital, capital medical universisy ethical committee, 2020-k-069.written informed consent was obtained from all individual participants. the authors declare that they have no competing interests received: 7 may 2020 accepted: 19 august 2020 all authors contributed significantly to the present research and reviewed the entire manuscript. y l: participated substantially in conception, design and execution of the study and in the analysis and interpretation of the data; also participated substantially in the drafting and editing of the manuscript. m w: participated substantially in conception, design and execution of the study and in the analysis and interpretation of the data; also participated substantially in the drafting and editing of the manuscript. y s: participated substantially in conception, design and execution of the study and in the analysis and interpretation of the data. j c: participated substantially in conception, design and execution of the study and in the analysis and interpretation of the data. key: cord-316620-zfhfgwsm authors: gui, li; gu, shen; lu, feng; zhou, bin; zhang, ling title: prehospital emergency care in shanghai: present and future date: 2012-10-06 journal: j emerg med doi: 10.1016/j.jemermed.2012.02.067 sha: doc_id: 316620 cord_uid: zfhfgwsm background: in shanghai, prehospital emergency medical services are provided by the public ambulance services. the 60th anniversary of the local ambulance services is a good opportunity to provide an overview of the current trends in prehospital emergency medical care in shanghai. objectives: in this report, the features of shanghai prehospital emergency medical care are described, as well as the shanghai model of purely prehospital emergency medical care, including the communications and dispatch system, ambulance depots and ambulances, and prehospital rescue teams. responses to major incidents including public health emergencies and natural disasters are also discussed, with the intention of highlighting future directions in emergency medical services, as well as the influence of international trends in emergency patient care. discussion: although shanghai has the most advanced dispatch system in china (equipped with a global positioning system, global information system, and more) and can be expanded quickly in case of mass casualty incidents, there is, as yet, no uniform emergency medical service (ems) dispatching for the entire city. nor are there certifications, degrees, or special continuing education programs available for ems dispatchers. although there are more and more ambulance depots spread all over shanghai, the city struggles with inadequate prehospital emergency caregivers, because every ambulance has to be staffed with a qualified emergency physician, and there are also recruitment problems for ambulance physicians. conclusions: although faced with many challenges, substantial progress is expected in shanghai prehospital emergency care. , abstract-background: in shanghai, prehospital emergency medical services are provided by the public ambulance services. the 60th anniversary of the local ambulance services is a good opportunity to provide an overview of the current trends in prehospital emergency medical care in shanghai. objectives: in this report, the features of shanghai prehospital emergency medical care are described, as well as the shanghai model of purely prehospital emergency medical care, including the communications and dispatch system, ambulance depots and ambulances, and prehospital rescue teams. responses to major incidents including public health emergencies and natural disasters are also discussed, with the intention of highlighting future directions in emergency medical services, as well as the influence of international trends in emergency patient care. discussion: although shanghai has the most advanced dispatch system in china (equipped with a global positioning system, global information system, and more) and can be expanded quickly in case of mass casualty incidents, there is, as yet, no uniform emergency medical service (ems) dispatching for the entire city. nor are there certifications, degrees, or special continuing education programs available for ems dispatchers. although there are more and more ambulance depots spread all over shanghai, the city struggles with inadequate prehospital emergency caregivers, because every ambulance has to be staffed with a qualified emergency physician, and there are also recruitment problems for ambulance physicians. conclusions: although faced with many challenges, substantial progress is expected in shanghai prehospital emergency care. ó 2012 elsevier inc. the people's republic of china is a country of 1.3 billion people, and is one of the most densely populated countries in the world (1) . since the late 1970s it has undergone considerable changes, since reforms known as the four modernizations improved agriculture, industry, technology, and defense, vastly raising living standards and making china one of the great powers. as a global city, shanghai exerts influence over commerce, finance, culture, art, fashion, research, and entertainment. the city is located in the middle portion of the chinese coast, and sits at the mouth of the yangtze river (2) . it is administratively a municipality that is equal to a province, is an autonomous region, and is divided into 18 county-level divisions, including 17 districts and one county ( figure 1 ). there is no single downtown district in shanghai. the urban core is scattered across nine districts that are collectively referred to as shanghai proper or the city center, and these account for three-fourths of the entire city. demand for emergency medical care is increasing in shanghai, along with the major epidemiological transition. it is one of the most populous cities in p.r. china, with a land area of 6340 km 2 . the permanent population is currently slightly over 19 million, whereas the migrant population is about 6 million. females account for about 50.1% of the entire population, slightly outnumbering males. the ratio of urban-to-rural population has been increasing for several years. the birth rate is one of the lowest in china, with 6.62 per 1000 persons (the rate for china overall is 12.13 per 1000 persons) and the mortality rate is 7.64 per 1000 persons. the average life expectancy at birth is 81.73 years (79.42 years for males and 84.06 years for females). only 10.4% of the population is aged younger than 18 years, with 24.1%, 43.0%, and 22.5% being 18-34 years, 35-59 years, and at least 60 years old, respectively. the growing elderly population has resulted in an increased need for proper emergency care. in 2009, there were 2.7 doctors per 1000 persons and 4.1 hospital beds per 1000 persons. emergency medical services provided to persons aged older than 60 years made up 61.6% of the whole service, whereas 4.4%, 12.7%, and 21.3% of the service was provided to those aged younger than 18 years, 18-34 years, and 35-59 years, respectively. according to data from the shanghai emergency medical center (semc), there were 585,298 cases of prehospital care in the city center during 2003-2007 (3) . the top three most frequent diseases responded to by ambulance services were injury, cerebrovascular disease, and cardiovascular disease, accounting for 36.7%, 23.5%, and 15.4%, respectively; this was dramatically higher than the comparable data from previous years (1991) (1992) (1993) (1994) (1995) (4) . being the top single disease, shanghai's total road injury cases numbered 38,472 from 2003 to 2007, with the ratio being 4.51% in 2003 but increasing to 8.32% in 2007 (3) . possible reasons for the increase are urbanization, crowding, and traffic congestion brought about by the significant economic and societal changes in shanghai. conversely, the percentage of tumor emergencies, acute upper gastrointestinal bleeding, and obstetrics/gynecology emergencies decreased significantly from 4.6%, 3.4%, and 3.4%, respectively, to 3.3%, 1.9%, and 2.1%, respectively (4). the shanghai model of prehospital emergency medical care administrative system of shanghai prehospital emergency care.with the vast territory of china and the significant locoregional differences in economic power, city size, history, and development of emergency service and catchment areas, there are five principal models of prehospital emergency service that exist across different areas. they are: purely prehospital care, independent emergency service center, prehospital care supported by general hospital, unified communication command center, and integrated within fire and police departments (5) . for many years, shanghai has employed the purely prehospital care model, comprising mainly a prehospital emergency service with no sickbeds, known as the shanghai model, which is similar to emergency medical services in germany. many major chinese cities, including tianjin, nanjing, wuhan, and hangzhou, also use this model. beijing, formerly in the model of independent emergency service centers, also has been using the shanghai model since 2005, mainly due to the rapid development and internationalization of the city (6). this means that an independent prehospital center with its own inpatient department cannot completely meet the needs of the citizens. although much progress has been achieved over the last 5 years, during which the 11 th 5-year guideline (a scheduled plan announced by the shanghai government every 5 years which sets the 5 years' developing goal for shanghai) has been applied, emergency medicine and prehospital emergency medical care in shanghai are still in the "developing" phase. in terms of administration, shanghai prehospital medical service is operated by the public health department of the local government, the shanghai health bureau. private prehospital medical care is not yet allowed in shanghai. the emergency medical service system (emss) in shanghai is divided into 10 emergency medical service (ems) areas, including shanghai ems (semc), which is located in the city center, and nine suburban district (county)-level emergency centers. these 10 centers work independently, and generally, semc can give advice for emergency care only to the nine suburban district (county)-level emergency centers. semc serves the nine districts in the city center, whereas the nine district (county)-level emergency centers in the suburbs are responsible for prehospital care of their own district or county. however, the prehospital ems will be organized by semc once disasters or public health emergencies occur. figure 2 shows the organizational diagram of semc. the emergency centers work with hospitals by emergency green channel (a term used in the area of emergency medicine to speed the initiation of the care of severely-ill patients) to establish an emergency chain between pre-and in-hospital care. the key point of the shanghai emss is to provide high-quality prehospital service to its citizens, including first aid at the scene, monitoring the patient during transportation, and safe transport. the service's tasks, in addition to the rapid and safe transportation of the patient to a hospital, include the restoration and maintenance of the patient's vital functions, as well as the alleviation of pain and suffering, stabilization, and the prevention of reinjury at the scene and during transportation. current status of shanghai prehospital emergency medical care.prehospital emergency medical care in shanghai consists of the essential components of an integrated emergency medical care system, including dispatch centers and communication system, rescue teams, ambulances, ambulance depots, and helicopter ems. from the establishment of new china in 1949 to the end of the 11 th 5-year construction, shanghai experienced vast change in the system. through 60 years' practice and development, a unique operational prehospital care model has been formed with the characteristics of unity of command, district-level dispatch system, distributed ambulance depots, on-the-spot medical aid, and fast transport. whereas few ambulance or emergency telephones could be found in 1949, ambulance command has evolved into a modern prehospital service provider with a well-decorated urban ambulance dispatch center equipped with global posi-tioning system, global information system, wireless communication system, and other advanced command system elements that can be expanded quickly in case of mass casualty incidents. it includes more than 500 ambulances and over 111 ambulance depots. however, prehospital emergency medical care in shanghai is currently provided by only about 800 prehospital emergency caregivers, 219 of whom are emergency physicians. these numbers are substantially lower than the targets set for medical staff by the shanghai 11 th 5-year guideline for emss (table 1) . because an emergency physician must accompany each ambulance run, this means the maximum of the ambulances that can be dispatched to provide prehospital emergency care is 219, even though there are more than 500 ambulances in the city. communications and dispatch system. the dispatch unit is one of the most important components of shanghai prehospital emergency medical care. all of the dispatch units in the city center or suburban areas can be accessed by dialing the unique emergency telephone number, 120, on a telephone. most of the dispatchers are trained as physicians, nurses, or other health care professionals. they have to undergo additional ambulance dispatch training before being allowed to take emergency calls in the centers. however, because no certification, degree, or special continuing education programs are offered for prehospital emergency medical care, most of the training courses are informal and the apprentice model is generally used to train the ems dispatchers. unfortunately, this makes the dispatch process non-standard and may even bring potential harm to patient care. the main duties of the dispatchers are receiving emergency calls, assessment of the received information, and dispatch of an emergency service team to the scene. the dispatchers also cooperate with the police, fire department, and other relevant services, and give telephone medical advice to callers. according to the incomplete data from semc, in 2009 the dispatchers received 6000-8000 ambulance calls per day, and the peak flow of ambulance dispatch by semc was 927 per day. average ambulance response time varies from one location to another ( table 2 ). the urban radius of service was decreased to 3 km in 2000. the target response time, from receipt of the call to the arrival of the emergency ambulance services, is 15 min, and it is higher in rural areas. with a network of ambulances and the new urban service radius, the average response interval in the city center can be expected to be reduced to 10 min. the reasons for the long response time at the present time are complex, and include: too few available ambulances and too few ambulance depots, traffic congestion, helicopter unavailability (only one helicopter station in the whole city), and so on. at present, there are seven dispatch units in shanghai. emergency calls are transferred, depending on the location where the emergency occurs or the type of call. all of the requests from mobile phones and those from landlines in the city center and new districts minhang, baoshan, and pudong are connected to the dispatch center of semc, whereas others are connected or transferred to suburban centers. direct lines and hospital-on-thenet allow the dispatch units to contact the ambulance depots. wireless communications between dispatch units and ambulances also play an important role. currently, emergency telephone calls to 110 or 119 are handled by the police or the fire department, and the direct lines between the police and fire brigade to the dispatch units allow the calls to be responded to as quickly as possible. considering the potential delay from calling to dispatch, most of the dispatch units are now considering integrating with the fire brigade and the police. ambulance depots and ambulances. with the exponential increase in population size, the need for a larger and better ambulance service has also grown. there are more and more ambulance depots spread out all over shanghai, especially in densely populated residential and industrial areas, that provide emergency services 24 h a day. the number of ambulance depots in 2008 and 2009 in the entire city reached 102 and 110, respectively, meaning there is one depot serving two to three towns or subdistricts, each of which has a population of 80,000-100,000 people. the ambulances are fully equipped and staffed at the physician ambulance service level. some ambulances are used to provide trans-province emergency care services and most of them have transportation times just short of 24 h (7). in rare cases, shanghai police helicopters have helped transport patients (8) . there is currently only one helicopter station that works closely with ambulance command. the helicopter stations are administratively separate and have developed independently. once a police helicopter is deployed, the emergency physicians will provide emergency care to the patient using onboard medical equipment such as a first aid kit, defibrillator, oxygen apparatus, and electrocardiographic monitor. if a patient requires special treatment on site and referral to a specialized department, the nearest hospital may be bypassed. there is also one mobile casualty treatment center (mctc) stationed in shanghai. when there is a major incident involving a large number of patients that requires more ambulances, the mctc is dispatched. the mctc, which is supplied with more sophisticated equipment in larger quantities than a standard ambulance, has played an important role in response to major incidents. one such incident was the shanghai 11.15 major fire disaster of november 15, 2010, when mctc provided advanced life support to the victims with the help of medical equipment such as a ventilator, advanced airway, transcutaneous cardiac pacemaker, and glucometer. a standard ambulance is usually fitted with a communication system such as a two-way radio, and medical supplies and equipment such as a defibrillator/monitor, syringe driver, suction machine, medications, infusions, intubation equipment, immobilization equipment, stretcher, emergency suitcase, and backpack. prehospital rescue teams. as in the german system, instead of paramedics, there are emergency physicians working in shanghai's ambulances, who typically graduate from medical school after 5 years' education. besides the general medical education requirement, no other special qualifications are required to be an emergency physician. every ambulance must be staffed with an emergency physician who can provide all necessary interventions on site or during transport. because emergency physicians were part of the shanghai ems system from its very beginning, it was thought that there was no need for non-physicians working in the ambulances to learn to perform interventions that legally only physicians are allowed to do, and there was no need for them to receive formal training. therefore, no staff member other than the emergency physician is formally authorized to give medications, establish intravenous access, defibrillate, or perform tracheal intubation. for these reasons, there is a large shortage of emergency physicians. to meet the high demands of ems in shanghai, the staff in the ambulance generally works 24-h shifts, and the number of shifts per month varies. besides the current shortage of emergency physicians, there are also problems recruiting applicants for the ambulance physician program each year due to unfavorable working conditions, too large of a workload, and too low a salary. these factors attract few graduates from the medical schools. the city struggles with an inadequate number of emergency physicians. currently, most of the emergency physicians working in ambulances are inexperienced and have received an inadequate education in emergency medicine. these jobs are frequently considered temporary. as a result, the number of emergency physicians has been decreasing, far from enough to staff all of the ambulances in shanghai. for the management of major incidents with mass casualties, every organization of shanghai emss is required to have a guideline or protocol for ems response. prehospital care in special circumstances (e.g., public health emergencies and environmental catastrophes) is generally done in coordination with the crisis headquarters of the health bureau and social affairs. prehospital care and public health emergencies. the outbreaks of severe acute respiratory syndrome (sars) and h1n1 flu certainly had an impact on shanghai emss. before 2003, when sars afflicted the entire country of china, including shanghai, there was no policy in place to guide emss to effectively respond to that or any other public health emergencies. however, when another public health emergency, avian influenza, hit shanghai in 2006, changes in policy were implemented rapidly and information was disseminated effectively to all personnel. in march and april of 2009, when an outbreak of a new strain of influenza commonly referred to as "swine flu" infected many people in the world, all prehospital emergency care personnel in shanghai were put on high alert. universal precautions were re-emphasized, and body temperature was monitored in both patients and staff. prehospital response to disaster.disaster can lead to mass casualty incidents (mci). examples of mci in the past in china include the wenchuan earthquake, landslides, flooding, and major fire incidents. shanghai prehospital emergency care personnel worked with others in china to respond to these mci. during the massive wenchuan earthquake on may 12, 2008 , in which 69,197 were confirmed dead, 374,176 were injured, and 18,222 were listed as missing, shanghai was unaffected but responded quickly by deploying six rescue teams to sichuan province 2 days after the earthquake (9). in their 3-6 months of operation, the field hospitals established by shanghai teams treated more than 10,000 patients. with more victims rescued out of the ruins, some patients severely injured in the earthquake were transferred to shanghai to receive intensive care. on november 15, 2010, a high-rise apartment building in shanghai caught fire. shortly after the disaster, semc sent all of their nearby ambulances to the scene. the medical director of semc arrived there quickly and took responsibility for supervision, resource planning, and quality management of the disaster response. the director also coordinated the activities of the ems with other institutions (e.g., police, fire brigade, hospitals). nine hospitals in shanghai established a green channel to treat people injured in the fire. the government also established an expert panel to direct the rescue efforts. being an immature system in shanghai, the emergency medical system is still under development, as the specialty of emergency medicine in china is now receiving considerable attention from the public and government. in the coming 5 years, the 12 th 5-year guideline will be implemented and substantial progress is expected in shanghai prehospital emergency care. during this advancing progress, more emphasis should be placed on full implementation of more evidence-based advanced prehospital interventions, as well as on area-wide emergency care including both metropolitan and rural settings. to provide an optimal level of emergency care, there is a need to increase the number of qualified emergency personnel, especially emergency physicians, and implement medical control and oversight for the emss. furthermore, efforts are needed to improve the efficiency and quality of the ems system, such as public education, improving patient outcomes, increasing patient satisfaction, and development of disaster preparedness. a uniform and integrated dispatch system should be developed and used in the entire city of shanghai to facilitate the dispatch of ambulances and to shorten the average ambulance response time. formal emergency medical dispatcher training courses also should be implemented for dispatchers. although physician-staffed ambulances will continue to play a role in the ems, a potential solution to the problem of ambulance staff shortage is to staff some ambulances with emergency medical technicians (emts) and paramedics. it may be a choice to organize different types of rescue teams similar to those in other countries such as germany and france (10, 11) . the emt/paramedic-based models of prehospital care, as used in the united states, also should be considered (12) . non-urgent patient transport (where staff includes only the driver or a technician and a driver) could be separated from ems. there is a need to improve coordination with other services within and between hospitals, as well as with prehospital services. enhanced coordination would have a variety of benefits for all concerned, including better ems relationships, better handover, better transfers, and enhanced ems personnel skills. it is essential to develop major incident and disaster plans and to promote organization for major emergencies in the various settings. special training courses and frequent drill exercises are also needed to improve the ems capability of coping with disaster. statistical communiqué of the people's republic of china on the 2009 national economic and social development available at: en.wikipedia.org/wiki/ shanghai preliminary epidemiological investigation on the road injury cases of shanghai prehospital care during an epidemiological investigation on the cases of shanghai prehospital care in ems systems in china available at: www.beijing120.com/inf_01_en. asp. accessed analysis of 194 trans-province emergency care cases in shanghai helicopter emergency medical care in shanghai casualties of the wenchuan earthquake wenchuan earthquake has already caused 69,196 fatalities and 18,379 missing ems systems in germany international ems systems: the united states: past, present, and future acknowledgments-this study was supported by the shanghai natural science foundation (grant no. 10zr1437800) and shanghai pujiang program. the grant provider did not play a role in collection, management, analysis, or interpretation of the data about shanghai prehospital emergency medical care, nor in the preparation, review, or approval of the manuscript. all authors had full data access, and take responsibility for data integrity, and accuracy of data analysis. key: cord-010477-g754gjvh authors: carney, kevin p.; crespin, ann; woerly, gray; brethouwer, nicholas; baucum, jeff; distefano, michael c. title: a front-end redesign with implementation of a novel “intake” system to improve patient flow in a pediatric emergency department date: 2020-02-27 journal: pediatr qual saf doi: 10.1097/pq9.0000000000000263 sha: doc_id: 10477 cord_uid: g754gjvh introduction: children’s hospital colorado is an academic, tertiary-care level 1 trauma center with an emergency department (ed) that treats >70,000 patients/year. patient volumes continue to increase, leading to worsening wait times and left-without-being-seen (lwbs) rates. in 2015, the ed’s median door-to-provider time was 49 minutes [interquartile range (iqr) = 26–90], with a 3.2% lwbs rate. ed leadership, staff, and providers aimed to improve patient flow with specific goals to (1) decrease door-to-provider times to a median of <30 minutes and (2) decrease annual lwbs rate to <1%. methods: an inter-professional team utilized quality improvement and lean methodology to study, redesign, and implement significant changes to ed front-end processes. key process elements included (1) new flow nurse/emt roles, (2) elimination of traditional registration and triage processes, (3) immediate “quick registration” and nurse assessment upon walk-in, (4) direct-bedding of patients, and (5) a novel “intake” system staffed by a pediatric emergency medicine physician. results: in the 12 months following full implementation of the new front-end system, the median door-to-provider time decreased 49% to 25 minutes (iqr = 13–50), and the lwbs rate decreased from 3.2% to 1.4% (a 56% relative decrease). additionally, the percentage of patients seen within 30 minutes of arrival increased, overall ed length-of-stay decreased, patient satisfaction improved, and no worsening of the unexpected 72-hour return rate occurred. conclusions: using quality improvement and lean methodology, an inter-professional team decreased door-to-provider times and lwbs rates in a large pediatric ed by redesigning its front-end processes and implementing a novel pediatric emergency medicine-led intake system. patient crowding is a problem facing emergency departments (ed) worldwide. [1] [2] [3] causes of crowding include increased use of eds, patient boarding in the ed, increased patient complexity, and inefficient ed operations. 4 crowding leads to longer wait times to see providers, patient safety concerns, worse outcomes in certain clinical scenarios, and decreased patient satisfaction. 2, 5, 6 there is an increased national focus on this important health topic, with the center for medicare and medicaid services identifying multiple operational metrics as key to evaluating the quality of care provided in an ed. 7 the american academy of pediatrics also recognizes this as a particular problem affecting the care of pediatric patients in the ed and in 2015 published a report outlining best practices for patient flow and care for these patients. 8 a key driver of ed patient flow is its "front-end system," consisting of all the operational steps that occur before a provider sees the patient. strategies employed to improve the front-end processes include the abolishment of traditional nurse-led triage, "split-flow" models that create separate patient streams depending on each individual's particular care needs, direct-bedding of patients, and placing providers in triage. [8] [9] [10] [11] a physician in triage and other models utilizing non-physician providers can decrease door-to-provider times and decrease left-without-being-seen (lwbs) rates. [12] [13] [14] [15] [16] [17] [18] most reports of patient flow improvements come from general eds, where the majority of patients are adults; thus, there are few reports of how similar strategies may impact pediatric-focused eds. 19, 20 children's hospital colorado has seen increased patient volumes and lwbs rates since moving into a new hospital in 2008 (fig. 1 ). in 2016, the ed leaders, staff, and providers wanted to improve patient flow via a large-scale front-end system redesign. the purpose of this report is to share the change process, specific operational changes implemented, and the resulting impact on patient flow in this tertiary-care pediatric ed. the specific smart aims were to redesign the frontend system by january 2017 with a goal to (1) decrease median door-to-provider times from 49 minutes to <30 minutes and (2) decrease annual lwbs rate from 3.2% to <1% by the following year. this study was approved by the institution's organizational research risk and quality improvement panel (orrqirp). the orrqirp was established by agreement between the academic institution's human subject research review board and the study institution in 2011. orrqirp is sanctioned by the institutional review board to review quality improvement (qi) project proposals to determine if they do not meet the criteria for human subjects research. this project took place in the ed of a 395-bed tertiary care, academic freestanding children's hospital. the hospital is a level 1 trauma center with a 48-bed ed that sees over 70,000 patients/year and has a 13% admission rate. ed medical providers include pediatric emergency medicine (pem) physicians, general pediatricians, advance practice providers (apps), pem fellows, residents (pediatric, emergency medicine, and family medicine), and medical students. the ed leadership team met in early 2015 to discuss improving operational flow. with the support of hospital executive leadership, the ed hired a process improvement specialist to help with these efforts. the ed medical director and assistant clinical nurse manager formed an ed operations committee in june 2015 to help lead the initial pdsa cycles and educate staff. starting in june 2016, an expanded inter-professional team including >20 members of ed leadership, physicians, apps, nurses, emts, and registration staff members began meeting to plan further large-scale improvement efforts. the team employed qi and lean methods to study the current system, including process-mapping of the front-end system and subsequent development of a value-stream map. the team determined that of the average 80-minutes patients spent waiting to see a provider, only 10 minutes was spent in-process, of which <3 minutes was considered value-added to the patient (fig. 2) . with a goal of operational changes in place by january 2017, the team decided to hold a 5-day kaizen 21 event to expedite system implementation. the team met in november 2016 for the kaizen and spent the first 3 days using lean methodology 22 to remove redundant and non-value-added steps from the front-end system. steps removed included questions previously placed in the triage process by other qi efforts but not considered critical to the front-end process. important questions such as patient/family safety questions and learning preferences were moved to later portions of the visit. the team developed new front-end processes (described below) and piloted the new system for 8 hours on kaizen day 4. the team observed the process during this initial trial and made changes both in real-time and at the day 5 session. concurrent with the clinical process development, the team engaged with information technology, compliance, facilities, and other hospital services to change crucial components of the electronic health record (ehr) and waiting room physical layout to accommodate the new process. after the 5-day kaizen, the team wanted to test the new front-end system once more before official implementation. the team chose the following monday (historically the highest volume day of the week) to test the system for 18 hours. the team arrived early and provided "just-intime" training for the staff and providers. despite seeing over 260 patients that day (making it 1 of the 10 highest-volume days of 2016), the team observed no significant safety or operational issues. the following day, the team resolved some small outstanding issues, and the new front-end system "went live" the next day on november 16, 2016-9 days after the start of the kaizen. volunteer "system super users" from the kaizen team and ed clinical leaders provided 2 weeks of 24 hours/day on-theground support. project leaders sent staff weekly updates with key metrics for 2 months after implementation. to prepare staff for the anticipated operational changes, the operations committee began educational efforts in the summer of 2015. didactics, open forums, and staff "town halls" allowed for staff to learn the basic theories of ed operations, patient flow, and the importance of front-end processes. in the summer of 2015, the operations committee also worked to develop "flow nurse" and "flow emt" roles. these departmental roles have no direct patient assignments, but rather are responsible for overall department flow. tasks include rooming patients from the waiting room, greeting ambulance arrivals, and facilitating room turnover. these roles are staffed every day from 11 am to 1 am to coincide with maximum patient volumes and were implemented in december 2015. to expedite registration and clinical assessment of walk-in patients, the kaizen team discontinued the original linear steps of patient registration and nurse-led triage processes. instead, the team developed a parallel process that occurs immediately after patient arrival consisting of "quick registration" and initial nurse evaluation (fig. 3) . the process: • walk-in patients are greeted immediately upon arrival by a patient access team member and "sorter nurse" • patient access team member performs "quick registration" while the nurse assesses the patient • "quick registration" consists of: • documenting the patient's name, date-of-birth, gender • obtaining a patient digital photo for the ehr • documenting who brought the patient to the ed (eg, parent, grandparent, etc.) • caregiver signs "consent-to-treat" form • placing identification wristband on the patient • "sorter nurse" assesses the patient and: • identifies critical illness requiring immediate rooming • documents chief complaint; any other key details • assesses patient using pediatric assessment triangle 23 • assigns emergency services index (esi) acuity level • records weight • records medication allergies • "sorts" patient to either "emergent bed," "direct bed" or "intake" status the previous front-end system required multiple linear steps before placing the patient in an ed room (fig. 3) . "direct bedding" means patients are immediately roomed after registration and a brief nursing assessment. in the new system, this process occurs 24 hours/day when beds are available. after rooming, the bedside nurse completes and documents a "secondary assessment," consisting of: the kaizen team developed, piloted, and implemented a new "intake" system, which is open daily from 11 am to 11 pm. intake operates in the 4 previously used triage rooms. the intake team includes a pem physician, scribe, nurse, and emt who work to assess patients rapidly, determine a disposition, and initiate orders (when appropriate). the process: • sorter nurse determines if the patient is appropriate for intake (see above criteria) • emt rooms patient and obtains vital signs • pem physician evaluates patient while a scribe documents in the ehr • pem physician places orders for medications, labs, or radiology studies (if needed) • pem physician determines patient disposition: • discharge from ed • roomed in ed ▪ "supertrack"-a patient expected to discharge home within 1 hour of intake evaluation. these patients usually require a simple clinical reevaluation or laboratory/radiology test. ▪ "main ed"-a patient expected to require >1 hour of further history-taking, work-up, consultations, or treatment. • if a patient is discharged from intake, the intake rn discharges the patient and escorts them to the registration check-out desk • if roomed, the ed "flow rn" monitors ehr for notification of "supertrack" or "main ed" disposition and escorts the patient from intake to room. primary outcome measures consisted of door-to-provider times and lwbs rates. "provider" is defined as a resident, fellow, pediatrician, pem attending, or app. secondary outcome measures included the percentage of patients seen <30 minutes after arrival, overall lengthof-stay (los), and patient satisfaction as measured by standardized hospital-wide post-visit surveys (prc, omaha, neb.). the unanticipated patient returns to the ed within 72 hours (% of total visits) were tracked as a balancing measure. the team extracted operational data from the hospital's ehr, epic systems corporation (verona, wisc.), and summarized the continuous outcomes of door-to-provider times and los with medians and interquartile ranges (iqr). groups were compared using wilcoxon rank-sum tests. χ 2 tests were utilized to compare lwbs percentage, percent of patients seen <30 minutes, and 72-hour return rates. the team created statistical process control charts using minitab statistical software (minitab llc, state college, pa.). we compared the 12-month post-implementation operational metrics to baseline operational data from 2015 (table 1 ). in 2015, the ed had 70,088 patient visits compared with 73,394 visits in the 12-month post-implementation period (a 5% increase). for the primary outcome measures, the post-implementation median door-to-provider time improved to 25 minutes (iqr 13-50), a nearly 50% decrease compared with the 2015 baseline of 49 minutes (iqr 26-90). in addition, the lwbs rate decreased from 3.2% in 2015 to 1.4% in the 12 months post-implementation. an annotated laney p' chart demonstrates lwbs rates and shows an overall decrease in weekly variation in the system compared with the 2015 baseline (fig. 4) . all secondary outcome measures improved in the 12 months post-implementation. the percentage of patients seen <30 minutes rose to 53%, a 77% relative increase compared with the 2015 baseline. figure 5 shows the increasing monthly percentage of patients seen in <30 minutes year-over-year between 2015 and 2017. the median los decreased from 173 to 159 minutes (8% decrease), including improvement for both admitted patients (4.5% decrease) and discharged patients (9% decrease). overall, patient satisfaction increased from 71% who reported the visit as "excellent" in 2015 to 75% in 2017. finally, the 72-hour return rates did not worsen following the implementation of the new system (table 1 ). much of the literature on ed operations has focused on general eds, where adults make up the majority of patients; thus, it is not fully known how previously described front-end principles apply to pediatric eds. 20 to the authors' knowledge, this project is the first to describe the implementation of a front-end system in a pediatric ed utilizing a split-flow model, including direct-bedding and a pem-staffed intake system. this project shows that by utilizing lean methodology, qi principles, and knowledge of ed operational principles, a large pediatric ed can realize similar patient flow improvements to those seen in adult systems. as hoped, the new front-end system drove patient flow by decreasing door-to-provider times, thereby improving los for all patients, and improved functional ed capacity allowing for a decreased lwbs rate. of note, patient flow metrics improved despite a 5% increase in volume compared with the baseline period. one could argue the observed operational improvements are a result of increased staffing rather than process redesign. the original front-end system was inefficient as it included many non-value-added processes leading to frequent patient flow bottlenecks due to queueing theory. merely adding staff to this inefficient system would not have made a meaningful improvement in patient flow. by decreasing the number of front-end steps (namely the discontinuation of nurse-led triage and the implementing direct-bedding), the new system allows for a decreased door-to-provider time by removing non-value-added steps rather than increased staff. the newly developed pem-led intake system is an adjunct to this more efficient system and allows for earlier initiation of care and saves critical ed bed space by facilitating rapid discharge of patients who need no further care. direct-bedding is a strategy frequently found in other front-end redesigns to help reduce door-to-provider times. 9, 24 it is a critical component in the success of our new front-end system but has challenges when the ed is full, and direct-bedding is no longer an option. at these times, we must enact backup processes to bring a nurse or emt from the main ed to the waiting room to obtain vital signs and initiate standing orders. also, in certain situations, patients previously assigned to a direct bed status may be seen in intake by the pem physician when there is no ed capacity. these backup processes ensure patient care continues despite the lack of room availability. patients and families report wait times as a key driver of satisfaction with pediatric ed visits. 25 as expected, with our nearly 50% decrease in door-to-provider times, parent visit satisfaction increased from 71% to 75%. while a notable improvement, opportunities exist for further an improved experience as the ed continues to experience large swings in patient volumes over the day and throughout the year. despite improvement efforts, we continue to experience periods when wait times become excessive, and patients decide to leave-without-being-seen. of note, outliers on the lwbs statistical process control chart (fig. 4) largely coincide with weeks of high patient volume and resulting increased door-to-provider times. expectantly, patient visit satisfaction decreases during these periods. previous studies attempted to calculate the financial impact of crowding and the return-on-investment of various front-end redesigns. [26] [27] [28] [29] due to the hiring of a process improvement specialist, and modest increases in staffing, the estimated incremental cost of our new system is $400,000/year. while a formal financial analysis is yet-to-be performed, the operational improvements are expected to yield positive financial gains. in 2015 nearly 2,300 patients left without a provider evaluation compared with approximately 1,000 in the 12 months following the front-end redesign. the difference of 1,300 is the number of patients who would have been expected to walk out in the previous system but now are seen and incur visit charges. if the ed maintains improved patient flow performance, we expect to realize a positive financial return while also providing a better patient care experience for patients and families. this project has several limitations to consider. first, as a project performed at a single pediatric ed, results may not be translatable to other institutions that have different local barriers to patient throughput. second, we obtained financial support from hospital executive leadership to hire a process improvement specialist as well as make modest staff increases, investments other institutions may not be in a position to make. finally, given our large number of ed providers and staff, we were able to utilize volunteers to have a "system superuser" in the department 24 hours each day for 2 weeks after implementation of the new system. this type of support may not be possible in smaller eds with more limited staff. the next steps include future pdsa cycles to improve backup plans for when the ed is full and direct bedding is not possible. this intervention includes an analysis of the sorting process to ensure safe and accurate assessments to minimize the risk of patients clinically decompensating while in the waiting room. criteria for which patients are appropriate for the intake system will be evaluated and adjusted as necessary to maintain adequate patient flow in the intake system. further analysis of the sub-processes in each patient stream (direct-bedding and intake) will help identify opportunities to improve efficiency and decrease system variation. finally, a formal financial analysis is planned to determine the impact of the system. using qi and lean methodology, an inter-professional team in a large, tertiary-care pediatric ed designed and implemented a novel front-end system and significantly improved patient flow by decreasing door-to-provider times 49% and lwbs rates by over 50%. key concepts included decreasing non-value-added steps in the front-end and implementing a split-flow system utilizing direct-bedding and a pem-led intake system to drive patient flow. the system has led to a meaningful improvement of overall ed los for all patients and improvement of patient satisfaction scores. future work will focus on maintaining these improvements during high-volume times of the day and throughout the year. the authors have no financial interest to declare in relation to the content of this article. the authors would like to thank the staff and providers of the children's hospital colorado emergency department for their unwavering commitment to improving the care they provide their patients and the chco executive leaders for support of the project. international perspectives on emergency department crowding overcrowding crisis in our nation's emergency departments: is our safety net unraveling? effect of inpatient admissions versus emergency department practice intensity improving patient flow and reducing emergency department overcrowding: a guide for hospitals pediatric emergency department overcrowding and impact on patient flow outcomes subcommittee on emergency department overcrowding and children, section of pediatric emergency medicine, american college of emergency physicians. emergency department overcrowding and children associations of emergency department length of stay with publicly reported quality-of-care measures american college of emergency physicians pediatric emergency medicine committee; emergency nurses association pediatric committee. best practices for improving flow and care of pediatric patients in the emergency department optimizing emergency department front-end operations implementation of a front-end split-flow model to promote performance in an urban academic emergency department established and novel initiatives to reduce crowding in emergency departments health care provider in triage to improve outcomes are split flow and provider in triage models in the emergency department effective in reducing discharge length of stay? a long-term analysis of physician triage screening in the emergency department impact of physician screening in the emergency department on patient flow the effectiveness of a provider in triage in the emergency department: a quality improvement initiative to improve patient flow physician in triage improves emergency department patient throughput impact of a triage liaison physician on emergency department overcrowding and throughput: a randomized controlled trial creating a leaner pediatric emergency department: how rapid design and testing of a front-end model led to decreased wait time improving low-acuity patient flow in a pediatric emergency department: a system redesign short-term action in pursuit of long-term improvements: introducing kaizen events application of lean thinking to health care: issues and observations the pediatric assessment triangle: accuracy of its application by nurses in the triage of children immediate bedding and patient satisfaction in a pediatric emergency department a comprehensive view of parental satisfaction with pediatric emergency department visits operational and financial impact of physician screening in the ed emergency department throughput, crowding, and financial outcomes for hospitals cost analysis and provider satisfaction with pediatrician in triage does an ed flow coordinator improve patient throughput? key: cord-313992-ogdqq3dl authors: kortuem, s. o.; frey, p.; becker, d.; ott, h.-j.; schlaudt, h.-p. title: corona-independent excess mortality due to reduced use of emergency medical care in the corona pandemic: a population-based observational study date: 2020-10-28 journal: nan doi: 10.1101/2020.10.27.20220558 sha: doc_id: 313992 cord_uid: ogdqq3dl background. a significant decrease in the number of cases of emergency medical care during the first phase of the corona pandemic has been reported from various regions of the world. due to the lack of or delayed use of medical assistance, particularly in the case of time-critical clinical pictures (myocardial infarction, stroke), a corona collateral damage syndrome is postulated regarding possible health consequences. the present study investigates changes in the use of preclinical and clinical emergency care and effects on overall mortality in a rural area. methods. the number of patients in the emergency department at the klinikum hochrhein and the ambulance service were retrospectively aggregated and analyzed regarding the total number and selected tracer diagnoses and alarm keywords. the investigation period was the 9th to 22nd calendar week 2020 compared to the identical period of the previous year. in addition, the death rates in the district were collected directly from the registries and related to the number of patients in emergency care. results. overall, the number of patients in clinical and preclinical emergency care declined significantly during the investigation period. this concerned in particular emergency inpatient treatment of patients with exacerbations or complications of severe chronic diseases. at the same time, excess mortality occurred in april 2020, which was still highly significant even after excluding deaths on or with covid-19. discussion. only about 55 % of the excess mortality in april 2020 can be attributed to covid-19 and is associated with the decline in inpatient emergency treatment, especially of chronically ill patients. since a drift of patients with the use of other service providers is unlikely, we assume that fears of infection in overburdened hospitals, one-sided public communication and reporting, and the extent of contact restrictions have contributed significantly to the decline in case numbers and to excess mortality (collateral damage). conclusion. for similar situations in the future, it is strongly recommended to make crisis communication and media coverage more balanced so as not to prevent people with acute health problems from receiving medical assistance. contact restrictions should be critically reviewed and limited to the objectively necessary minimum. with the increasing spread of sars-cov-2 from january 2020 and in view of the dynamics of infection in other countries [1] , a considerable burden on the health care system had to be expected in germany as well. the main aim of the measures taken by policy-makers was to prevent overburdening, particularly of clinical care structures, by slowing down the spread of infection and to protect the most vulnerable groups. in this context, it was repeatedly and clearly communicated both in professional circles and to the public that less urgent treatments should be postponed and that the emergency medical structures should not be burdened with minor cases [2, 3] . the feared storm did not occur. on the contrary, the absence of patients with time-critical illnesses in emergency departments was already the subject of public discussion in early april 2020 [4] . in the meantime, publications from various regions of the world are available on this subject. the authors report decreases in the number of cases in emergency departments of between 22 % and 41.9 % [5] [6] [7] [8] [9] [10] . with regard to particularly time-critical diagnoses, a decrease in admissions due to myocardial ischemia (stemi/nstemi) of between 20 % and 50 % is reported [5, 9, [11] [12] [13] [14] [15] [16] [17] [18] [19] , due to acute cerebral ischemia of between 38 % and 60 % [5, 6, 9, 20, 21] . other studies also show a delayed presentation of patients with time-critical clinical pictures, resulting in an increased complication rate and/or poorer treatment options (e.g. revascularization) [17, [22] [23] [24] [25] [26] . there is evidence that patients with decompensation of a chronic condition (copd, heart failure) also visited emergency departments less often or later [5, 9] . in the field of preclinical emergency care, a decline in the number of cases was also observed in some cases, although less pronounced than in hospitals [8] and not primarily in the particularly time-critical diagnoses of myocardial infarction and stroke [27] . however, a significantly higher incidence of preclinical cardiac arrest in the early pandemic phase is reported from lombardy and paris. the high proportion of unobserved events without beginning bystander resuscitation and with poor outcome was striking [28, 29] . with regard to the health consequences of these developments for patients, the term "corona collateral damage syndrome" was coined [30] and frequently postulated in published studies. however, to the authors' knowledge there is no direct link between the changed use of emergency medical care systems and population-related mortality. this paper investigates changes in the use of clinical and pre-clinical structures of emergency medical care as well as effects on overall mortality in a rural supply area during the first phase of the corona pandemic (9th to 22nd calendar week 2020). the district of waldshut, germany, has about 170000 inhabitants. there are no significant differences between the period under investigation and the reference period in terms of population and age structure. emergency care is provided by a single hospital and the rescue service, which is dispatched from a single central control center. the data evaluated in the following is a complete survey for the district. the patient data of the emergency department at the hochrhein clinic and of the ambulance service were analyzed retrospectively, completely anonymized and aggregated. the data were collected for the 9th to 22nd calendar week 2020 (24 february to 31 may 2020) and compared with the identical calendar weeks of the previous year (25 february to 02 june 2019). when collecting the data of the emergency department, in addition to the total number of cases, the specialty (traumatological, non-traumatological), the case type (outpatient, inpatient) and the main diagnosis of the treatment case according to icd-10 were recorded. is the author/funder, who has granted medrxiv a license to display the preprint in (which was not certified by peer review) preprint the copyright holder for this this version posted october 28, 2020. ; https://doi.org/10.1101/2020. 10.27.20220558 doi: medrxiv preprint as tracer diagnoses, myocardial and cerebral ischemia, copd, heart failure, tumor diseases, sepsis, gastroenteritis and psychological and behavioral disorders caused by alcohol were considered separately. the selection of diagnoses represents acute emergency situations with high urgency, exacerbations and complications of chronic diseases, clinical pictures of potentially infectious genesis, less serious presentations and psychosocial acute situations. from the information system of the integrated control center waldshut, the total number of operations, the alarm keyword assigned by the control center, the involvement of an emergency doctor and operations with or without transport to a hospital were recorded for the identical periods. the alarm causes cardiovascular, respiratory, neurological, alcohol, resuscitation and presumed death were evaluated separately as tracers. all data were aggregated to the respective calendar week and, after testing for normal distribution (anderson-darling, shapiro-wilk), were checked for statistical significance using the t-test for 2 dependent samples and the chi-square test. deviations from the same period of the previous year were shown as percentage differences for the individual parameters. a probability of error p < 0.05 was assumed to be significant. the monthly death figures in the district of waldshut for the years 2016 to 2020 were collected directly from the registry offices of the towns and communities belonging to the district. in accordance with the methodology of the federal statistical office [31] , the number of deaths in 2020 was compared with the average of the corresponding month in the four previous years and changes were recorded as percentage deviations. in addition, in the event of increased mortality, the z score was determined according to the euromomo system and the excess mortality was classified accordingly [32]. due to an inhomogeneity in the course of the study period, especially in the mortality figures, the data from april 2019 and april 2020 were also analyzed comparatively. the patient numbers in the emergency department in the 9th to 22nd calendar week 2020 were a total of 34.9% lower than in the same period of the previous year (4251 vs. 6465, p < 0.001). the decline in patient contacts was already evident in the 9th calendar week (figure 1 ). . cc-by-nc-nd 4.0 international license it is made available under a perpetuity. is the author/funder, who has granted medrxiv a license to display the preprint in (which was not certified by peer review) preprint the copyright holder for this this version posted october 28, 2020. ; https://doi.org/10.1101/2020. 10.27.20220558 doi: medrxiv preprint from the 12th calendar week onwards, in the temporal context of the first confirmed covid-19 cases in the district, there was a further drastic drop in patient numbers, which reached its maximum in the 17th calendar week with -46.9% compared to the same period of the previous year. from the 18th calendar week, a slow recovery began, but by the end of the investigation period the previous year's level had not been reached again. the number of outpatient contacts in the emergency department was 39.4 % below the previous year's level in the study period (2556 vs. 4217, p < 0.001) with a maximum of -54.6 % in the 13th calendar week, coinciding in time with the entry into force of the 2nd corona regulation in baden-württemberg. in the period under review, a total of 24.6% fewer inpatient emergency patients were admitted to hospital (1695 vs. 2248, p < 0.001), with a maximum decrease of 37.7% in the 14th calendar week (figure 2 ). here, a clear recovery effect was evident from the 18th calendar week onwards. at the end of the investigation period, the decline was still 9.6%. in the year-on-year comparison, 39.1% fewer patients (1725 vs. 2834, p < 0.001) were treated with traumatological diagnoses in the emergency department (figure 3 ), while the decline in nontraumatological diagnoses was 30.4% (2526 vs. 3631, p < 0.001). . cc-by-nc-nd 4.0 international license it is made available under a perpetuity. is the author/funder, who has granted medrxiv a license to display the preprint in (which was not certified by peer review) preprint the copyright holder for this this version posted october 28, 2020. ; https://doi.org/10.1101/2020. 10.27.20220558 doi: medrxiv preprint the difference between these groups of patients is particularly evident in the 9th and 10th and in the 13th and 14th calendar week. the case numbers for the admission causes myocardial ischemia (-13.9%), cerebral ischemia (+8.2%) and alcohol (-12.7%) did not change significantly in the study period compared to the previous year ( figure 4 ). in contrast, the decrease in the number of cases for exacerbations and complications of chronic disease patterns was highly significant (copd -51.8%, p < 0.01; heart failure -48.5%, p < 0.001; tumor diseases -49.4%, p < 0.01). the number of presentations with gastroenteritic symptoms as a tracer for mild and less urgent diseases decreased by 54.3% (p < 0.001). a septic clinical picture was recorded 65.6% less frequently as an admission diagnosis (p < 0.001). in the period under review, the number of operations of the ambulance service declined significantly compared to the previous year, although less markedly than in the emergency department (5064 vs. 5742, -11.8 %, p < 0.001). the development of case numbers in the ambulance service and the emergency department was not synchronous (figure 1 ). in particular, the average frequency of rescue operations in the 13th to 16th calendar week remained virtually unchanged compared to the previous year, while a significant decline of 24.9% was recorded from the 17th calendar week onwards. the proportion of emergency doctor interventions was almost identical in both years (+0.34%, n.s.). however, the share of operations without transport to a hospital had risen significantly in 2020 (+11.7 %, p < 0.001). the analysis of the alarm keywords assigned by the control center showed no significant changes compared to the previous year for the cardiovascular, resuscitation and alcohol events ( figure 5 ). the key words neurology (-19.0%, p < 0.05) and respiration (-24.7%, p < 0.01) declined during the period under review. noticeable was a significant increase in the alarm keyword "presumed death" (+105 %, p < 0.05). this keyword is assigned if, when a lifeless person is found, there are clear indications that the person has been lying there for a longer period of time or that there are certain signs of death. the increase in the number of primary deaths recorded by the ambulance services correlated significantly with the decrease in the number of inpatient emergency admissions (r: -0.68, p <0.01). is the author/funder, who has granted medrxiv a license to display the preprint in (which was not certified by peer review) preprint the copyright holder for this this version posted october 28, 2020. after adjusting the figures for confirmed covid-19 associated deaths (n=34), 193 deaths remain in the district in april 2020 ( figure 6 ). this corresponds to an excess mortality rate of 16.8% and a z-score of 4.78 (moderate excess mortality). for the months of march and may 2020, no excess mortality compared to the average of previous years could be determined (z-score < 1). due to the excess mortality calculated for the month of april, which to a considerable extent is not directly related to a disease caused by an infection with sars-cov-2, individual key indicators from clinical and preclinical emergency care were additionally considered separately for this period ( figure 7) . is the author/funder, who has granted medrxiv a license to display the preprint in (which was not certified by peer review) preprint the copyright holder for this this version posted october 28, 2020. ; https://doi.org/10.1101/2020. 10.27.20220558 doi: medrxiv preprint in april 2020, the number of patient contacts in the emergency department (-43.1 %, p < 0.001) and the number of inpatient emergency admissions (-33.3 %, p < 0.001) were still significantly below the average for the entire period under review. in parallel with the increase in mortality, inpatient admissions due to exacerbations or complications of chronic diseases even decreased by 73.3% compared to april 2019. the frequency of use of the ambulance service as a whole and with the indication resuscitation showed no significant change in april 2020. in the period under review, the structures for clinical and preclinical emergency care were used significantly less frequently than in the same period of the previous year. the decline in the number of cases in the emergency department was much more pronounced than in the ambulance service, was observed earlier and -in agreement with the reports of other authors [20] -cannot be explained solely by the regional incidence of covid-19 and its perception in the population. we assume that the developments observed, particularly at the beginning and towards the end of the period under review, were significantly influenced by media reporting, official crisis communication and the imposed contact restrictions ("lockdown"). for example, a public request by the regional government in the 9th calendar week to keep the emergency departments free for "serious cases" coincided with a first significant decrease in case numbers, without a single covid-19 case being confirmed in the region at that time. the disproportionate decline in the number of outpatient presentations and cases of low severity and urgency (e.g. gastroenteritis) seems plausible in this context, especially since common motives for direct presentation in the emergency department [33] may have receded into the background compared to fears of infection in the hospital or assumed insufficient treatment capacities. it can be assumed that patients from this group have sought alternative access to health care or postponed treatments without playing a significant role in proven excess mortality. the number of emergency contacts associated with alcohol consumption as an indicator of psychosocial problems did not change significantly during the period under review. the observed significant decrease in septic diseases follows a nationwide trend and is explained by the ministry of health as positive effects of general hygiene measures during the pandemic [34] . is the author/funder, who has granted medrxiv a license to display the preprint in (which was not certified by peer review) preprint the copyright holder for this this version posted october 28, 2020. ; https://doi.org/10.1101/2020. 10.27.20220558 doi: medrxiv preprint we cannot confirm a decline in the number of cases described elsewhere for the particularly timecritical admission diagnoses or a delayed presentation in the clinic for our supply area. neither for myocardial nor for cerebral ischemia were there significant differences compared to the same period of the previous year, the number of revascularizing therapies performed even increased slightly (not significant). the decrease in inpatient emergency admissions with a maximum from the 13th calendar week, i.e. immediately after the entry into force of extended contact restrictions, is primarily due to a decrease in patients with complications or exacerbations of chronic diseases. at the same time there has been a significant increase in the number of deaths in our supply area, only about 55% of which can be attributed to deaths on or with covid-19. in connection with excess mortality during the first phase of the coronary pandemic, other authors discuss the possibility of undetected covid-19 cases due to lack of testing capacity or incorrect assignment of symptoms to other diseases [35] . we consider this explanatory model to be unlikely because of the existing framework conditions here, with a high level of sensitivity among the population and doctors in private practice, and sufficient testing capacities at all times. due to a lack of knowledge of the actual causes of death of the deceased, a complete proof of causality will not be possible. nevertheless, the results suggest that, in our supply area, secondary pandemic mortality (collateral damage) with a quantifiable excess mortality rate of more than 16% compared to the average of previous years has occurred in connection with reduced use of emergency medical structures. this primarily affected people with serious chronic diseases. this development during the first phase of the pandemic can be due to several factors. it can be assumed that avoidance behavior for fear of infection with sars-cov-2 within potentially overburdened health care facilities has played a role. public perception was clearly influenced by images of overflowing hospitals and intensive care units in other european countries. in addition, there were reports of outbreaks with sometimes fatal consequences in hospitals, also within germany, as well as repeated public calls by political leaders for restraint in using the health care system in order to save resources for the expected high inflow of patients. the significantly increased share of rescue service interventions without subsequent transport to a hospital (transport refusal) compared to the previous year also speaks for an active avoidance behavior of patients. we assume that the contact restrictions imposed, and the required social distancing have also contributed to the development of collateral damage. particularly in the case of older people with chronic pre-existing conditions, who should be particularly protected by the measures taken, it is the relatives as a supporting network who often trigger the use of acute medical care as catalysts. social distancing may have led to increased isolation and fewer visits from relatives, especially in the group of risk patients. this assumption is supported by the highly significant increase in primary deaths in our ambulance services and by results from other regions [28, 29] . in the end, it can be stated that all public communication and reporting was focused exclusively on the topic of covid-19. other health issues relevant to population medicine have completely faded into the background during the first phase of the pandemic, apparently also in the consciousness and perception of our patients. in future comparable situations, communication should focus more on encouraging vulnerable and chronically ill people to seek medical assistance if their health deteriorates. is the author/funder, who has granted medrxiv a license to display the preprint in (which was not certified by peer review) preprint the copyright holder for this this version posted october 28, 2020. ; https://doi.org/10.1101/2020. 10.27.20220558 doi: medrxiv preprint the present study is a retrospective monocentric analysis of aggregated data obtained from various it systems. in particular, it must be considered that the treatment diagnoses coded in the emergency department and the alarm keywords assigned by the integrated control center are not congruent even in their systematics and therefore a direct comparison is not possible. however, due to the structure of our supply area (one local authority with one integrated control center and one acute hospital providing sole care), the study is a complete survey for the period under review, which also allows appropriate conclusions to be drawn due to the strength of the effects observed. migration or shifts in acute medical care to other service providers cannot be ruled out with absolute certainty but appear very unlikely due to the care structure and physical distances to alternative treatment facilities. likewise, it cannot be excluded that regionally significant developments and events have influenced the results and limit an uncritical transfer to other supply areas. a causality between the reduced use of acute medical care by chronically ill patients and the excess mortality in april 2020 established independently of covid-19 seems very plausible but cannot be proven with absolute certainty from the available data. the same applies to the individual reasons for reduced use, where further research should follow. the reduced use of acute and emergency medical care systems observed during the first phase of the corona pandemic particularly affects people with severe chronic pre-existing conditions and is associated with significant excess mortality without an infection with sars-cov-2. a one-sided focus of public communication and reporting and extensive contact restrictions have most likely contributed to the quantifiable secondary pandemic mortality (collateral damage). for similar situations in the future, it is strongly recommended that crisis communication and media coverage be more balanced so as not to discourage people with acute health problems from seeking necessary medical assistance. contact restrictions, especially in the private sphere, should be critically examined and limited to the objectively necessary minimum. no studies on humans or animals were conducted by the authors for this paper. the quoted studies are subject to the respective ethical guidelines covid-19 in europe: the italian lesson to control the covid-19 outbreak, young, healthy patients should avoid the emergency department jeder sollte sich fragen: muss ich wirklich in die klinik? weniger notfallpatienten in krankenhäusern admissions to veterans affairs hospitals for emergency conditions during the covid-19 pandemic collateral damage -impact of a pandemic on stroke emergency services collateral damage of the covid-19 outbreak: expression of concern notaufnahme während der coronapandemie: weniger non-covid-19-notfälle medical emergencies during the covid-19 pandemic -an analysis of emergency department data in germany impact of covid-19 pandemic on emergency department services acuity and possible collateral damage collateral damage: the cardiovascular cost of suppressing covid-19 transmission in australia acute myocardial infarction admissions in berlin during the covid-19 pandemic reduced rate of hospital admissions for acs during covid-19 outbreak in northern italy reduction in st-segment elevation cardiac catheterization laboratory activations in the united states during covid-19 pandemic collateral damage of covid-19-lockdown in germany: decline of nste-acs admissions decline of acute coronary syndrome admissions in austria since the outbreak of covid-19: the pandemic response causes cardiac collateral damage admission of patients with stemi since the outbreak of the covid-19 pandemic. a survey by the european society of cardiology population trends in rates of percutaneous coronary revascularization for acute coronary syndromes associated with the covid-19 outbreak the covid-19 pandemic and the incidence of acute myocardial infarction collateral effect of covid-19 on stroke evaluation in the united states falling stroke rates during covid-19 pandemic at a comprehensive stroke center collateral damage: medical care avoidance behavior among patients with myocardial infarction during the covid-19 pandemic collateral damage of a global pandemic: implications of covid-19 for australians with cardiovascular disease collateral damage of covid-19 pandemic: delayed medical care collateral damage: the impact of the covid-19 pandemic on acute abdominal emergency presentations impact of the covid-19 outbreak on acute stroke pathways -insights from the alsace region in france emergency ambulance services for heart attack and stroke during uk's covid-19 lockdown out-of-hospital cardiac arrest during the covid-19 outbreak in italy a population-based, observational study. the lancet public health first do no harm with covid-19: corona collateral damage syndrome statistisches bundesamt (2020) sterbefallzahlen im april 2020 8 % über dem durchschnitt der vorjahre. pressemitteilung nr. 194 vom 29. mai 2020 patient motives behind low-acuity visits to the emergency department in germany: a qualitative study comparing urban and rural sites coronapandemie: elf prozent weniger herzinfarkte excess deaths from covid-19 and other causes key: cord-317588-yxu8m55m authors: calvello hynes, emilie j.; bills, corey b. title: emergency care systems: the missing link for effective treatment of covid-19 in africa date: 2020-07-14 journal: disaster medicine and public health preparedness doi: 10.1017/dmp.2020.239 sha: doc_id: 317588 cord_uid: yxu8m55m cases of covid-19 are rising quickly on the african continent. a critical element of any health system response to such a surge of active cases is the existence of functional emergency care systems. yet, these systems are markedly underdeveloped in african countries. this short letter reviews the key role emergency medicine plays in epidemic disease response and actions that ministries of health can take now to shore up gaps in emergency care capacity to avoid needless death and suffering of covid-19 patients. t he rising spread of severe acute respiratory syndrome coronavirus 2 (sars-cov-2) on the african continent is gravely concerning. in recent weeks, there has been a large rise in documented coronavirus disease (covid-19) cases, with over 1 million current cases and 23 000 deaths. 1 the united nations estimates the disease will cause at least 300 000 deaths in africa and shift another 30 million people into poverty. 2 during the current pandemic, emergency departments have been highlighted as mission critical locations to screen for syndromic disease, isolate and protect patients and health care workers, triage, and provide immediate care for emergency conditions associated with covid-19, such as respiratory failure and shock. while emergency care systems are necessary for a successful health sector response, they remain inadequately supported in low-and middle-income countries. a review of 59 countries highlighted the major limitations of emergency care delivery: markedly higher mortality rates than high-income countries and inadequate training across all cadres of health care providers. 3 during epidemics, weak emergency care systems can become overwhelmed by increased demand or directly compromised by the impact of the outbreak. when service delivery is undermined, both direct disease mortality and preventable mortality from everyday emergency conditions can increase dramatically. this is especially true of emergent health conditions that rely on skilled health personnel, medicine, and equipment for treatment. during the 2014 ebola outbreak, strains on the overall health system led to excess mortality from non-ebola-related conditions, including malaria and emergency obstetric conditions. 4 targeted capacity augmentation for emergency departments is necessary now to avoid excess mortality from the expected surge in covid-19 cases in africa. table 1 recommends targeted interventions, based on guidance provided in the 2019 world health assembly resolution 72.16, "emergency care systems for universal health coverage: ensuring timely care for the acutely ill and injured," that can have far reaching implications for health outcomes. 5 as africa braces for a possible explosion of covid-19 cases in the coming months, excess mortality is not letter to the editor coronavirus: africa could be next epicentre, who warns emergency care in 59 low and middle income countries: a systematic review counting indirect crisis-related deaths in the context of a low-resilience health system: the case of maternal and neonatal health during the ebola epidemic in sierra leone emergency care systems for universal health coverage: ensuring timely care for the acutely ill and injured the authors have no conflicts of interest to declare. key: cord-020342-u8jzmloq authors: nan title: index to volume 42, january–june 2003() date: 2003-11-20 journal: ann emerg med doi: 10.1016/s0196-0644(03)01106-5 sha: doc_id: 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blood lead levels associated with the consumption of moonshine among emergency department patients in detecting a subarachnoid hemorrhage by measuring cerebrospinal fluid bilirubin in patients with normal computed tomography scans indications for brain hypothermic therapy in cardiac arrest patients emergency physician compliance with annual purified protein derivative testing morrison l (see bandiera et al) mower w (see bracken et al) mower w (see medzon et al) muelleman rl (see wadman et al) ac (see sullivan et al) alternative for automated communication in research neumar rw (see pollack et al) when is a patient safe for discharge after procedural sedation? the timing of adverse effect events in 1,367 pediatric procedural sedations charted records of emergency department dizzy patients suggest overemphasis on symptom quality may be associated with diagnostic errors buffering lidocaine increases the duration of absolute anesthesia effect of acetaminophen and ibuprofen on stool volume in febrile diarrhea effect of chloroethane spray in the treatment of spastic torticollis in children and adolescents nicely jd (see mcninch et al) acetaminophen is effective in treating moderateto-severe post-oral surgery pain the relation of patient transfers to insurance status c (see bulloch et al) novobilski aj (see fesmire and novobilski) do pediatric disaster patients have special needs? descriptive analysis of disaster medical assistance team deployments nufer ke (see sattari and nufer) nypaver mm (see gregor et al) re (see megargel et al) fying children at low risk for brain injuries after blunt head trauma national study of pneumococcal and influenza vaccinations among adult emergency department patients palmisciano l (see wittels et al) incidental findings in a level i trauma population a prospective analysis of airway management by emergency medicine residents in the aeromedical setting pang ps (see thomas et al) troponin i as diagnostic and prognostic marker of severe heart failure in heart failure care unit failure of progesterone as a predictor of ectopic pregnancy in patients with quantitative -human chorionic gonadotropin values below the ultrasonographic discriminatory threshold of 2,000 miu/ml parramore cs (see morgan et al) prevalence of pathologic emergency ultrasonographic scans over three years at an emergency medicine residency program early initiation of intravenous vasoactive therapy improves heart failure outcomes: an analysis from the adhere registry database characteristics of chronic dialysis patients treated with nesiritide (b-type natriuretic peptide): data from the acute decompensated heart failure national registry bioimpedance monitoring changes therapy in dyspneic emergency department patients: the impact trial peacock wf (see pollack et al) offerman sr (see schneir et al) ogunji o (see miller et al) olamigoke oc (see haltiwanger et al) laughlin d (see hick et al) s38 (research forum abst olson lm (see knight et al) bj (see bastani et al) bj (see pollack et al) cardiac arrest and resuscitation epidemiology in singapore (care i study) spontaneous pneumothorax outcome study (spot phase i): a two-year review ong s (see karras et al) orellana f (see radeos et al) hematuria in renal colic hospital emergency preparedness assessment using the hospital emergency analysis tool overhage jm (see finnell et al) pearlman m (see probst et al) peery d (see armada et al) pekow p (see fordyce et al) a modified approach to supraclavicular subclavian vein catheter placement: the pocket approach the basic and advanced disaster life support courses pequeno r (see salen et al) paco 2 -etco 2 gradient for critically ill patients in very early management early hemodynamic measurement in severe trauma patients using transesophageal echo doppler: a step forward perera t (see lowenstein et al) potential usefulness of ddimers in the diagnostic evaluation of aortic dissection out-of-hospital indiscriminate use of naloxone: a continuing tale using heat index as a predictor of the number of patients that will require care at a mass gathering event perron ad (see kurz et al) perron ad (see pines et al) petri rw (see richman et al) petruschke ra (see chang et al) physician extenders and lower acuity tracks in the emergency department pretest probability estimates: a pothoven k (see irvin et al) pribble cg (see bassett et al) pribble cg (see guenther et al) application of topical local anesthetic at triage reduced treatment time for children with lacerations: a randomized controlled trial emergency department sickle cell treatment guidelines caveat emptor: the positive d-dimer slippery slope pursell kj (see trzeciak et al) short-term followup of adults presenting to the emergency department with undifferentiated abdominal pain: predictive value of history and physical examination rainer th (see cameron et al) does the use of bedside ultrasonography decrease the time needed to emergency medicine residents to remove soft tissue foreign bodies? child passenger deaths and drinking drivers: the role of repeat offenders rassmussen m (see junkins et al) rathlev nk (see bittner et al) rathlev n (see bracken et al) rathlev n (see medzon et al) the clinical utility of evidence-based medicine organophosphate poisonings in hungary the treatment of pain in acute extremity injury: are we treating the radiograph or the patient? does video-assisted instruction help the novice intubator? pines jm (see haltiwanger et al) pines j (see plautz et al) piper d (see trzeciak et al) pitetti rd (see newman et al) the effect of perceived malpractice risk on diagnostic test ordering in academic emergency medicine practice plint a (see bulloch et al) plummer d (see miner et al) in patients with unstable angina and non-st-elevation myocardial infarction, off-hours presentation is associated with less urgent interventional treatment but similar outcomes identifying patients at risk for deep venous thrombosis in the emergency department: data from the deep venous thrombosis free registry status report: development of emergency medicine research since the macy report the lack of science behind the standard of care use of ischemia-modified albumin in emergency department risk stratification of chest pain is both clinically effective and cost-effective osteopathic physicians in emergency medicine porcher r (see taboulet et al) porto sm (see dribben et al) physicians' conformity with the advanced cardiac life support protocols you are commanded to appear": the subpoena and the emergency medicine resident rentz ac (see zebrack et al) change in patient management with the use of a portable ultrasonography device in a remote setting coronary no-flow and ventricular tachycardia associated with habitual marijuana use rhee sh (see ginde et al) rhodes kv (see asplin et al) rice p (see hutson et al) public access naloxone: preliminary results of a public health initiative mathematical model of the hypoventilating patient: implications for the emergency department rich jd (see merchant et al) clinical characteristics of emergency department patients who rule in versus rule out for pulmonary embolism by computed tomography chest angiography and indirect lower extremity computed tomography venography richman pb (see fiesseler et al) ridella sa (see sochor et al) rothenberger s (see pines et al) use of expired antidotes rumoro dp (see silva et al) does the wbc count predict which febrile children from 90 days to 36 months of age will have a positive urine culture? are pediatric computed tomography scanners now drug-free zones? sadarangani sp (see tiah et al) does resident-selected patient follow-up lead to improvements in patient care? evaluation of the educational utility of patient follow-up sadosty at (see arendt et al) safi c (see lowenstein et al) sala x (see coll-vinent et al) a three-year study of mortality in a university emergency department is screening for myocardial infarction improved by the addition of the combination of creatine kinase and creatine kinase index to the second generation troponin i? what is the impact of child-specific motor vehicle restraints on pediatric morbidity and mortality from motor vehicle crashes in pennsylvania from 1992 to does the presence or absence of sonographically identified cardiac activity predict resuscitation outcomes of pulseless patients? riesz l (see chathampally et al) riffenburgh rh (see park et al) ritter g (see fordyce et al) sexually transmitted disease prevalence in patients presenting for initial evaluation after sexual assault riviello rj (see davis-moon et al) riviello rj (see kurz et al) mannitol for acute traumatic brain injury (cochrane review) roe mt (see pollack et al) mobile hyperbaric chamber: an essential need in emergency medicine? roit z (see schwaner et al) optic sheath nerve diameter in normal human patients in the supine, trendelenburg, and reverse trendelenburg positions romano a (see manfredini et al) roppolo l (see idris and roppolo) recidivism in an emergency department observation unit population sexual assault in postmenopausal women: epidemiology and severity of anogenital injury awareness of coronary artery disease risk factors and homocysteine treatment in high-risk patients does the accuracy of potential cardiac histories depend on question type? sama ae (see hirsh et al) sama ae (see schwaner et al) is there a sixth sense for detecting patients with acute coronary syndrome before treating them? unscheduled returns to a chest pain unit: what did we do wrong? no coronary patients attending chest pain units: should we do other than just discharge them? sánchez m (see coll-vinent et al) sanou bt (see van alem et al) utility of emergency department cervical magnetic resonance imaging in evaluation of cervical spine injury saver jl (see eckstein et al) schafermeyer rw (see pollack et al) schauer ba (see palchak et al) barriers to donation after cardiac death: a national focus group study of health care professionals scheatzle md (see caterino and scheatzle) can we rely on synovial fluid white blood cell count to rule out infectious arthritis? shah mb (see nufer et al) continuity of antibiotic therapy in patients admitted from the emergency department shah sp (see schreck et al) what are the barriers to the use of outpatient enoxaparin therapy in deep venous thrombosis? s28 (research forum abst sharer r (see trzeciak et al) serum cortisol but not macrophage migration inhibitory factor levels increase at altitude in response to acute mountain sickness shembekar ad (see haydel and shembekar) the utility of blood cultures in the emergency department optimal method to achieve a warm water bath for a frostbitten extremity shih rd (see beauboeuf et al) shih rd (see hochman et al) shingles j (see salen et al) shofer fs (see sparano et al) shofer fs (see takakuwa et al) shope jt (see gregor et al) external thrombosed hemorrhoids: surgical treatment by traction, excision, and suture in the emergency department onychocryptosis: surgical treatment in the emergency department predictors of self-reported use of motor vehi schillinger m (see vlcek et al) the tuskegee syphilis study and informed consent emergency department overcrowding: a point in time complications of diagnostic physostigmine administration to emergency department patients a real-time cardiac marker for acute infarction: eigenvalues of the measured and derived ecg mathematical modeling of the electroencephalogram lack of emergency physician adherence to published american college of cardiology/american heart association guidelines for medical treatment of acute coronary syndromes schull m (see bandiera et al) a comparison of traditional cricothyrotomy and a single incision cricothyrotomy method using a deer neck model schwartzapfel bl (see merchant et al) out-ofhospital emergency response to terrorism training: cognitive results of a simulation-enhanced curriculum misdiagnosis of stroke in tissue plasminogen activator-treated patients: characteristics and outcomes seaberg dc (see cutro et al) seem d (see schears et al) sege r (see hayes and sege) delivery temperature of warmed saline or blood at variable flow rates cles with air bags among motor vehicle crash patients role of air bags in preventing motor vehicle crash-related serious injuries: perceptions among emergency department patients shurtz e (see pines et al) sierzega gm (see bazuro et al) emergency ultrasonography fellowships: a review of format, fellowship requirements, and goals silbergleit r (see scott and silbergleit) silka pa (see aazami et al) sill b (see holsti et al) incidence of asthma in emergency departments: impact of a heat wave incidence of emesis in pediatric patients receiving oral prelone: can we predict those at risk for emesis? silverman me (see felegi et al) age-related seasonal patterns of emergency department visits for acute asthma in an urban environment appropriation of simple radiography interpretation by an emergency medicine resident s88 (research forum abst an educational intervention to reduce oligoanalgesia in the emergency department first aid knowledge among parents singer aj (see gulla et al) singer aj (see niegelberg et al) sex differences in asthma precipitants in african americans and hispanic americans in an urban emergency department toxicologic screening in trauma patients singh r (see pentheroudakis et al) sise m (see paluska et al) sites fd (see sparano et al) sites fd (see takakuwa et al) sivak s (see chumsri et al) skiendzielewski j (see stead et al) tance rates: participation in emergency medicine clinical research enhances chances of getting into medical school data collection in the emergency department: shared versus split responsibility for patient enrollment sparto pj (see krell et al) spiller d (see nibhanipudi and spiller) -hydroxybutyrate serum levels and clinical syndrome after severe overdose agreement of canadian triage and acuity scale with stake ce (see martens et al) stark mj (see singer et al) needs assessment of the academic emergency medicine community antiplatelet agents for acute ischemic stroke correlation of emergency department diastolic blood pressure and mortality in acute ischemic stroke corticosteroid treatment for acute ischemic stroke stead lg (see eberlein et al) stead lg (see jacobson et al) stead lg (see sadosty et al) sterner a (see tarsi et al) sterner l (see tarsi et al) sklar dp (see hoerneman et al) s74 (research forum abst intubation confirmation techniques associated with unrecognized nontracheal intubations by out-of-hospital providers smithline ha (see fordyce et al) smit p dev (see cameron et al) smulian ag (see jauch et al) outpatient antibiotic therapy: are emergency physicians aware of the cost of commonly used antibiotics? simulation of atlanto-occipital injury using a mathematical dynamic model concepts) sokolosky m (see mahler et al) emergency department crowding: consensus development of potential measures concepts) song hg (see han et al) injury characteristics by type of vehicle and restraint: are light trucks safe? sorondo b (see chumsri et al) sorondo b (see deitch et al) sorondo b (see kelly and sorondo) sorondo b (see williams et al) out-of-hospital rapid sequence intubation: are we helping or hurting our patients? spaite dw (see de maio et al) effect of academic associate program on medical school accep tracheal rupture and the creation of a false passage after emergency intubation s98 (research forum abst stickney re (see atkinson et al) stiell ig (see bandiera et al) stiell ig (see de maio et al) necrotizing fasciitis in a large urban hospital immunization against streptococcus pneumoniae in the emergency department: is there a need? storrow ab (see schrock et al) streger mr (see barishansky and streger) stremski es (see yen et al) the urine dipstick cannot reliably exclude renal insufficiency in unselected emergency department patients analysis of child traffic injuries and means for prevention and safety within a safe community program high-dose insulin induces wortmannin-sensitive phosphorylation of akt in vulnerable neurons after transient global brain ischemia suman f (see antro et al) summers rl (see peacock et al) summers r (see pollack et al) summers rw (see pollack et al) comparison of etomidate and midazolam for rapid sequence intubation in the air medical setting swanson er (see fosnocht et al) ughi g (see manfredini et al) ullman ea (see kurz et al) urbino r (see antro et al) informed consent process in an inner-city community hospital uzbielo a (see jang et al) rospective review from a public, urban hospital emergency department current susceptibilities of bacteria isolated from lower respiratory tract and central nervous system infections a novel approach to morbidity and mortality review: high fidelity simulation reenactment of life-threatening emergencies vretta c (see irvin et al) vukov lf (see eberlein et al) the pyramid of injury: using ecodes to accurately describe the burden of injury wadwa a (see milzman et al) waeckerle jf (see darling et al) wakai a (see roberts et al) observation of medical students during a fourth-year emergency medicine clerkship wali go (see fesmire et al) walker c (see atkinson et al) warden cr (see gausche-hill et al) a different approach to safety in emergency medicine weaver al (see arendt et al) weaver al (see sadosty et al) vaca fe (see kwon et al) valentine c (see davis et al) interruption of cardiopulmonary resuscitation with the use of the automated external defibrillator in out-of-hospital cardiac arrest vance cw (see palchak et al) vandemheen kl (see bandiera et al) vanderburg kc (see nick et al) van order p (see rossman et al) van patot mt (see sheets et al) van wie d (see chasm et al) velez li (see mills et al) emergency physician and nurse attitudes toward family presence during resuscitation the effect of decreasing ambulance diversion hours on emergency department interfacility transfers san diego county improved patient destination trial to decrease emergency department diversion hours and diverted patients vilke gm (see davis et al) acute drug-induced akathisia: simplified criteria for diagnosis and grading emergency contraception and risk of ectopic pregnancy: is there need for extra vigilance? treating headache in the emergency department: avoiding the migraine-meperidine trap association between course of blood pressure within the first 24 hours and functional recovery after acute ischemic stroke the cost of unfunded end-stage renal disease patients who present to a busy emergency department in the hope of being dialyzed: a ret weaver al (see stead et al) weaver wd (see mccord et al) wegner s (see chasm et al) alternative for automated communication in research weinick rm (see solberg et al) dissemination of unfavorable information about other emergency medicine residencies and asking discriminatory questions during the emergency medicine interview weiss sr (see hirshon et al) data-driven total quality management in the emergency department at a level i trauma and tertiary care hospital wells ga (see bandiera et al) the emergency medicine workforce prevalence of partner violence among women presenting to an orange county emergency department eight-hour emergency department observation for blunt abdominal trauma patients with initially negative diagnostic studies adverse outcomes in the emergency department: assessment using malpractice claim files white m (see houry et al) the tuskegee syphilis study and informed consent whyte im (see balit et al) sex differences in the perpetrator-victim relationship among emergency department patients presenting with nonfatal firearm-related injuries effect of ethanol and glasgow coma scale score on the sensitivity of the history and physical examination in detecting acute pelvic trauma matching clinical questions to appropriate databases yamamoto lg (see boychuk et al) effect of ethnicity and race on the use of pain medications in children with long bone fractures in the emergency department yost mm (see haltiwanger et al) bacterial oantigen promotes early bacteremia during gram-negative pneumonia in mice younger jg (see pollack et al) management of neonatal hyperbilirubinemia in a pediatric emergency department observation unit: a novel alternative to inpatient admission zlidenny am (see kwon et al) development of a survey to differentiate at-risk youths in the emergency department the effect of noise in the emergency department zwemer fl (see schneider et al) are emergency medicine residency programs using a valuable resource to educate the residents in caring for sexual assault victims? j (see palchak et al) g (see nufer et al) comparison of the glasgow coma scale to its motor component for the prediction of trauma outcomes the effectiveness of a scooter safety video as a teaching method in the emergency department s28 (research forum abst wolf fa (see merchant et al) wolfson a (see medzon et al) accuracy of emergency physician compression ultrasonography and d-dimer in the bedside diagnosis of deep venous thrombosis wootton-gorges sl (see palchak et al) interrater reliabilities of the emergency severity index versus the canadian triage acuity scale: a randomized controlled trial worster a (see fernandes et al) wuerz rc (see stair et al) how to find evidence key: cord-103214-3lz33pj3 authors: kortuem, s. o.; becker, d.; ott, h.-j.; schlaudt, h.-p. title: the role of the emergency department in protecting the hospital as a critical infrastructure in the corona pandemic strategies and experiences of a rural sole acute-care clinic date: 2020-09-09 journal: nan doi: 10.1101/2020.09.07.20185819 sha: doc_id: 103214 cord_uid: 3lz33pj3 background. the klinikum hochrhein is responsible as a regional sole provider for the acute and emergency medical treatment of more than 170.000 people. against the background of the pandemic spread of sars-cov-2 with expected high patient inflows and at the same time endangering one's own infrastructure due to intraclinical transmissions, the hospital management defined the maintenance of one's functionality as a priority protection objective in the pandemic. an essential strategic element was a very short-term restructuring of the emergency department with the objectives of reducing the number of cases within the clinic, detecting covid-19 cases as sensitively as possible and separating the patient pathways at an early stage. methods. the present work is a retrospective analysis of the processes and structures established in the emergency department between 27 march 2020 and 20 may 2020. in addition, a retrospective descriptive evaluation of the epidemiological and clinical data of the patients is carried out at the time of first contact during the period mentioned above. results. after establishing a pre-triage with structured algorithms, all confirmed covid-19 cases were identified before entering the clinic and assigned to an appropriate treatment pathway. unprotected entry into hospital structures or nosocomial infections were not observed, although almost 35% of patients with confirmed infection were admitted due to other symptom complexes or injuries. 201 inpatient patients were initially isolated without covid-19 being confirmed. the number of cases in the emergency department was 39% lower than the previous year's period, thus avoiding crowding. discussion. the reduction in the number of cases was strategically intended and is primarily the result of a restrictive indication of in-clinical treatment but supported by a decline in emergency consultations that can be noticed anyway. the proportion of false positive triage results is probably dependent on epidemiological activity and was accepted for safety reasons as sufficient resources were available for isolation. conclusion. short-term organizational, spatial and procedural restructuring of the zna has enabled the clinic to achieve its goal of managing the pandemic. the algorithms we developed are particularly well suited to guarantee the desired level of safety in the case of a high pre-test probability. the klinikum hochrhein is a hospital of advanced care with 9 main departments and supplementary sections with affiliated specialists. the clinic meets the requirements for emergency care in level 2 (extended emergency care). the emergency department is run as an independent specialist department and treats approximately 25.000 patient per year with a rate of inpatient admissions of almost 50 %. the nearest hospitals with acute and emergency medical care are not reachable with a travel time of less than 50 minutes, clinics of maximum care not less than 75 minutes. due to the geographical and structural conditions, klinikum hochrhein is responsible for ensuring emergency care and inpatient treatment for more than 170.000 people as the sole regional provider. as early as the end of january 2020, the first infections with sars-cov-2 were reported in germany and transmissions by asymptomatic virus carriers were described [1, 2] . regarding the dynamics of the infection process in italy, the challenge that was probably faced by hospitals in germany became clear: 1. providing clinical resources for a high number of additional acutely ill patients 2. for a prolonged period of time 3. at the same time endangering one´s own functionality through transmissions within the hospital, 4. and at the same time ensuring acute and emergency care for all other (not covid19) patients. a pandemic infection situation means an external and internal hazard over a longer period of time, for which the existing arrangements for a conventional mass casualty incident are insufficient [3] . when developing an appropriate strategy should not be ignored, as outbreaks of sars-cov-2 with some fatal consequences have been reported in hospitals and nursing facilities, with asymptomatic virus carriers playing a major role in the infection chains [4] [5] [6] [7] . in china, there were approx. 4% of all confirmed cases healthcare staff [8] . from italy, a share of about 20% of infected people reported in this group of people [9] , which, even after the end of a quarantine period, can still be considered as a source of infection [10] . the overarching protection objective was defined by the hospital management as ensuring the acute and emergency medical care of all emergency patients while maintaining the functionality of the hospital. in view of the expected high influx of patients, an upstream or parallel infrastructure was established elsewhere as a "buffer zone" for the clarification of the need for treatment, including outpatient smear diagnostics, thus effectively expanding the existing hospital structure [11] [12] [13] [14] [15] . however, this strategy puts a strain on the hospital's limited human, spatial and material resources, which are then unavailable for the original tasks. at the klinikum hochrhein, this option had to be discarded at an early stage due to the lack of space reserves in the existing building and the lack of development areas (inner-city location). nevertheless, the expected overcrowding of the clinic structures, and in particular of the emergency department, entails the risk of mixing infected and non-infected patients and thus of transmissions, . cc-by-nc-nd 4.0 international license it is made available under a perpetuity. is the author/funder, who has granted medrxiv a license to display the preprint in (which was not certified by peer review) preprint the copyright holder for this this version posted september 9, 2020. . https://doi.org/10.1101/2020.09.07.20185819 doi: medrxiv preprint including to medical staff [11] [12] [13] 16] . treatments in the core area of the emergency department should only be carried out when there is an objective medical need [17] . the hospital management and the crisis unit therefore defined a strategy for the isolation of the hospital with the following key elements: 1. suspension of all elective outpatient and inpatient hospital treatment 2. limitation of family visits to very few exceptions 3. close all entrances and use of security personnel, access only with employee id 4. use of security personnel on the access for the rescue service 5. reversing of all patients arriving on foot to an upstream practice with separate access. only after appropriate indication forwarding to the emergency department 6. reassignment of 2 wards in a separable part of the building with its own access from outside to isolation areas 7. restriction of outpatient and inpatient treatment to patients who, at the time of presentation, with medical indication need the specific resources of the hospital irrefutable and not deferrable 8. referring all safely outpatient patients to practicing physicians and/or the health office, including required medical clarification regarding covid-19 the strategic orientation was coordinated with the external partners at district level (district administration, health office, practicing physicians, ambulance service) and largely implemented without problems. the established range of tasks and services of the emergency department as the first point of contact and switching point for all acute and emergency patients will remain unrestricted even in the pandemic [18] . however, an additional focus had to be placed on the protection of the functioning of the hospital by preventing unnoticed entry of infections with sars-cov-2. after the entrances and elective outpatient units were closed, patients could only enter the hospital via the emergency department, which should act as a "second line of medical defense" [19] against the spread of infection. since an early separation of patient pathways (infectious vs. non-infectious) contributes significantly to the prevention of transmissions [11, 15, 16, 19] , the decision on the necessary isolation measures and the necessary level of protection of employees should be made before the patient reaches the building. parallel to the establishment of separate inpatient and intensive care areas for confirmed covid-19 cases, suspected cases and non-covid-19 patients, 3 outposts of the emergency department were established: -the rooms of a practice outside the actual clinic building as a first contact for patients arriving on foot -a triage place around the ambulance service access for the first contact with lying patients -two isolation wards with separate access for the reception and initial care of covid-19 patients and suspected cases this "decentralization", implemented within a few days, meant extensive interventions in the structures and core processes of the emergency department, requiring rapid rethinking and high personal commitment by all employees. is the author/funder, who has granted medrxiv a license to display the preprint in (which was not certified by peer review) preprint the copyright holder for this this version posted september 9, 2020. . https://doi.org/10.1101/2020.09.07.20185819 doi: medrxiv preprint the established first assessment (here: manchester triage system) had to advance 3 core issues (pre-triage) considering the strategic orientation of the clinic: 1. is the treatment of the patient with the resources of the hospital in the specific situation irrefutable and not deferrable necessary? 2. is there a suspicion or case of differential diagnostic clarification regarding covid-19? 3. in which area of the hospital is the first aid for the patient safest, considering infection protection and medical criteria? at the beginning of march 2020, a covid-19 rapid query was first established in the emergency department, which was still very closely based on the official case definition published by the robert-koch-institute, berlin, germany. an identical query could also be agreed with the persons responsible for the ambulance service, so that suspected cases could already be preclinically identified and communicated before arriving at the emergency department. however, the first two cases treated with covid-19 at the klinikum hochrhein were not covered by the official case definition at the time of presentation at the emergency department. transmissions within the clinic could be prevented, but against the background of increasing autochthonous transmissions in the region and the heterogeneous symptoms, neither the clinical nor the epidemiological criteria of the case definition proved to be sufficiently sensitive. based on the initial experience, it was decided to develop our own algorithms for case detection and patient allocation. the aim was to achieve the highest possible sensitivity in the detection of covid-19, while a low specificity with a high number of precautionary isolations was deliberately accepted if inpatient treatment was necessary. appropriate stationary resources were available due to the overall restrictive indication and could have been extended if necessary. the clinical symptoms of covid-19 were already described as very heterogeneous in the literature in march 2020. this is all the more true when focusing on the time of first contact in the emergency department. the leading symptoms fever, cough and dyspnea are observed in a maximum of 70% of cases [20] [21] [22] [23] . in addition, non-specific general symptoms, silent hypoxemia or olfactory disorders are reported even without concomitant respiratory symptoms [23] [24] [25] [26] [27] . a significant proportion of patients present themselves asymptomatic at the time of first contact [20] . in addition, patients with covid-19, whose severity of disease requires hospitalization, often have significant comorbidities that push themselves into the foreground of clinical perception and may lead to misjudgments as to possible infectivity. also, for admissions on other reasons (e. g. fall or fracture) infection with sars-cov-2 as an easily overlooked concomitant disease may occur, which nevertheless requires isolation of the patient. screening based solely on imaging techniques cannot be recommended [28] . this also applies to laboratory parameters available for emergency diagnostics, which are at best indicative and are not immediately available at the time of initial contact [29] [30] [31] . is the author/funder, who has granted medrxiv a license to display the preprint in (which was not certified by peer review) preprint the copyright holder for this this version posted september 9, 2020. . https://doi.org/10.1101/2020.09.07.20185819 doi: medrxiv preprint a direct detection of pathogens by means of rt-pcr is considered to be a diagnostic gold standard [32] but is not of use for pre-triage screening due to the duration of time until the findings are available. the rapid tests for antibodies to sars-cov-2 available since february 2020 are not suitable for rapid exclusion or for confirming the diagnosis with the necessary safety due to the dynamics of the immune response and the technical test parameters [33, 34] . the epidemiological history according to the official case definition (stay in risk areas and/or contact with confirmed cases) can be helpful in the early phase of an outbreak with defined clusters, but with the occurrence of autochthonous transmissions in the respective region, it is no longer sufficiently certain from the aspect of the protective function of the emergency room [13, 35] . in summary, a simple one-dimensional screening with high sensitivity is not available at the time of the first contact. in regions with proven autochthonous transmission, it would seem appropriate to handle all patients with symptoms compatible with covid-19 as suspected cases or as cases of differential diagnostic clarification [36] and to continuously develop its own multimodal algorithms for case detection and patient allocation, taking into account the local framework conditions [12, 19, 37] . is the author/funder, who has granted medrxiv a license to display the preprint in (which was not certified by peer review) preprint the copyright holder for this this version posted september 9, 2020. . https://doi.org/10.1101/2020.09.07.20185819 doi: medrxiv preprint as of march 27, 2020, a specially developed algorithm for case detection was established, which, in addition to broader range of clinical criteria, focuses on the regionally observable epidemiological events in risk facilities, e. g. nursing homes (figure 1 ). the expected number of ultimately not confirmed suspected cases was knowingly accepted in order to avoid nosocomial transmissions with the highest possible safety. all unplanned incoming patients were assigned 5 defined case categories and allocated spatially separated treatment pathways using a checklist (figure 2) . is the author/funder, who has granted medrxiv a license to display the preprint in (which was not certified by peer review) preprint the copyright holder for this this version posted september 9, 2020. . https://doi.org/10.1101/2020.09.07.20185819 doi: medrxiv preprint case detection and patient management were carried out by interprofessional triage teams in the context of a pre-triage around the ambulance service access (in the vehicle) or for patients on foot in the practice upstream of the emergency department. by clearly defining responsibilities and drawing up special service plans personal protective equipment in high-risk areas could be used very consistently and at the same time in a resource-saving manner. completely unprotected contacts were avoided by a face mask obligation for all persons within the hospital building. the ambulance service agreed on a checklist simplified in terms of clinical criteria (figure 3 ) in order to identify as many potential covid-19 patients as possible and to support early and targeted communication at the interface between pre-clinic and emergency department. is the author/funder, who has granted medrxiv a license to display the preprint in (which was not certified by peer review) preprint the copyright holder for this this version posted september 9, 2020. . https://doi.org/10.1101/2020.09.07.20185819 doi: medrxiv preprint in addition, from 27. march 2020, a doctor from the central emergency room was continuously available to the rescue service as a contact person in cases of doubt ("infodoc"), who was alerted via the control center on request. to provide technical support to the infodoc, a control center workstation was set up in the emergency department at short notice. in the period from 27. march 2020 to 20. may 2020 a total of 2,184 patients were registered in the emergency department (previous year period: 3, 585) . this corresponds to a decrease of almost 39%, which is at least partly due to the consistent focus on irrefutable and not deferrable hospital treatments. all patients were assessed using the case-finding checklist as part of the pre-triage and assigned to a treatment path. 288 of the 2,184 patients (13. 2%) were identified as covid-19 suspicious and assigned to case category a or b (figure 4) . of the 288 patients in case categories a and b, 32 (11. 1 %) were discharged into further outpatient treatment after prestationary treatment and appropriate information. in 256/288 patients (88. 9%), the clinical indication was given for inpatient admission to one of the isolation wards. the age of inpatient patients ranged from 26 to 97 years, median 78 years. covid-19 was confirmed in 55 out of 256 inpatient patients (21. 5%). in case of persistent clinical suspicion despite negative smear test results, isolation was maintained, and the diagnosis was repeated. in 6 patients (10. 9%), the first smear test was negative. in 2 patients (3. 6%), the diagnosis of covid-19 was finally confirmed only in the third test. primary reasons for admission 29 of the 55 confirmed covid-19 disorders (52. 7%) were admitted and announced as a suspected case after the introduction of the "checklist ambulance service", 7 patients (12. 7%) as "other respiratory problems". the remaining 19 patients (34. 6%) initially were presented for other reasons in the emergency department (table 1 ) and would not have been isolated at first without pre-triage. is the author/funder, who has granted medrxiv a license to display the preprint in (which was not certified by peer review) preprint the copyright holder for this this version posted september 9, 2020. . https://doi.org/10.1101/2020.09.07.20185819 doi: medrxiv preprint considering the intended reliable and early identification of cases, it is significant that 21. 8% (12/55) of patients did not show any respiratory symptoms at the time of first contact. 12. 7% (7/55) had neither respiratory symptoms nor fever. unspecific worsening of the general condition and the tendency to collapse were the focus of the clinical picture in these -often very old -patients. in 29 (52. 7%) of the patients, neither direct contact with confirmed covid-19 cases nor a stay in high-risk areas or facilities could be recorded at the time of pre-triage ( figure 6 ). only 1 patient had been in one of the officially listed risk areas prior to the disease. 4 out of 7 (57. 1 %) of patients with only non-specific general symptoms were correctly identified as suspected case due to the admission from a risk facility. is the author/funder, who has granted medrxiv a license to display the preprint in (which was not certified by peer review) preprint the copyright holder for this this version posted september 9, 2020. . https://doi.org/10.1101/2020.09.07.20185819 doi: medrxiv preprint the primary objective of maintaining acute clinical care for all patients (covid-19 and non-covid19) was achieved according to the strategic orientation of the clinic. at this point, the emergency department has the key function of identifying those patients who need treatment with the hospital resources for medical reasons and referring other cases to the outpatient sector. at the same time, covid-19 (suspected) cases must be identified with the highest possible sensitivity in order to prevent an unnoticed spread within the hospital safely. in order to fulfil this task, extensive organizational, spatial and process adjustments had to be implemented in the shortest possible time in the daily operation of the emergency department, which required a high degree of flexibility from all parties involved. the reduction in the number of cases observed during the investigation period of almost 39% compared to the previous year's period was strategically intended to prevent the overloading of clinical structures feared according to the early reports from italy and france. it is primarily the result of a restrictive indication of in-clinical treatment, but undoubtedly favored by a decline in emergency consultations also observed elsewhere. this procedure also explains the very low proportion of suspected cases with only outpatient or preinpatient treatment. pure "work-up examinations" were not carried out by us in consultation with the competent health authority at any time. the overall concept was only successful because a close cooperation and coordination with the outpatient structures (corona consultation hours, fever outpatient unit, smear test site, telephone hotline) was reliably possible. the algorithms for case detecting and patient allocation have proven to be effective under our framework conditions. all confirmed covid-19 cases were correctly identified in the structured pretriage, unprotected contacts with employees or other patients did not take place, nosocomial transmissions were not known. 20 % of our patients had neither respiratory symptoms nor contact with covid-19 cases, not even in the context of a recognizable outbreak, and would not have been immediately recognized if the "official" case criteria had been applied. almost 35% of patients with covid-19 in our patient population were admitted primarily due to other symptoms or injuries. diese können hinweise auf ein infektiöses geschehen überdecken und/oder davon ablenken, was die notwendigkeit einer hoch sensitiven fallfindung unterstreicht. the high number of false positive results from the pre-triage is not satisfactory, but was accepted in favor of reliable case detection to avoid unnoticed transmissions within the hospital. this presupposes that the appropriate clinical resources for the isolation of patients are actually available within the framework of an overall concept. in this context, it should also be noted that the proportion of incorrectly positive triage results is not constant, but appears to depend on the epidemiological activity (pre-test probability) and was significantly lower at the beginning of the investigation period. further analyses and a prospective reevaluation of the algorithms are planned. the very heterogeneous epidemiological data of our patients reflect an already pronounced -partly subclinical -autochthonous transmission of the infection. stays in risk areas played a completely subordinate role in our patient population, not least because of demographic data (very old people). the definition of risk facilities when admitting or relocating patients, considering the regional course of infection, has proven to be effective. is the author/funder, who has granted medrxiv a license to display the preprint in (which was not certified by peer review) preprint the copyright holder for this this version posted september 9, 2020. . as a limiting factor, it should be noted that our strategic approach has been successful in the context of the regional framework conditions and the structure of the hospital and cannot therefore be transferred uncritically to other areas. due to the influence of the pre-test probability, the developed algorithms are particularly suitable for use in times of high epidemiological activity with autochthonous transmissions. due to the relatively low number of cases so far, further evaluation is necessary and planned. through short-term organizational, spatial and procedural restructuring of the emergency department, the clinic's goal of coping with the pandemic was achieved. the algorithms we have developed are particularly well suited to ensure the desired level of security when there is a high probability of pre-testing. outbreak of covid-19 in germany resulting from a single travel-associated primary case transmission of 2019-ncov infection from an asymptomatic contact in germany translating covid-19 pandemic surge theory to practice in the emergency department: how to expand structure presymptomatic sars-cov-2 infections and transmission in a skilled nursing facility transmission of covid-19 to health care personnel during exposures to a hospitalized patient erfolgreiche eindämmung eines covid-19 ausbruchs in einem universitären mutter-kind zentrum bei gleichzeitiger aufrechterhaltung der patientenversorgung fast nosocomial spread of sars-cov2 in a french geriatric unit lyon study group on covid-19 infection characteristics of and important lessons from the coronavirus disease 2019 (covid-19) outbreak in china: summary of a report of 72 314 cases from the chinese center for disease control and prevention covid-19 and italy: what next? sars-cov-2 in the employees of a large university hospital 2020) fight covid-19 beyond the borders: emergency department patient diversion in taiwan creating a covid-19 surge clinic to offload the emergency department umgang mit covid-19 in der notaufnahme : erfahrungsbericht der interdisziplinären notaufnahme des universitätsklinikums münster covid-19-versorgung -strategien der taskforce coronavirus und erfahrungen von den ersten 115 fällen am universitätsklinikum freiburg buffer areas in emergency department to handle potential covid-19 community infection in taiwan hospital emergency management plan during the covid-19 epidemic to control the covid-19 outbreak, young, healthy patients should avoid the emergency department coronapandemie: rolle der zentralen notaufnahme clinical value of the emergency department in screening and diagnosis of covid-19 in china characteristics of sars-cov-2 patients dying in italy clinical characteristics of coronavirus disease 2019 in china characteristics of emergency department patients with covid-19 at a single site in northern california: clinical observations and public health implications epidemiological and clinical characteristics of 99 cases of 2019 novel coronavirus pneumonia in wuhan, china: a descriptive study neurologic manifestations of hospitalized patients with coronavirus disease olfactory and gustatory dysfunctions as a clinical presentation of mild-to-moderate forms of the coronavirus disease (covid-19): a multicenter european study clinical characteristics of patients who died of coronavirus disease 2019 in china clinical features of patients infected with 2019 novel coronavirus in information der ag thoraxdiagnostik der deutschen röntgengesellschafty hinweise zu erkennung, diagnostik und therapie von patienten mit covid-19 lymphopenic community acquired pneumonia as signature of severe covid-19 infection the characteristics of 50 hospitalized covid-19 patients with and without ards detection of 2019 novel coronavirus (2019-ncov) by real-time rt-pcr performance of vivadiag covid-19 igm/igg rapid test is inadequate for diagnosis of covid-19 in acute patients referring to emergency room department virological assessment of hospitalized patients with covid-2019 containing covid-19 in the emergency room: the role of improved case detection and segregation of suspect cases national institute for the infectious diseases "l. spallanzani", irccs. recommendations for covid-19 clinical management preliminary results of initial testing for coronavirus (covid-19) in the emergency department no studies on humans or animals were conducted by the authors for this paper. the quoted studies are subject to the respective ethical guidelines. key: cord-323334-ie7iklr4 authors: tartari, f; guglielmo, a; fuligni, f; pileri, a title: changes in emergency service access after spread of covid19 across italy date: 2020-04-27 journal: j eur acad dermatol venereol doi: 10.1111/jdv.16553 sha: doc_id: 323334 cord_uid: ie7iklr4 the italian national health system is currently living through some catastrophic days, owing to the rapid spread of covid‐19 across the country. at the time of writing, our government has passed emergency laws (march 11, 2020), with a view to preventing widespread viral infection among the population, which may well lead to an increase in the number of people requiring intensive care unit (icu) hospital treatment. currently, most of the northern italian regions are close to saturation point in terms of the number of available icu inpatient beds. this article is protected by copyright. all rights reserved the italian national health system is currently living through some catastrophic days, owing to the rapid spread of covid-19 across the country. at the time of writing, our government has passed emergency laws (march 11, 2020) , with a view to preventing widespread viral infection among the population, which may well lead to an increase in the number of people requiring intensive care unit (icu) hospital treatment. currently, most of the northern italian regions are close to saturation point in terms of the number of available icu inpatient beds. albeit dermatologic "true" emergencies are a small number, many patients access our emergency services (es) for routine diseases in order to avoid having to wait any length of time for a scheduled dermatological examination. the aim of our study is to analyse any possible changes in access to our es by examining two different weeks before and after covid-19 emergency in italy. the first week in the pre-covid-19 era was randomly selected, while the second was chosen during the actual covid-19 emergency. we analysed a six-day workload because our unit does not operate an es on sundays. diseases such as burns, drug eruption, acute urticaria-angioedema, skin rash (including psoriasis and bullous autoimmune dermatitis) involving more than 10% of the body surface area, along with acute infection (bacterial or viral) were identified as real emergencies. the remaining pathologies were considered to be unjustified consultations. the week between october 21 and 26, 2019 was identified as the pre-covid-19 (no closure of the outpatients' surgeries available in our unit for holidays or meetings). the days between march 12 and 18, 2020 characterised the weekly activity of our emergency service during the covid-19 era (days in the run-up to the government decree law). in the pre-covid-19 era, 106 patients accessed our emergency outpatients' room, whereas just 20 cases were examined after the emergency decree law. the number of unjustified accesses was 60 in pre-covid era, 46 patients showed "true" emergencies. acute bacterial/viral infections on a par with diffuse skin rashes (19 cases each) were the most common problems, while 8 patients accessed the es for burns. after march 11, 2020, 19 patients referred to the es. five patients turned up for an unjustified consultation, while 14 showed a "true" problem (4 diffuse rashes, 7 acute infections and 3 burns). see table 1 for all the patient details. this article is protected by copyright. all rights reserved the misuse of the emergency consultation facility is a bad habit and it has been estimated that at least half of the patients do not have a "true" emergency (range 49-82%) 1-6 , which is confirmed by our study (60 vs 5 unjustified accesses, before/after the covid19 pandemic). however, emergencies still exist, even in the presence of a potentially life-threatening virus. patients suffering from acute myocardial infarction will refer to the es even in the covid19 era and the same will occur in the case of dermatological emergencies. drago et al 7 appropriately defined a "true emergency" in dermatology as a severe dermatosis that requires immediate medical attention and an observation period lasting at least 24 hours. a possible bias in our research may be due to the panic related to the covid19 disease, which can explain the drop in the number of consultations (106 vs 19, for an 81% reduction). our data clearly show a decrease in unjustified referrals (60 vs 4, for a 93% reduction, p-value for fisher exact test 0.0032) highlighting the misuse of the es at our unit. to conclude, a solution for select patient access to es could be to: 1) implement the number of scheduled examinations by recruiting more dermatologists; 2) have more outpatients accessing during the daytime, especially in afternoon (an infrequent event in italy); 3) train general practitioners to recognize and diagnose the most commonly occurring dermatosis. dermatologic emergencies: descriptive analysis of 861 patients in a tertiary care teaching hospital cutaneous conditions leading to dermatology consultations in the emergency department primary care and pattern of skin diseases in a mediterranean island evaluation of emergency dermatological consultations in a tertiary care centre in north india global coronavirus pandemic (2019-ncov): implication for an italian medium size dermatological clinic of a ii level hospital medical education and care in dermatology during the sars-cov2 pandemia: challenges and chances dermatological consultations in an observation unit of an emergency department in italy this article is protected by copyright. all rights reserved this article is protected by copyright. all rights reserved accepted article key: cord-347135-g2hx32xa authors: miller, elaine title: dealing with uncertainty: lessons learned from covid-19 date: 2020-06-10 journal: pain manag nurs doi: 10.1016/j.pmn.2020.06.001 sha: doc_id: 347135 cord_uid: g2hx32xa nan the covid pandemic turned our world upside down and altered routines and priorities. we took many things for granted and now suddenly faced a new situation that changed how we performed customary activities such as going to the grocery store, going to work, keeping scheduled doctors' visits, going to the dentist, and socializing with family, colleagues and friends. framed within this new set of circumstances have been increased stress, anxieties, and for some, loss of family, friends, income, and home. on the other hand, several positives have emerged such as the expanded use of telemedicine and many of us becoming more adept in using technology to participate in online school activities, church services, work related and civic meetings, and family events. as a result of social isolation, altered connectivity, and disruption of normalcy, we now have greater insights into how the lives and circumstances of individuals with chronic or acute pain may be temporarily or permanently altered. even in normal circumstances, chronic pain management affects over 116 million us adults (iom 2011), is the most frequent reason individuals seek healthcare, and is challenging to treat even in the best of circumstances (daubresse et al., 2013) . although there are many factors to consider as we provide care during disaster or emergency situations, several critical elements must remain in the forefront of our thinking: • in large scale disasters or emergency situations, whether natural (e.g., pandemic, hurricanes), environmental (e.g., deepwater horizon oil spill) or traumatic (e.g., mass shootings, world trade center attack), there are increases in depression, loneliness, anxiety, posttraumatic stress disorders, substance abuse, along with behavioral disorders such as child abuse and domestic violence (neria, nandi, & galea, 2008; galea, merchany, & lurie, 2020) . unfortunately, the impact of these events often affects mental health in the short-term and general quality of life in the long-term (galea, merchany, & lurie, 2020) . as a result, mechanisms must be put in place to address the signs/symptoms of mental health disorders while monitoring the successes of our interventions. • during the covid pandemic, numerous individuals experienced difficulties obtaining the necessary resources to survive such as prescribed and over-the-counter medications, supplies and food. for those with limited transportation, economic hardships, and reduced social support systems, there were even greater difficulties obtaining basic necessities. these sudden new challenges contributed to the deterioration of the physical, mental and pain status of individuals experiencing pain. • another stressor exhibited by many was fear of seeking professional care and if admitted to a facility, of being isolated from family and friends. as we look to the future of similar situations, how can we creatively address these concerns? • research further indicates that community dwelling adults with more severe or poorly managed pain often have impaired attention capacity, diminished decision-making capabilities and memory impairment (nadar, jasem, & manee, 2016; van der leeuw, eggermont, shi, millerg, gross et al. 2016) . in conditions such as a pandemic or other disaster/emergency situations, consistently monitoring these individuals and finding ways to provide care are critical. what have we learned that will help clients experiencing pain survive pandemics or other disaster or emergency situations? it is evident that planning for potential disaster/emergency situations is essential. moreover, planning is critical for persons with chronic and disabling conditions including pain, mobility, sensory, or cognitive issues (barth, 2019; owens, stidham, & owens, 2013; fema, 2004 · disaster and emergency supplies must be ready and in one place prior to an actual disaster or emergency. supplies should last at least 3 days and be placed in easy to carry containers (e.g., backpack) with id tags displaying name and contact information. label all equipment such as wheelchairs, canes, walkers with the client's name, address, phone number and significant others. make sure the disaster kit is up-to-date, and review contents every 6 months. it is vital that individuals have disaster or emergency plans, escape routes, and designated meeting places. in addition, it is important to keep in the forefront how vision, hearing, mobility, and cognitive or emotional impairments may affect preparation and outcomes. families should have their own communication plans and carry information in their wallets, listing out-of-town contact persons as a main contact, and these out-of-town contact persons must be aware of these plans. keep emergency contact numbers near the telephone or in phone number listings, make plans for those with disabilities, as well as for pets or service animals. know what the community warning system is for disaster or emergencies and what services are offered. determine if smart911 is available in your community and sign up so emergency responders are aware of the clients' location and specific needs. for more information about the types of disaster or emergencies (e.g., hurricanes, earthquakes, tornadoes, floods, chemical spills) possible in your community, visit www.ready.gov (http://www.ready.gov) or call 1800-be-ready. once this information is obtained, it is essential to adapt this information to an individual's personal circumstances and make every effort to follow instructions given by local authorities. adults with disabilities should know the community warning system and how residents are to be notified of a potential disaster or emergency situation. disaster and/or emergencies situations are never ending. in 2020, there have already been 181 disaster declarations made by fema (2020). it is imperative that we are prepared for the next disaster and work with our clients to take action now. meeting the needs of people with physical disabilities in crisis settings ambulatory diagnosis and treatment of nonmalignant pain in the united states fema 2020 disaster declarations preparing for disaster for people with disabilities and other special needs the mental health consequences of covid-19 and physical distancing: the need for prevention and early intervention relieving pain in america: a blueprint for transforming prevention, care, education and research the cognitive functions in adults with chronic pain: a comparative study post-traumatic stress disorder following disasters: systematic review disaster evacuation for persons with special needs: a content analysis of information on youtube pain and cognitive function among older adults living in the community preparedness for natural disasters among older us adults: a nationwide survey key: cord-011971-h78639ld authors: wood, d. brian; jordan, jaime; cooney, rob; goldfam, katja; bright, leah; gottlieb, michael title: conference didactic planning and structure: an evidence-based guide to best practices from the council of emergency medicine residency directors date: 2020-07-03 journal: west j emerg med doi: 10.5811/westjem.2020.5.46762 sha: doc_id: 11971 cord_uid: h78639ld emergency medicine residency programs around the country develop didactic conferences to prepare residents for board exams and independent practice. to our knowledge, there is not currently an evidence-based set of guidelines for programs to follow to ensure maximal benefit of didactics for learners. this paper offers expert guidelines for didactic instruction from members of the council of emergency medicine residency directors best practices subcommittee, based on best available evidence. programs can use these recommendations to further optimize their resident conference structure and content. recommendations in this manuscript include best practices in formatting didactics, selection of facilitators and instructors, and duration of individual sessions. authors also recommend following the model of clinical practice of emergency medicine when developing content, while incorporating sessions dedicated to morbidity and mortality, research methodology, journal article review, administration, wellness, and professionalism. supporting data, the authors based recommendations on their experience and consensus opinion. the entire cord best practices subcommittee reviewed the manuscript after which time it was posted on the cord website for review by the entire cord community. many factors may influence programmatic decisions regarding timing, frequency, and duration of didactic curricula in addition to the desire to optimize education. these may include regulatory requirements, clinical work schedules, locations of faculty and trainees, personnel (teachers and learners), and space availability. the concentrated blocked weekly didactic format (i.e., a single, dedicated conference half day per week) is highly prevalent in other specialties such as family medicine and neurology, in addition to em. 8, 9 residents appreciate having protected educational time and, compared to shorter daily formats, the blocked weekly didactic structure has demonstrated higher learner satisfaction, improved attendance, and fewer interruptions. [10] [11] [12] [13] while learners perceive improved learning with this format, studies have failed to demonstrate differences in objective outcomes such as scores on standardized tests or board examinations. [10] [11] [12] [13] [14] however, given the perceived and logistical benefits, including improved attendance, which is essential to maintaining accreditation, combined with the nature of em clinical schedules, the authors recommend the blocked weekly format. the acgme places certain requirements on programs regarding faculty participation in didactics. these include that each core faculty member must attend at least 20% of planned didactic experiences and that em faculty members must present at least 50% of resident conferences. 2 while there is limited data evaluating faculty conference attendance and objective learning outcomes, one study found that higher faculty conference attendance was associated with higher pass rates on em oral boards for trainees. 15 additionally, residents perceive that faculty presence at conference facilitates learning. 16, 17 one approach to increase faculty presence at conference would be to offer incentives for attending conference. 18 providing continuing medical education credit for didactic conferences can also increase faculty attendance. 19 conference didactics are most often presented by faculty or residents. 8, 9, 16, 15, 20 some have advocated for residents to give didactic lectures to ease the burden on faculty time and sharpen resident public speaking skills. 21 while residents perceive that faculty lectures greatly contribute to their educational experience, 11,l 6 limited data has demonstrated that residents can learn from resident-given lectures, and that no difference in learning outcomes (e.g., test scores, board passage rates) were found between resident-given lectures vs faculty-given lectures. 15, 20, 22 additionally, it may be appropriate to incorporate other professionals (e.g., nurses, pharmacists) as lecturers depending on the topic. smith et al found no difference between lecture evaluation scores for nurse-given lectures compared to conference didactic planning and structure faculty-and resident-given lectures. 23 given that the specialty of em interfaces with many other disciplines, it may also be beneficial to incorporate multidisciplinary conferences with other medical professionals into the didactic curriculum to enable collaborative learning, coordinated patient care, and a better understanding of the roles of other professions. [24] [25] [26] the acgme recommends the inclusion of multidisciplinary conferences as part of the resident didactic experience. 2 limited research suggests that trainees value this type of experience 24, 27 ; however, robust objective data on learning outcomes are lacking. instruction should be tailored to the level of the learner. 28, 29 however, this may be especially challenging in program-wide didactic conferences in which the learners differ significantly in terms of stages of training and faculty are at varying career stages and experience. in recent years, we have seen the development of a national em curriculum specific to the training level and the nearly universal presence of a dedicated intern orientation in residency programs. 30, 31 to date, there are no objective data evaluating training level-specific didactics on learning outcomes; however, faculty and residents have been shown to view this targeted instruction positively. 32, 33 resident didactic instruction has traditionally been delivered via lectures despite calls for alternatives. 34, 35 common criticisms of lectures include lack of engagement due to an emphasis on passive learning, 36 overwhelming students' ability to learn by providing too much information, 37 and waning attention due to the duration of the session. 38 despite calls to minimize the use of lectures, data support their continued effectiveness as a teaching modality. [39] [40] [41] the common criticisms can be overcome through intentional learner-centered instructional design. cognitive load theory states that there are three main components involved in the creation of long-term memories: intrinsic load; extraneous load; and germane load. 28 while intrinsic load and germane load are generally fixed, extraneous load is highly modifiable and heavily influenced by the manner in which material is presented to learners. 28 since the amount of working memory is generally fixed for a given person at a set time, increases in extraneous load (i.e., presenting information in an overly complex manner) will detract from learning and retention. 28 therefore, instructors should focus on ensuring that talks are focused on delivery of information, while limiting unnecessary information or overly complex presentations of the information. multimedia learning theory informs principles of slide design and is one effective method that can be used to increase the long-term retention of taught material 42 (table 3) . with regard to the duration of lectures given at conference, the notion that shorter may be better is based on data of learner attention spans. 45 in a classic study of medical students, stuart and rutherford found that the attention span peaked at 10-15 minutes and fell steadily thereafter, with the authors recommending that lectures not exceed 25-30 minutes. 45 in more recent years, we have seen the implementation of shorter lectures in em both at the local and national level. 34, 46 limited studies have compared shorter (8-to 30-minute) segments compared to the more traditional 50-to 60-minute lecture and found the learners typically prefer the shorter format [47] [48] [49] ; however, few have looked at objective learning outcomes. one study by bryner did evaluate knowledge acquisition and retention between 20-minute and 50-minute lectures and found no significant difference. 50 more research is needed to determine the optimal length of didactic sessions with an emphasis on outcome-based evaluations. 51 when it is not possible to reduce the duration of a lecture, incorporating pauses, interactive questioning, and intermittent summarization can re-engage learners and improve attention to the content. 52 handouts are an additional method to increase the effectiveness of lectures. while many lecturers will distribute copies of their presentations, a more effective technique is the 1. coherence principle: avoid extraneous words, pictures, and sounds. they can detract from learning. 2. signaling principle: add cues to highlight the essential materials. on-screen text can detract from learning. people learn better from graphics and narration alone as opposed to graphics, narration, and on-screen text. 4. spatial contiguity principle: corresponding words and pictures should be presented near each other rather than far from each other on the screen. corresponding words and pictures should be presented simultaneously rather than successively. 6. segmenting principle: multimedia lessons should be presented in learner-controlled segments rather than as a continuous unit. 7. pre-training principle: when students already know the names and behaviors of system components, they will learn more from the session. 8. modality principle: learning is more effective when words are presented as narration rather than on-screen text. 9. multimedia principle: learning is more effective when words are combined with pictures as opposed to include words alone. 10. personalization principle: information delivery is more effective when words are presented in a conversational style rather than formal style. 11. voice principle: learning is more effective when narration is spoken in a friendly human voice rather than a machine voice. 12. image principle: learning is not necessarily more effective when the speaker's image is added to the screen table 3 . mayer's 12 principles of multimedia learning. 43, 44 concept of guided notes. guided notes are a hierarchical outline of the presentation with key information intentionally left blank. learners will "fill in the blanks" as the lecture progresses, thus increasing attention and discovering the relationships in the presented material. additionally, the fact that the notes are mostly complete allows for effective note-taking and allows attention to be directed at the presenter instead of the notebook. 53 while lectures can still be effective, active learning has been shown to positively impact objective learning outcomes, by incorporating other instructional techniques. [54] [55] [56] [57] [58] [59] [60] [61] [62] [63] active learning is "any instructional method that engages students in the learning process" 64 and can include techniques such as games, flipped classroom, audience response systems, casebased problems, and team-based activities. 6 real-time electronic broadcasts of lectures and video conferencing can be another good use of technology to support resident education. 66 this has been demonstrated to be an effective educational model that is positively viewed by trainees and can improve access and attendance at didactic offerings for both residents and faculty. [67] [68] [69] for training programs with multiple sites or that have struggled with maintaining the required attendance percentage for accreditation, this may be a valuable option to consider. our understanding of how learning occurs has evolved as cognitive scientists continue to refine effective methods for teaching and learning. unfortunately, effective methods are often not incorporated into medical curricula. educators should avoid using or encouraging the use of learner-initiated summarization, highlighting and underlining, mnemonics, imagery, and rereading as these techniques have not been shown to enhance learning. 70 effective techniques with a strong effect size include practice testing and distributed practice. additionally, there is likely some benefit from the use of elaborative interrogation, self-explanation, and interleaving. 70 practice testing is the use of no-or low-stakes tests that can be completed independently by the learners. these can include recall via flashcards, practice problems, or traditional types of test questions. 70 teachers may choose to implement this technique using shared card decks or applications (apps), or web-based asynchronous question banks. anonymous audience-response systems are popular and have also been shown to improve student learning in medical education. 71, 72 distributed practice (also known as spaced repetition) refers to the spreading out of learning over time as opposed to massed practice or "cramming." 70 implementation of this technique can be accomplished by content mapping that allows for repeated exposure to the concepts from prior didactics, the use of handouts or summarization materials between didactic sessions, or by using email to re-expose learners to the material. 73 elaborative interrogation involves the use of selfquestioning to enhance learning. this would involve the learner seeking out the underlying rationale or etiology using questions such as "why does this occur?" similarly, self-explanation involves directing learners to explain their logic during task completion. 70 educators can easily incorporate this technique through simple questioning exercises during their lectures. interleaving is an education organizational technique in which multiple topics and themes are mixed and covered over time instead of having discrete blocks dedicated to single topics. 74 the flipped classroom, also known as the reverse classroom, 75 is an instructional design method in which independent learning, often via previously-viewed video lectures or pre-reading, is combined with face-to-face classroom activities. 76 when studied, the flipped classroom appears to be effective [77] [78] [79] ; however, caution should be exercised as recent systematic reviews have found high methodological diversity, inconsistent results, and risk of bias. 76, [80] [81] [82] gamification is another active learning technique, which involves the utilization of games and competition to support learning. 83 as a technique, gamification may support learning of skills, 84 emergency department (ed) throughput, 83 decision-making, 85 and medical knowledge. [86] [87] [88] [89] team-based learning (tbl) is an instructional method used with increased frequency in both undergraduate medical education and graduate medical education, which is often combined with the flipped classroom model. [90] [91] [92] [93] prior to tbl, learners are expected to prepare and complete a pre-session test individually ahead of time. during the tbl sessions, learners then work in teams to solve a series of realistic, complex problems. faculty serve as facilitators encouraging peer-learning, cooperation, and ensuring the discussion stays on track. this approach requires upfront training of faculty in discussion facilitation and learner buy-in to prepare for sessions. 91, 94 best practice recommendations: 1. didactic lectures should be administered as blocked, weekly sessions (level 2b; grade b). 2. encourage faculty attendance and participation in conference (level 3b; grade b). 3. lecture can still be an effective method to present didactic content. when this technique is used, the lecturer should ensure that their presentation complies with cognitive load theory, multimedia learning theory, and active learning principles (level 1a; grade b). 4. real-time video conferencing can be considered to improve access and attendance (level 3b; grade c). 5. educators should incorporate the use of spaced repetition and no-or low-stakes testing into didactic instruction to increase long-term retention of content (level 1a; grade a). 6. utilization of recorded lectures, flipped classroom, and gamification can supplement or replace the traditional lecture (level 1a; grade b). after a thorough review of the literature, we found no prospective studies evaluating which specific topics should be included in the conference didactic curriculum. for this reason, conference didactic planning and structure the core content as described by the model of the clinical practice of emergency medicine, or the "em model," 95 is most commonly used as the de facto foundation of the conference curriculum in most residencies. while this was designed using expert consensus data, it is heavily informed by those areas most relevant to the emergency physician. in fact, during the creation of the em model, hospital data from over 90 million ed visits were compared to its content and found to have 82% overlap, validating the content of the em model. 96 the em model is further refined every three years to identify new areas to cover. 97 as it is used to inform board certification examinations, it is important for residents to be familiar with all of the topics covered and is a critical initial reference for most conference planners. 98 while there is no strong data to help prioritize specific subject matter during conference time, intraining examination coverage of various areas may help guide emphasis on high-yield topics. while the em model may be used as a guide for resident education, conference didactics should be viewed only as one component of resident education with its unique strengths and weaknesses. as such, rather than focusing solely on "covering" all topics in the em model, the priority of conference didactic design should be on maximizing the learning potential of this modality. 99 additionally, some topics can best be taught through other components of resident education including clinical experience, outside reading, simulation and use of free open access medical education (foam). 4 the acgme program requirements for graduate medical education (gme) in em mandate specific conference content to be taught as part of didactics. 2 these include five main components listed in table 4 . additionally, the acgme requires a number of other specific themes to be included in residency training. 2 we suggest incorporating the following into your conference topics to assure completion of these requirements. residents should be educated in a culture of safety, including understanding safety goals, diagnostic error, response to adverse events, continuous quality improvement, and ultimate accountability of the physician for the care of the patient. this can also be combined with m&m conference sessions. 100 professionalism residents must be aware of their professional responsibilities toward their patients and peers, as well as their relationship with the health system on a local and national level. residents should also appreciate the necessity of their own need for ongoing education after residency and how to obtain and maintain board certification. in recognition of the prevalence of depression, burnout, substance abuse, and suicidality among residents and medical students, the acgme now mandates teaching on the identification and mitigation of these concerning issues. while there is no set curriculum provided or recommended by the acgme itself, materials are available, such as the educational toolkit provided by the 2017 resident wellness consensus summit. 101 this incorporates modules on second victim syndrome, mindfulness and mediation, and positive psychology. all residents must be able to recognize limitations in their ability to care for patients due to sleep deprivation and fatigue; they should be made aware of options for fatigue management and transition of care to another provider, should the need arise. given the limited evidence-based data on curricular content of didactics further dedicated research on possible curricular content and the weighting of topics taught may be beneficial. 1. curriculum presentations 2. quality improvement/morbidity and mortality 3. research seminars (including education on how to conduct and understand research in a clinical context) 4. journal review and evidence-based medicine concepts 5. administrative seminars (to include operations and administrative practices in emergency medicine) table 4 . main components of conference didactics. 1. core content topics for conference should be derived from the conditions and skills described in the em model (level 5, grade d). 2. curriculum presentations, morbidity and mortality sessions, research seminars, journal review, and administrative seminars should be included as part of the conference design (level 5, grade d). there are several limitations to consider for this review. first, it is possible that some articles were not identified using our search strategy; however, an experienced medical librarian conducted the search with a broad search strategy using multiple databases. additionally, we searched bibliographies of all included articles, contacted topic experts, and underwent pre-submission peer review by the entire cord community. given the breadth of this topic, we were unable to address all aspects of conference planning and some components (e.g., simulation, journal club) were therefore not included in the current review. however, journal club was previously covered available at: https:// www.acgme.org/what-we-do/accreditation/common-program-requirements acgme program requirements for graduate medical education in emergency medicine pfassets/programrequirements/110_emergencymedicine_2019. pdf? journal club in residency education: an evidence-based guide to best practices from the council of emergency medicine residency directors individualized interactive instruction: a guide to best practices from the council of emergency medicine residency directors wellness in resident education: an evidence-based guide to best practices from the council of emergency medicine residency directors clinical teaching: an evidencebased guide to best practices from the council of emergency medicine residency directors oxford centre for evidence-based medicine -levels of evidence family medicine didactics revisited the academic half-day in canadian neurology residency programs megaconference: a radical approach to radiology resident education with full-day weekly conferences implementation of an academic half day in a vascular surgery residency program improves trainee and faculty satisfaction with surgical indications conference positive impact of transition from noon conference to academic half day in a pediatric residency program expanding resident conferences while tailoring them to level of training: a longitudinal study characteristics of emergency medicine residency curricula that affect board performance increasing faculty attendance at emergency medicine resident conferences: does cme credit make a difference? the pedagogic characteristics of a clinical conference for senior residents and faculty an academic relative value unit system: do transparency, consensus, and accountability work? increasing faculty participation in resident education and providing cost-effective self-assessment module credit to faculty through resident-generated didactics the effectiveness of grand rounds lectures in a community-based teaching hospital residents as educators: a modern model resident learning and knowledge retention from resident-prepared chest radiology conferences nursing lectures during conference time are well received by both residents and faculty mental health education for medicine trainees through a primary care interprofessional case conference: promoting collaborative learning and addressing challenges cler look at morbidity and mortality conferences. 36th annual meeting -society of general internal medicine presented at the: celebrating generalism: leading innovation and change development of a multidisciplinary curriculum for education af trauma teams during weekly emergency medicine residency conference cross-specialty integrated resident conferences: an educational approach to bridging the gap ten cate o. cognitive load theory: implications for medical education: amee guide no the adult learner: a neglected species emergency medicine resident orientation: how training programs get their residents started a needs assessment for a longitudinal emergency medicine intern curriculum pgy-specific conference in emergency medicine alternatives to the conference status quo: addressing the learning needs of emergency medicine residents lecture halls without lectures: a proposal for medical education a controlled trial of active versus passive learning strategies in a large group setting effects of lecture information density on medical student achievement lectures for adult learners: breaking old habits in graduate medical education effectiveness of an adult-learning, selfdirected model compared with traditional lecture-based teaching methods in out-of-hospital training adult learning models for large-group continuing medical education activities comparison of the effect of lecture and blended teaching methods on students' learning and satisfaction teaching for understanding in medical classrooms using multimedia design principles cognitive constraints on multimedia learning: when presenting more material results in less understanding e-learning and the science of instruction: proven guidelines for consumers and designers of multimedia learning medical student concentration during lectures trends in national emergency medicine conference didactic lectures over a 6-year period bstmode (bite-sized teaching mode): an innovative approach to maximizing residents' educational efficiency through a faculty-coached peer teaching exercise. presented at the: society of general internal medicine annual meeting rapid fire" emergency medicine resident conference: a pilot the 30 minute minimum: implementation of a shorter resident lecture format in a large emergency medicine residency program learning as a function of lecture length alternatives to the conference status quo: summary recommendations from the 2008 cord academic assembly conference alternatives workgroup the educational value and effectiveness of lectures anatomy of learning: instructional design principles for the anatomical sciences active learning increases student performance in science, engineering, and mathematics a 5-day intensive curriculum for interns utilizing simulation and active-learning techniques: addressing domains important across internal medicine practice active learning on the ward: outcomes from a comparative trial with traditional methods learning through debate during problembased learning: an active learning strategy problem-based learning in comparison with lecture-based learning among medical students a novel teaching tool combined with active-learning to teach antimicrobial spectrum activity comparison of chiropractic student scores before and after utilizing active learning techniques in a classroom setting student knowledge and confidence in an elective clinical toxicology course using active-learning techniques comparison of lecture and team-based learning in medical ethics education learning outcomes of "the oncology patient" study among nursing students: a comparison of teaching strategies does active learning work? a review of the research tracking active learning in the medical school curriculum: a learning-centered approach rethinking residency conferences in the era of covid-19 residency building from your home office: effectiveness of videoconference based tele-education for emergency medicine residents and providers in vietnam e-conferencing for delivery of residency didactics videoconferencing of a national program for residents on evidence-based practice: early performance evaluation improving students' learning with effective learning techniques: promising directions from cognitive and educational psychology do questions help? the impact of audience response systems on medical student learning: a randomised controlled trial effect of an audience response system on resident learning and retention of lecture material spaced learning using emails to integrate psychiatry into general medical curriculum: keep psychiatry in mind teaching the science of learning the reverse classroom: lectures on your own and homework with faculty academic outcomes of flipped classroom learning: a meta-analysis improved learning outcomes after flipping a therapeutics module: results of a controlled trial the flipped classroom: a course redesign to foster learning and engagement in a health professions school flipping the classroom to improve student performance and satisfaction does the flipped classroom improve learning in graduate medical education? a systematic review of the effectiveness of flipped classrooms in medical education flipping the classroom in graduate medical education: a systematic review creating gridlocked: a serious game for teaching about multipatient environments serious games and blended learning; effects on performance and motivation in medical education the use of "war games" to enhance highrisk clinical decision-making in students and residents using game format to teach psychopharmacology to medical students survivor torches "who wants to be a physician? educational games in an obstetrics and gynecology core curriculum learning clinical neurophysiology: gaming is better than lectures free open access medical education (foam) resources in a team-based learning educational series a pilot study of team-based learning in one-hour pediatrics residency conferences use of learning teams to improve the educational environment of general surgery residency use of team-based learning pedagogy for internal medicine ambulatory resident teaching a narrative review and novel framework for application of team-based learning in graduate medical education the 2016 model of the clinical practice of emergency medicine creating the model of a clinical practice: the case of emergency medicine the 2013 model of the clinical practice of emergency medicine the model of the clinical practice of emergency medicine understanding by design stop the blame game: restructuring morbidity and mortality conferences to teach patient safety and quality improvement to residents educator toolkits on second victim syndrome, mindfulness and meditation, and positive psychology: the 2017 resident wellness consensus summit key: cord-022076-zpn2h9mt authors: chaffee, mary w.; oster, neill s. title: the role of hospitals in disaster date: 2009-05-15 journal: disaster medicine doi: 10.1016/b978-0-323-03253-7.50012-1 sha: doc_id: 22076 cord_uid: zpn2h9mt nan when the first rain began to fall in houston,texas, in june 2001, did hospital staff know they would soon be providing care for hundreds of patients without electrical power or running water in flooded hospital buildings? on april 19, 1995 , did the emergency department staff arriving for the day shift at 13 oklahoma city hospitals know that a former soldier was driving a rented van filled with 4000 pounds of ammonium nitrate toward the murrah federal building and that they would soon be faced with 324 bombing victims? in 1984, did restaurant patrons in wasco county, ore., have any idea, as they selected food from salad bars, that they would soon be evaluated in hospitals for profuse, watery diarrhea from intentional food contamination by a religious cult? in march 2003, did the 11 toronto healthcare workers who were caring for patients with respiratory symptoms know they would soon become infected with severe acute respiratory syndrome (sars) ? we can be quite certain that none of them knew. the capricious nature of disaster implies victims and responders are generally caught unaware. but we do know some things. we know there will be hurricanes, typhoons, tornadoes, earthquakes, mudslides, fires, and blizzards this year. we know people will pick up firearms, make bombs, and inflict pain and suffering on others. we know there will be casualties from train accidents, cars crumpled in chain reactions, building collapses, and explosions.we know infectious diseases will do what they do best: spread, sicken, and kill. we know terrorists have not given up their violent assaults. we know there will be mental health symptoms in accident survivors and the caregivers who respond to their needs. it is the hospital, at the heart of the health system, that will receive the injured, infected, bleeding, broken, and terrified from these events. we know the victims will seek life-saving care, comfort, and relief at hospitals, but many u.s. hospitals continue to prepare for disaster as though it will not happen to them. there are more than 5700 hospitals in the united states that form a diverse patchwork of healthcare services. u.s. hospitals vary greatly by geographic location (urban, suburban, and rural); financial and management structure (for profit, not-for-profit, private, public); type of care (general medical services or specialty care, such as psychiatric or pediatric); and government affiliation (department of defense,veterans health administration, or public health service). any of these hospitals may be called on to respond to the next disaster or may be the victim of a disaster. many experts believe that these hospitals are not adequately prepared to respond effectively ( the hospital was of little significance in american healthcare before the civil war. only 178 hospitals existed in 1873 when the first survey was conducted-a time when no proper gentleman or lady would venture into a hospital by choice. 1 the murky medical practices of the 1800s offered little that couldn't be found in homes, and physicians had little in their armamentarium to change the course of disease and injury. however, discovery and scientific advance changed that. effective anesthesia, surgical antisepsis, antibiotics, the x-ray, and other advances turned the hospital into a place of comfort, hope, and healing. the 20th-century hospital became a sophisticated financial institution, the core of medical education, and the site of dazzling technological display. medical advances offered aid not only to the chronically ill but offered hope to those who suffered acute trauma or medical or psychiatric emergency. past events illuminate the variety and complexity of demands placed on a hospital in a disaster: the potential impact of disaster is staggering. the release of 40 tons of methyl isocyanate from the union carbide factory in bhopal, india, in december 1984 exposed more than 500,000 to the deadly gas and killed about 6000 in the first week after the release. in september 1987, workers scavenging a dismantled cancer clinic in goiania, brazil, took home a source containing cesium-137. they sold it to a junkman who showed the glowing item to friends and neighbors. once radiation exposure victims presented to hospitals, and the release became well known, hospitals were overwhelmed. although 250 were actually exposed and 28 showed signs of radiation sickness, 112,800 people were evaluated. when the aum shinri kyo cult placed sarin on five trains in the tokyo subway system on march 20, 1995, 4000 people made their own way to hospitals, 641 were transported by authorities, and 245 hospital staff and rescue personnel were contaminated due to poor or nonexistent decontamination procedures. 10 on sept. 11, 2001, when u.s. hospitals and healthcare professionals were confronted with the worst attack on american soil, and again during the anthrax attacks along the eastern seaboard, individuals and organizations responded heroically. a powerful change in thinking, also called a paradigm shift, occurred after the terror attacks: the health system came to be viewed as a foundation of national security. another perspective has changed as well. in the event of a disaster, emergency medical services (ems), police, and fire have long been recognized as first responders. however, just recently, hospitals also have been designated as first responders-and first receivers. the value of the hospital in national security has been increased, and hospitals are recognized as safe havens in communities, the public expects hospitals to be prepared to care for their needs, and the hospital is now recognized as a first responder in emergencies. however, hospitals remain significantly underprepared to respond as effectively as the public expects. most importantly, preparedness is at direct odds with productivity. daily operating requirements stretch most hospitals' resources. allocating funds to improve emergency response capabilities that may never be used could be viewed as foolhardy. community integration is now seen as necessary, but hospitals (other than those in networks or that are government facilities) have had few reasons to build healthy relationships with other hospitals in their communities. to meet the needs of communities in a disaster, business competitors must work as partners. hospitals play a vital role in the health,social structure,and economic life of a community. patients expect hospitals, and health system workers, to be available to provide care for them in all circumstances. a level of preparedness that was viewed as adequate in the past is no longer seen as acceptable. to be more highly prepared and to be able to respond effectively, hospitals must make substantial investment in equipment, training, facilities improvements, and supplies. 11 hospitals depend on public trust; poor performance during a disaster could be financially crippling to a facility. rubin 12 writes that hospitals are expected to handle whatever they receive and do it right the first time. hospitals are vulnerable to the stresses of disaster responses due to a number of inherent characteristics: • complexity of services: hospitals are facilities that provide healthcare but must also function as laundromats, hotels, office buildings, laboratories, restaurants, and warehouses. • dependence on lifelines: hospitals are completely dependent on basic public services: water, sewer, power, medical gases, communications, fuel, and waste collection. • hazardous materials: the hospital environment contains toxic agents and poisonous liquids and gases. • dangerous objects: heavy medical equipment, storage shelves, and supplies can fall or shift during an event such as an earthquake. 13 multiple forces have placed hospitals in a precarious preparedness posture. the capacity of the health system has been scaled down to a bare minimum to cut operating costs. emergency departments are crowded with the uninsured and the underinsured who have no other access to care. the nursing workforce has withered, and physicians have left practice due to uncontrolled liability insurance costs. many hospitals determine their surge capacity by the number of patients they could comfortably care for using standard spaces, quality care standards, and additional teams of personnel to help. in reality, a disaster is not going to comply with the limits of hospital capacity. if 300 bombing victims arrive at a 50-bed community hospital, spaces will need to be converted and used that planners may have never imagined, such as chapels, hallways, and offices. nurses accustomed to a certain nurseto-patient ratio may find the ratio in a disaster much higher and have to adapt practice accordingly. surge capacity must not be viewed only as the number of beds or spaces that can be allotted to care for patients, but it must include all supporting hospital services that are involved in patient care. if hospital services fail during a disaster, the hospital fails the population depending on it. the population includes not just the victims of the disaster, but the others presenting for needed care-women preparing to give birth, patients with chronic disease exacerbation, and children with lacerations that need sutures. a vital hospital emergency management program acts as an insurance policy that increases the chances of continued operations under difficult circumstances. an effective hospital emergency management program guides the development and execution of activities that mitigate, prepare for, respond to, and recover from incidents that disrupt the normal provision of care. 14 the program should include the following components: • emergency manager: the emergency manager is the primary point of leadership in the development, improvement, exercise, and execution of the hospital's emergency management plan. • emergency management plan: the plan identifies the hospital's response to internal and external emergencies. deliberate (advance) planning permits the development of strategies while the organization is not under pressure to react. • executive leadership: hospital executive leadership charts the course for an organization. a hospital that lacks executive leadership committed to emergency preparedness will be significantly hampered in its efforts. • strategic planning: the hospital's strategic plan is the blueprint that guides all efforts to achieve its mission. it is critical that emergency management and preparedness efforts are woven into strategic planning. • emergency management committee: extremely broad membership is desired to ensure all hospital operations that will be stressed in a disaster are integrated and well prepared. • hazard vulnerability analysis (hva): the hva is a tool used to assess the risks in a specific environment. the emergency management plan can be tailored to address the hazards most likely to affect hospital operations. • vulnerability analysis: every aspect of hospital operations that will be depended on in a disaster should be assessed to determine whether there are weaknesses present that fail when stressed. hospitals in the u.s. navy medical department and a number of civilian hospitals in new york have had their level of preparedness assessed using the hospital emergency analysis tool (heat). the heat examines more than 230 factors that contribute to effective emergency preparedness and response. after the systematic analysis by a team of experts, the hospital receives an after-action report that documents strengths and weaknesses and permits the development of a strategic plan to improve preparedness. 15 • staff training, exercise, and continuous improvement: the joint commission on accreditation of healthcare organizations requires hospital staff members involved in the execution of the emergency management plan to receive orientation and education relative to their role in an emergency. exercise of the emergency plan is also required. lessons learned should be integrated into plans to continuously revise them. a commitment to the following philosophies will enhance hospital emergency preparedness: • imagine the unimaginable: when flood waters rise in a community, when a tornado touches down and demolishes an elementary school, when a disgruntled hospital employee opens fire with an automatic weapon in the emergency department, when a passing train derails and spills toxic chemicals, or when a wildfire closes in, it is too late to update an old plan, train staff to respond effectively, check phone numbers, and stock disaster supplies. disaster complacencybelieving a problem won't happen to you or your hospital-is a significant threat to effective planning and response. • protect the staff: only a true obsession with self-protection will ensure that staff members are not injured or become ill during disaster response. adequate stockpiles of gloves, masks, and other equipment must be available, along with training and leadership commitment to self-protection policies. • build in redundancy: expect the primary plan to fail and build in alternatives to every emergency measure. • rely on standard procedures whenever possible: people perform best in unusual situations when they perform activities that closely mirror what they do under normal conditions. • maintain records: patient care records are critical to obtaining reimbursement for disaster care provided. • plan to degrade services: normal levels of services cannot be maintained during disaster response. identify services, such as elective surgery, that can be temporarily curtailed or minimized so that personnel and resources can be reassigned. the federal government has implemented programs to augment local and state capabilities when they are overwhelmed. the united states has a well-established emergency medical safety net: the national disaster medical system (ndms). the ndms has two primary capabilities designed to enhance disaster medical response. the first is specialized disaster response teams who augment the medical emergency response at the site of disaster. the second ndms capability is a plan to share the inpatient bed capacity of the civilian and federal health systems in the event either system is overwhelmed with patients requiring inpatient care. ndms federal coordinating centers (fccs) play a regional role in maintaining a supply of ndms hospital members and providing training and exercises. when the ndms is activated, fccs coordinate patient reception and distribution of patients being evacuated. hospitals enter into a voluntary agreement to participate in the ndms. they must be accredited and generally have more than 100 beds. the agreement commits a hospital to provide a certain number of acute care beds to ndms patients; however, it is recognized that hospitals may or may not be able to provide the agreedupon number of beds. hospitals that receive ndms patients are reimbursed for care by the federal government. 16 the strategic national stockpile the strategic national stockpile (sns) was established in 1999 as the national pharmaceutical stockpile. it is now managed by the u.s. department of homeland security and serves as a national repository of antibiotics, chemical antidotes, antitoxins, intravenous therapy, airway management equipment, and medical/surgical items. the stockpile is designed to supplement local agencies that are overwhelmed by a health emergency. the noble training center in anniston,ala., (on the site of the former fort mcclellan army base) is the only hospital facility in the united states that trains healthcare professionals in disaster preparedness and response. the department of homeland security operates the noble training center, which offers a variety of training programs, including one for hospital leadership. more information is available online at: http://training.fema. gov/emiweb/ntc/. even though the federal government has many emergency response assets that can help in the response to an emergency, experience has shown that hospitals must be prepared to be self-sufficient for 24 to 72 hours after an event. 14 a comprehensive hospital emergency management program must address a number of critical elements to adequately protect patients and staff and permit the facility to continue to operate. these are discussed in the following. just as one team leader is necessary for a controlled response to a cardiac arrest, an organized approach is essential to a successful hospital-wide emergency response. the hospital emergency incident command system (heics) is designed to provide that coordination. developed and tested in orange county, calif., in 1992, it provides structure to response. heics uses: • a reproducible, predictable chain of command • a flexible organizational design that can be scaled to the scope of the problem • checklists for each position to simplify response and carefully define each task • a common language that permits communication with outside agencies the eoc will serve as the command post for operations during an emergency response. it should be fully operational and integrated into local and county emergency operations (box 5-1). hospital disaster drills have often been treated as annoyances and are planned in ways to render them futile. exercises are generally announced (unlike actual events), planned during regular business hours, and rarely include all hospital operations that will be affected by an actual event. hospitals are encouraged to drill individual units-frequently and during nights and weekends-and then build up to full, functional exercises involving management of moulaged "casualties." community participation is critical to identify elements that work or that need fine-tuning. only through exercise will the plan be adequately stressed so that failure points are identified. the facility's structural integrity and essential services are an often overlooked part of preparedness. box 5-1 recommended equipment and supplies for a hospital eoc (hvac) system so that it can be shut down and, ideally, so that specific zones can be manipulated to control airflow in the building in case of contamination • maintain a fuel source for full-load demand for 3 to 4 days' duration • develop a plan for the management and disposal of increased volumes of contaminated waste maintaining the physical security of the structure is important on a daily basis but becomes more of a challenge during a disaster. to ensure that the environment remains safe, egress must be controlled. additional elements of the physical security plan should include the following: • a security force with full-time security responsibilities; the force should have undergone criminal background checks and professional law enforcement training. • all entrances and exits should be controlled, monitored, and capable of being locked. • the hospital should be able to perform perimeter security protection ("lockdown") within minutes of notification. • hospital staff should be trained and drilled on the performance of lockdown. • hospital leadership should know what triggers the execution of a lockdown procedure. • a plan should exist for supplementing security staff in a disaster. it is critical that a hospital be able to rapidly assess the impact of a disaster on its operations and communicate the status to leadership in a situation report (often referred to as a "sitrep"), or a rapid needs assessment (ran). the assessment should, at a minimum, include the following: • the extent and magnitude of the disaster and the scope and nature of casualties • the status of operations and any disrupted critical services • the impact of disruptions on operations and the ability to sustain operations 17 hospital staff must be able to receive timely and accurate notifications in a disaster, including when and where to report and for how long and other essential information. contact information for all staff members must be continuously updated and tested. additionally, the facility must be able to receive warnings and notifications from external agencies and be able to send warnings. triage is performed daily in emergency departments, where the most critical are treated first. but during a dis-aster, triage procedures must adapt to become like what is used on the battlefield, where the greatest good is offered to the greatest number. multiple disaster triage systems exist, including start (simple triage and rapid treatment), id-me (immediate, delayed, minimal, expectant), and mass (move, assess, sort, and send). it is important that a hospital use a system that is consistent with what is being used by services delivering patients to the facility. whatever system is selected, there must be predisaster training and exercises. when casualties present to an emergency department in numbers that overwhelm the facility, an alternative area must be available to manage overflow. the alternative triage area should be lit so that it can be used at night, weatherproofed, and temperature-controlled. a plan for working with the media will be needed. it is not recommended that media personnel be permitted access to a hospital during a disaster, but rather be provided regular, factual updates on activities and the status of the facility at a predetermined meeting place. risk communications involve using credible experts to deliver carefully worded messages to communicate most effectively in a high-stress, low-trust environment, such as a disaster. preparing hospital leaders in risk communications principles will ensure that they are able to communicate effectively to the public via the media. there is conflicting evidence about the value of certain types of mental health services in the wake of disaster, but it is clear that every disaster creates emotional trauma victims. primary victims are those who have been directly affected by the disaster. secondary victims are rescue workers in whom symptoms develop, and tertiary victims are relatives, friends, and others who have been affected. the critical incident disrupts a victim's sense of control as daily life is abruptly changed. 18 hospitals must plan for providing mental health services to disaster victims but must also consider the needs-acute and long-term-of the hospital staff who attempt to respond to an overwhelming event. it is recommended that hospitals have trained crisis intervention teams that are well integrated into the emergency management plan. in the event of an intentional act that results in mass casualties, not only must a hospital care for the victims, but it has a critical role in bringing perpetrators to justice. hospital staff members require training in proper management of potential evidence-in both collection and preservation. evidence collection containers, including 50-gallon drums for patient decontamination run-off, should be available as well as bags to preserve other types of evidence. law enforcement agencies and forensic departments can provide training and guidance. staff members should be familiar with and follow procedures for maintaining chain of custody for evidence that is collected during patient care activities. a disaster will place significant demands on the food service system of a hospital. the adequacy of food supplies for patients and staff should be evaluated. because a hospital may need to be self-sufficient for several days in a disaster, a 3-to 4-day supply of food products is advisable. food service personnel should be included in disaster exercises. volunteers may or may not be of assistance, depending on their relationship with the hospital and their background. a volunteer pool that consists of individuals who serve regularly at the facility, are familiar with standard procedures, and participate in exercises can add valuable manpower to a disaster response effort. on the other hand,disasters will draw volunteers who wish to assist,a phenomenon known as "convergent volunteerism," in which unexpected and uninvited healthcare workers arrive and wish to render assistance at a large-scale incident. 19 these "freelancers" may cause problems or may even be impostors. despite "just-in-time" supply schedules and empty warehouses, hospitals should maintain dedicated disaster supplies and arrangements for rapid resupply in the event of a disaster. disaster response will rapidly deplete critical supplies-administrative as well as clinical. conducting realistic exercises will help with the determination of the adequacy of stock and can be done without opening actual supplies so they can be restocked. disaster supplies can be rotated into the daily-use stream to ensure stock does not expire. experience with disasters has demonstrated a number of predictable pitfalls that occur in hospital disaster response. because immediate on-scene control of a disaster is chaotic and communication is often problematic, patients will present to the closest hospital available. this often leaves other nearby facilities with capacity and personnel that go unused. hospital personnel must be experts in protecting themselves, or they will become part of the problem and fur-ther stress the facility. some controversy exists over the level of protection needed in certain environments, but it is clear that masks (n95) and gloves (latex or nonlatex) will prevent transmission of biological agents. communications failure has often been identified as a predictable failure in disaster response. hospitals need to examine both internal communications systems (with staff and patients) and with external agencies. multiple layers of redundancy are essential to deal with expected failures and include the use of 800-mhz radios, dedicated trunk lines in the emergency operations center, two-way communications for hospital units and essential personnel, communications-on-wheels (cows), and access to amateur radio (ham) operators. the last resort is using runners who carry messages. hospitals must be able to identify and decontaminate patients who have been exposed to radiation or a compound that poses a threat to the patient's health and the safety of the facility. if the hospital depends on an external agency or has decontamination equipment that requires time to set up, an immediate alternative must be in place, such as a hose and hose bib outside of the emergency department. consideration should be given to patient privacy, managing patient valuables and clothes, and handling weapons brought into the hospital. a trained, exercised, and well-equipped team will be the foundation of successful efforts. hospitals will benefit from having a plan to care for children and other dependents of staff. in a disaster, staff will be called on to work extended hours, and usual family care arrangements may be unavailable. the creation of emergency patient admission packs that are maintained with disaster equipment will facilitate the admission of a large number of patients. if an automated patient tracking system is used, a back-up manual system should be available. all systems should be able to manage unidentified (john and jane doe) patients. many hospitals have wholly inadequate or nonexistent plans to manage mass fatalities. morgue space is generally limited in most facilities, so additional surge capacity must be identified in advance. arrangements for refrigerated storage trucks, refrigerator space, and other alternatives, including ice rinks, should be addressed with socially sensitive plans. complex cultural and religious issues may come into play in the event that there are contaminated remains and should be examined in advance. emergency drugs must be available at the point of care. often they are secured in pharmacy departments or warehouses, resulting in precious minutes of life-saving time being lost as personnel try to locate and obtain critical medications. in addition to drugs needed to respond quickly to nerve agents and other emergency situations, stockpiles of antibiotics should be maintained to provide prophylaxis to patients and staff. in a disaster, patients converge on the place they know they can obtain care-the hospital-and they arrive using any means possible. furthermore, with the victims of disaster, come their families, loved ones, and the media-all who have very important needs that must be addressed. hospitals can no longer approach disaster planning with a minimalist attitude that relies heavily on luck and belief that it will be someplace else that gets hit by the disaster. the hospital that received the most patients from the rhode island nightclub fire got lucky-the victims began arriving during a change of shift so there were two shifts of nursing staff available. however, the hospital also attributes its effective response to having drilled critical departments and procedures. emergency planning is the backbone of preparedness, but events will occur in each disaster that demand creative responses under pressure. this ability to respond flexibly is known as planned innovation. good plans will use general "all hazards" templates for disaster management but will permit independent initiative and a tailored response to a specific situation. 20 the u.s. health system appears to be emerging from the dark ages of emergency planning. a minimalist attitude of preparedness was acceptable in the past despite the regular occurrence of natural disasters. the threat of terrorism and the resulting health system impact have stimulated investment in research, a resurgence of disaster training in nursing and medical schools, and visionary projects such as er one. er one is a national prototype for a next-generation emergency department. located in washington, d.c., it is developing new approaches to the medical consequences of terrorist attacks, natural disasters, and emerging illnesses. more information is available online at: http://er1.org. the next phase of hospital emergency management will be a renaissance if creative planning prevails over naysayers, if resources are applied to priority preparedness activities, and if healthcare leaders are committed to ensuring that all who depend on hospitals will receive the care they need in a disaster (box 5-2). the care of strangers-the rise of america's hospital system combined external and internal hospital disaster: impact and response in a houston trauma center intensive care unit implications of hospital evacuation after the northridge, california, earthquake lessons learned from the activation of a disaster plan: 9/11 two new york city hospitals' surgical response to the a test of preparedness and spirit emergency department impact of the oklahoma city terrorist bombing tragedy and response-the rhode island nightclub fire the station nightclub fire and disaster preparedness in rhode island mass decontamination: why re-invent the wheel? meeting new challenges and fulfilling the public trust: resources needed for hospital emergency preparedness recurring pitfalls in hospital preparedness and response pan american health organization. principles of disaster mitigation in health facilities health care at the crossroads-strategies for creating and • auf der heide e. principles of hospital disaster planning department of health and human services. (includes recommendations on prehospital and hospital care preparing for the psychological consequences of terrorism-a public health strategy. this 2003 publication of the national academies of science includes an examination of current infrastructure and response strategies guide to emergency management planning in health care regional care model for bioterrorist events • the hospital emergency incident command system • the international critical incident stress foundation box 5-2 hospital preparedness and response resources sustaining community-wide emergency preparedness systems dvatex: navy medicine's pioneering approach to improving hospital emergency preparedness advanced disaster medical response-manual for providers. boston: harvard medical international trauma and disaster institute critical incident stress making room for outside the box thinking in emergency management and preparedness key: cord-284454-malfatni authors: mccall, w. travis title: caring for patients from a school shooting: a qualitative case series in emergency nursing date: 2020-08-19 journal: j emerg nurs doi: 10.1016/j.jen.2020.06.005 sha: doc_id: 284454 cord_uid: malfatni introduction: emergency nurses are at risk for secondary traumatic stress, compassion fatigue, and burnout as a result of witnessing the trauma and suffering of patients. the traumatic events perceived as being most stressful for emergency nurses involve sudden death, children, and adolescents. multicasualty, school-associated shooting events are, therefore, likely to affect emergency nurses, and recent reports indicate an increase in multicasualty, school-associated shootings. this research is necessary to learn of emergency nurses’ experiences of caring for patients from a school shooting event in an effort to benefit future preparedness, response, and recovery. this manuscript describes these experiences and provides opportunities for nurses, peers, and leaders to promote mental health and resilience among emergency nurses who may provide care to patients after such events. methods: a qualitative case series approach, a theory of secondary traumatic stress, and the compassion fatigue resilience model guided the research. the emergency nurses who provided care to patients who were injured during a 2018 multicasualty, school-associated shooting in the southeastern united states were invited to participate. results: the themes identified by this research with 7 participants were preparation and preparedness, coping and support mechanisms, and reflections and closure. discussion: the results identified through this research may be translated to policies and practice to improve emergency nurses’ welfare, coping, resilience, and retention. patient outcomes may also be improved through planning and preparedness. secondary traumatic stress is the incidence of thought intrusions, heightened arousal, situational avoidance, and/or emotional numbing in those who witness traumatic events or provide care to critically ill or injured patients. 1 it is often associated with the development of compassion fatigue, defined as the impairment in a clinician's ability to care for others effectively. 2 the presence of secondary traumatic stress among emergency nurses can negatively affect their resilience, 3 which may ultimately contribute to burnout and departure from the nursing profession. 4 emergency nurses are frequently exposed to traumatic events through the delivery of care to injured patients. the types of events that have been identified as being most distressing to nurses are those involving sudden death, children, or adolescents. [5] [6] [7] [8] therefore, providing care to patients who are injured during school-associated shooting events is likely to be particularly stressful for emergency nurses. although the rates of multicasualty, schoolassociated shootings declined from july 1994 to june 2009, the incidence rates increased between july 2009 and june 2018. 9 the study defined "multiple-victim" as including more than a single victim and reported that 38 of these events resulted in 121 youth homicides between july 1994 and june 2016. 9 a recent study exploring nurses' suicide rates in the united states identified that the rates among female and male nurse subpopulations were significantly higher than those in the general female and male populations, respectively. 10 additional research to identify risk factors and effective interventions is needed to improve mental health and combat the prevalence of suicide among nurses. moreover, nurse burnout and departure from the profession may exacerbate nursing shortages and staffing challenges, which may directly affect emergency departments. therefore, research is indicated to identify how health care professionals who are tasked with providing medical care to the victims of school shooting events are affected mentally and emotionally. the benefits of this research include improved understanding of how these events may affect emergency nurses and identification of factors that may promote welfare, coping, resilience, and retention. the purpose of this study was to learn how emergency nurses describe their experiences to identify themes and findings that may translate to practices for improving the mental health and wellness of emergency nurses who care for patients from a multicasualty, school-associated shooting incident. a qualitative case series methodology using the data collection and analysis methods described by yin, 11 which includes steps to plan, design, prepare, collect, analyze, and share, was used to guide this research. the study was performed after approval was received from the vanderbilt university institutional review board (irb #190980). these methods include the use of structured interviews and reliance on theoretical propositions in the analysis. 11 the interviews were conducted approximately 18 months after the adult emergency department of a level 1 trauma center received 5 patients by helicopter emergency medical transport from the scene of a schoolassociated shooting event. the emergency nurses who participated in the trauma resuscitations or assisted with the transition of these patients from the receiving helipad to the emergency department were eligible to participate. ten registered nurses were identified by review of the ed daily assignment sheet, and their patient care roles were confirmed from patient electronic medical records. these nurses were invited to participate by e-mail distribution of a recruitment flyer. the processes and flow of the receiving emergency department were known to the researcher, who had more than 3 years of experience as a clinician in this department. the researcher did not have any personal experience with providing care to patients from a school-associated shooting event. a list of avaiilable support services was provided to each participant at the time of their interview. semistructured interview questions and analysis of the data were informed by a theory of secondary traumatic stress and the compassion fatigue resilience model, 12 as well as the professional quality of life model. 13 the conceptual variables identified in the compassion fatigue resilience model ( figure) and an examination of how those concepts related to the experiences described by these nurses benefited the development of the interview questions (supplementary appendix) and interpretation of the data. the professional quality of life model defines professional quality of life as incorporating aspects of compassion satisfaction and compassion fatigue. although compassion satisfaction reflects positivity in helping others, compassion fatigue consists of the concepts of burnout and secondary trauma. 13 burnout includes symptoms such as exhaustion and depression, whereas secondary traumatic stress represents negative symptoms that result from trauma experienced through work activities. 13 the interviews were recorded with an audio recorder and transcribed verbatim by the researcher or a transcriptionist who had signed a confidentiality agreement. field notes were recorded by the researcher at the end of the interview and reviewed before coding activities. each transcript was reviewed by the researcher for accuracy. the framework method was used in the analysis of the data. this method uses stages of transcription, familiarization, coding, analytical framework development, analytical framework application, data charting into framework matrix, and data interpretation. 14 key phrases and meaning units from the transcriptions were identified and coded by the researcher using nvivo 12 software (qsr international). 15 the categorization of codes generated themes that represented what the participants shared. seven nurses agreed to enroll and completed an informed consent. there was no verbal or written response from the 3 eligible participants who did not enroll. the participants' ages ranged from 30 years to 41 years, and 6 were female. two of the participants shared that they were parents. the researcher was known to 4 of the participants before the interviews. it was anticipated that the interviews would last between 30 minutes and 60 minutes and the median duration was 37.7 minutes. the associate nursing officer for emergency services agreed to pay the 5 participants who remained actively employed by the health care institution for their interview time. two participants had resigned from their positions and were compensated with a gift card at the expense of the researcher. a single interview with each participant was performed over a period of nearly 4 weeks. the interviews were conducted in private without the presence of nonparticipants. the interviews were conducted at a location identified by the participant, and 3 were performed by video conference owing to distance or participant availability. although the participation of 7 eligible nurses limited the ability to ensure saturation, the identified themes and findings were consistent through the interviews. the emergency nurses often reported being in "nurse mode" and described taking immediate actions to promote readiness of the receiving trauma bays. focusing on tasks allows you to kind of push the sadness and the trauma to the side so that you can complete your tasks successfully and give the best chance at living, or keeping their arm, or anything like that. we had to compartmentalize that [...] these were actually children and just focus on the job we knew we needed to do. the nurses described placing signage indicating the air ambulance service and unit number as well as age and known injuries for each corresponding patient on the door of each resuscitation room during the planning stage prior to the arrival of the patients. this planning was described as beneficial in that it allowed the emergency nurses to gather the supplies and equipment needed to effectively care for the patients. if my room is better prepared, i can take care of the patient better. the participants described the importance of being proficient in providing care to trauma patients. although these patients were all transported to the receiving trauma center by helicopter, the limitations in air medical resources such as weather restrictions or ambulance availability could necessitate the stabilization of patients from multicasualty school shooting events in community departments where resources are likely to be more limited. these limitations may include bed capacity, number of available providers and staff, supplies and equipment, blood product availability, and access to support services. one participant indicated that nurses in community settings who may face such a mass or multicasualty event should maintain trauma nursing certification to promote proficiency in trauma care. nurses that work in those community hospitals. my advice is to become tncc [trauma nursing core course] certified. one nurse expressed concern regarding the frequency of these events, which underscored the need to maintain high levels of readiness. i don't think it's going to get any better with time. i think it's going to get worse. i don't think that we're going to be able to stop it. another participant predicted that community or critical access emergency departments receiving patients from a multicasualty school shooting event may experience even greater emotional challenges because these departments are more likely to have staff who may personally know the victims or their families. compounding variables may create unique challenges for teams and individuals who are providing care to these patients. these factors or limitations may include personal matters, interpersonal challenges, multiple simultaneous traumatic events, high patient censuses, and staffing or equipment constraints. for instance, 1 nurse recalled tension with a staff member from another department who was encountered during transition to the emergency department. comprehensive trauma centers routinely experience high censuses and preparing to accommodate the influx of patients from a mass casualty can be daunting. underlying personal or departmental issues may also compound the stresses associated with caring for these patients. recognizing existing factors or limitations, and taking action to control these effects, may mitigate the stresses associated with potential external variables. some emergency nurses described an increased presence of hospital personnel coming to the department during the care of the patients. everybody who was anybody, administratively. whether they had anything to do with what we were actually doing there, was there. two of the emergency nurses reported their disapproval of individuals who were not directly involved in patient care being present for the resuscitation efforts. one of the emergency nurses described the attendance of some individuals as their "just [wanting] to be enmeshed in that story, in that drama." another participant reflected on: .the feeling of having people there who were just there to kind of watch this terrible thing and just kind of live.vicariously through us. in addition, this emergency nurse further described that when observers are present in a resuscitation that the nurse perceives as difficult, it may result in increased emotional or psychosocial challenges. when it's really bad or it affects you personally, and there's someone in there looking at you, it's very hard, at least for me, to not feel just angry, or just disgusted by the whole thing. some nurses found the attendance by individuals who were not directly participating in the care of the patient to be unhelpful and one described it as "inappropriate." coping and support mechanisms most participating emergency nurses described the importance of maintaining a self-care routine to foster personal well-being and promote emotional recovery after such events. coping and self-care strategies or routines that were described by the emergency nurses included cooking, exercising, walking, hiking, kayaking, humor, or talking with peers. one participant did admit that her usual mechanism after witnessing such trauma was to "bury it," but she found some benefit to participating in activities in the outdoors when needing to cope with a situation. the participants who offered that their significant other or spouse worked in a health care role identified the benefits of gaining their support after challenging patient situations. however, another shared previous challenges with discussing stressful work situations with a significant other who did not work in health care. none of the nurses discussed negative coping strategies or mentioned avoiding work or certain patient assignments after caring for these patients. a formal debriefing event, taking place after the patients were transitioned from the emergency department to receiving operating rooms or units, was recalled by most participants. the emergency nurses offered varied perceptions of the formal debrief, and some questioned its effectiveness in promoting coping and recovery of the emergency nurses in attendance. some participants indicated that the debrief focused on clinical assessment of the resuscitations rather than on the emotional components of being involved in the patients' care. [they] talked about things that went well, and things that didn't go well. some of the nurses discussed being unfamiliar with those who came to the department to lead the debriefing session. some participants also reported limited perceived efficacy of the session. reasons for this perceived limited efficacy included a lack of a rapport with the debriefing session lead. one of the nurses admitted that she would not have voiced a perceived need for formal support during the debrief because she didn't "feel comfortable." another nurse admitted being reluctant to share emotions with a group of people, many of whom she did not know, during the formal debrief after the resuscitations. it was all these people, most of whom i had never seen before. one of the emergency nurses valued the availability of an employee assistance program but described that its resources would be most appropriate to provide to nurses after the acute phase of the incident. i do think there's a benefit to having someone who's.objective and has been trained on how to be.an emotional mediator and [to] reflect things back at you.i do think that has its place. [but] i think maybe [when] it's in the moment.that it, it really doesn't fit. therefore, the presence of employee assistance professionals in the affected emergency department may be most appropriate during the days or weeks that follow the multicasualty event to coordinate any desired individual appointments for counseling or resources. one nurse shared: i think if you want to safeguard the staff's emotions you should keep [it] in the family. the emergency nurses identified that peer-to-peer interactions after the event were beneficial for coping and recovery but indicated some reluctance in making immediate use of formal resources provided by individuals who had not participated in the care of these patients. they reported the perceived benefits of participating in peer-led activities to promote discussion and closure after caring for these patients. they offered me services, but i feel like i got the most help from my coworkers. some of the participating nurses expressed that they would have preferred peer-support sessions and informal conversations to the debriefing that occurred after the ed resuscitations. i feel like the most effective way to have dealt with that, for me, would have been for us to have a conversation. like the people involved. despite the passage of 18 months between the event and the nurses' participation in the research interviews, each participant provided recollections of these patients and their interactions. most admitted that having such vivid recollections of a patient after such a length of time was not common. every time i hear about a school shooting in the news, anything like that, i just remember [my patient] in my bay. the participating emergency nurses often described reflecting on the patients while they were away from work. one nurse admitted to thinking about the patients for months after the event. another participant described nightmares that she experienced in the week after the event. i did have a few nightmares that i was actually at the school and i was trying to save some kids through a gym and going behind the stairs. media coverage of the school shooting event was described as providing a context for the incident but heightening thought intrusions. it was all over the news that day.i was just looking at news reports to see what had been reported. social media and the frequent sharing or posting of media information limited the ability to separate from the event after the shift. you can't escape, you may not be [seeking out] the articles on things, but.you're reading people posting the articles. and then they inevitably [add] their own commentary on it. the emergency nurses described a lack of closure because hospital policy prevented access to medical records after a patient's departure from the emergency department. if they're not in the er, we're not supposed to access them. i think about them often when i hear of school shootings and wonder how they are. we didn't get really good follow-up on them, actually, which i think might have been helpful. two participants also expressed curiosity related to how these patients had recovered from the emotional trauma of the event. the emergency nurses described the development of heightened situational awareness of potential acts of violence against themselves, family members, or friends as a result of being involved in the care of victims of acts of violence. those nurses who identified themselves as parents described having increased thoughts of such situational awareness and acknowledged a concern for potential risks to their own children. this nurse later transitioned her children to home school after the incident. another participant who did not identify as being a parent added: i can't imagine having kids that are at that age and having to work something like that. the identified themes of preparation and preparedness, coping and support mechanisms, and reflections and closure were identified through an analysis of interviews with the emergency nurses. within these themes were findings that may be translated to implications for emergency nurses (table 1) . this study was conducted to examine the psychosocial effects of providing emergency nursing care to patients who were injured in a multicasualty, school-associated shooting event. in a discussion of the theory of secondary traumatic stress, ludick and figley 12 (p118) identified that preparation and preparedness nurses felt that preparation, planning, and trauma nursing proficiency are essential. nurses stressed the importance of removing nonessential staff and unfamiliar contributors. compounding variables from professional and personal lives may worsen associated stress. coping and support mechanisms the use of self-care routines fosters underlying nurse welfare. nurses shared varied perceptions and opinions related to the formal debrief. nurses discussed the benefit of peer activities to promote wellness and healing. nurses shared vivid recollections of the patients even after 18 months. nurses often described reflecting on the patients while away from work. one participant described nightmares experienced in the following week. there was a lack of achieving closure because patient outcomes were often unknown. extensive media coverage and social media provided context for the incident but increased thought intrusions. heightened situational awareness was evident, particularly among those nurses who are parents. "qualitative data offers targeted information and specific insights that unearth valuable, unique information and opens new lines of research." because the events perceived as being most distressing to nurses involve sudden death, children, or adolescents, 5-8 qualitative research among emergency nurses who provided care to patients from a multicasualty, school-associated shooting may provide opportunities to learn how to best support nurse welfare and resilience among emergency nurses. the themes identified by this study include preparation and preparedness, coping and support mechanisms, and reflections and closure. these themes parallel the theoretical sectors and variables of empathic response, empathic concern, other life demands, self-care, detachment, social support, traumatic memories, sense of satisfaction, and secondary traumatic stress. 12 this research aligns with the literature that has identified the prevalence of secondary traumatic stress among emergency nurses. [16] [17] [18] [19] [20] the symptoms identified among the nurses who participated in this study included the presence of vivid recollections 18 months after providing care to the patients from the multiple-victim, school-associated shooting. some participating emergency nurses also discussed the presence of thought intrusions when not in the clinical or work setting. although none of the participants reported avoidance of patient care situations in their clinical roles, some reported having increased situational awareness of the potential for violent acts that could directly affect them, family members, or friends. qualitative research studies among emergency nurses also provided themes consistent with those identified through this study. the importance of supportive relationships, which was described by participants in a study conducted by alzghoul, 6 was also identified in this study. the findings also agree with results suggesting the importance of having protective mechanisms for coping with working with trauma patients and that experience and proficiency are essential for trauma nursing. 6 the importance of having strategies to mitigate stress, such as talking with peers, was identified by drury et al. 21 the participants from the study performed by drury et al 21 also discussed being less likely to use external counseling services than pastoral or peersupport resources. positive emotions, as described by alzghoul, 6 include the reward of seeing patients improve and may not be experienced by emergency nurses who care for these patients for only a short duration and are unable to learn of their outcomes. differing opinions related to formal debriefs were also discussed by morrison and joy. 20 experiences with "poly-stressor effect" 20 mirror the discussion of compounding variables that may affect the nurses' ability to cope with such traumatic events. the themes and findings from this study and review of the available literature yield implications for emergency nurses that may mitigate the negative psychosocial effects of providing care to patients from multiple-victim, school-associated shootings. expanded research to include professionals from various health care disciplines and specialties is indicated to examine further the effects of caring for these patients and to identify those clinicians who are most at risk for secondary traumatic stress. the research efforts may also be broadened to include other clinical specialties in the emergency department such as emergency medicine physicians, trauma surgeons, paramedics, respiratory therapists, or social workers. future research may expand beyond the emergency department and could include clinicians from the responding prehospital agencies, air medical transport services, operating rooms, trauma and surgical intensive care units, step-down units, mental health services, and rehabilitation facilities. gathering data from community emergency departments that have received patients from multicasualty school shooting events is likely to further the understanding of how clinicians and departments without the vast resources of a trauma center are affected by these events and what unique challenges were experienced. continued research efforts are also indicated to evaluate the effectiveness of interventions aimed at alleviating the symptoms associated with secondary traumatic stress, compassion fatigue, and burnout. the implications for emergency nurses are applicable to the preplanning, response, and recovery phases associated with providing care to these patients. emergency nurses, nurse leaders, and nurse educators should encourage positive coping skills and self-care routines to mitigate the incidence of secondary traumatic stress and related symptoms. these skills and routines may support effective recovery after the provision of care to patients from multicasualty school shooting events. peer-focused sessions, which encourage open discussion and reflections, are likely to promote coping and recovery after caring for patients from these events. this aligns with research that identified debriefing with peers as being more effective, and recommending the facilitation of debriefings by a nurse. 22 actively promoting the use of employee assistance professionals may be essential to helping affected clinicians cope after such an event; however, these services should complement, rather than supplant, peer-to-peer support that occurs immediately after patient care. nurse managers and hospital administration may consider providing paid administrative leave for clinicians immediately after patient resuscitations and subsequent dispositions to facilitate participation in peer conversations to promote coping and recovery. in addition to the implementation of peersupport mechanisms immediately after the event, comprehensive employee assistance services, which may include counseling or formal support services, may be appropriate to support clinicians involved in the care of these patients. available resources that may mitigate secondary traumatic stress and promote mental health among health care professionals are provided in table 2 . the restriction of nonessential staff in resuscitation rooms is likely a best practice to promote patient privacy and confidentiality while alleviating some of the emotions described by these emergency nurses. likewise, as the participating emergency nurses indicated that not learning how the patients had recovered prevented their gaining closure after the event, notification of patient outcomes in compliance with state and federal laws and regulations is likely to benefit the clinicians involved in the care of these patients. although patient confidentiality is critical, individually sharing patient outcomes with the nurses, providers, and staff who were involved in the emergency care of these patients would likely prove beneficial and may be facilitated by gaining consent from parents or guardians. for those departments from which patients are transferred to other facilities for definitive care, the receiving facilities should perform outreach to the referring clinicians and their departments to inform them of patient outcomes to promote closure after the event. because research has identified barriers to obtaining trauma education among rural clinicians, 23 education and outreach by trauma centers to community facilities can improve clinical preparedness for mass and multiple casualty events while promoting wellness and self-care resources to lessen secondary traumatic stress. such education and outreach efforts may include trauma nursing curricula, assistance with event simulations, provision of training with patient care scenarios, and facilitation of patient transfers through the creation of autoacceptance agreements. assistance with mass casualty drills that include mock patients who may be pediatric is also likely to support preparedness for such events. the study participants were emergency nurses who received these patients at a level 1 comprehensive trauma center with vast resources, capacity, and personnel. the emergency nurses who participated in this study have access to employee assistance professionals, full-time social workers in their department, and clinical resources that include surgeons, surgical capacity, supplies, equipment, and blood products. emergency departments and facilities with more limited resources are likely to experience greater challenges with accommodating the volume of patients from a multicasualty, school-associated shooting event. the participating nurses were from a single medical center and provided care to patients from 1 school shooting event. there may be some limitations in the transferability of these results to community ed settings with fewer specialty resources. in addition, the participating emergency nurses from the level 1 comprehensive trauma center would be expected to have more experience caring for patients injured by gun violence. this experience is likely to afford clinical and emotional benefits that supported these nurses' abilities to cope during and after their roles in the care of the victims from this event. emergency departments are typically the front line of hospital-based medical care. multicasualty school shooting events often occur without warning and bring unique challenges to the clinicians and departments that are tasked with receiving and caring for these patients. learning from emergency nurses who care for patients from a multicasualty, school-associated shooting event may promote personal and departmental preparedness and improve coping and recovery among the involved clinicians. the identification of themes and the findings from this study translate to implications for emergency nurses that may improve patient table 2 internet links for secondary traumatic stress and mental health resources for health care professionals outcomes through planning and preparedness while benefiting the welfare, resilience, and retention of emergency nurses who are likely to be emotionally affected by their roles caring for the victims of multicasualty, school-associated shootings. further research is indicated to explore the experiences of nurses after caring for patients from other school shooting events to better understand the psychosocial effects and define the most effective support methods. advancing science and practice for vicarious traumatization/secondary traumatic stress: a research agenda secondary traumatic stress self-care issues for clinicians, researchers, and educators emergency nurses association. ena topic brief: the well nurse burnout and its association with resilience in nurses: a cross-sectional study the impact of traumatic events on emergency room nurses: findings from a questionnaire survey the experience of nurses working with trauma patients in critical care and emergency settings: a qualitative study from scottish nurses' perspective stress in emergency departments: experiences of nurses and doctors an exploration of factors associated with post-traumatic stress in er nurses characteristics of school-associated youth homicides -united states nurse suicide in the united states: analysis of the center for disease control 2014 national violent death reporting system dataset case study research and applications: design and methods toward a mechanism for secondary trauma induction and reduction: reimagining a theory of secondary traumatic stress the concise proqol manual using the framework method for the analysis of qualitative data in multi-disciplinary health research nvivo qualitative data analysis software. version 12 prevalence of secondary traumatic stress among emergency nurses secondary traumatic stress among emergency nurses: a cross-sectional study the effectiveness of an educational program on preventing and treating compassion fatigue in emergency nurses secondary traumatic stress among emergency nurses: prevalence, predictors, and consequences secondary traumatic stress in the emergency department compassion satisfaction, compassion fatigue, anxiety, depression and stress in registered nurses in australia: phase 2 results pediatric emergency department staff preferences for a critical incident stress debriefing trauma outreach education: assessing the needs of rural health care providers submissions to this column are encouraged and may be submitted to steve weinman the study was supported by a clinical nurse scholars training grant award from the vanderbilt university medical center nursing research office.conflicts of interest: none to report. supplementary data related to this article can be found at https://doi.org/10.1016/j.jen.2020.05.018. do you recall what your thoughts were when you learned that your department was going to be receiving victims from a school shooting?do you recall your feelings while you were preparing to receive these patients, providing care to them, or reflecting on your role as part of the involved health care team?what was it like for you as you cared for these patients? do you recall if you experienced any increased stress while preparing for the patients' arrivals?do you recall reflecting on or thinking about those patients in the days, weeks, or months after the incident?were there family members, peers, or managers who you talked with about this incident?were any services provided by the medical center to help the emergency department team after this incident?did you feel that these services were sufficient and/or helpful?did you find yourself seeking more information from the media about the event?do you think that these patients affected you any differently than those trauma patients who you routinely care for?did you find yourself avoiding situations or patient care assignments where you may encounter similar patients?did you experience any disruptions in your normal routines, such as difficulty sleeping or concentrating on other tasks, due to thinking about those patients?do you think that you were "jumpy" or more aware of the potential for violent incidents which could affect you, a family member, or a friend?were there any activities that you found to be helpful as a coping mechanism after the incident?if you have left your position at this medical center, do you feel that this event had an effect on your decision to leave?is there anything else that you would like to add that would help me understand the challenges that you experienced as a result of caring for these patients? key: cord-340153-q0zmnq26 authors: ha, kyoo-man title: examining professional emergency managers in korea date: 2016-09-23 journal: environ impact assess rev doi: 10.1016/j.eiar.2016.09.004 sha: doc_id: 340153 cord_uid: q0zmnq26 although the number of emergency managers has risen in south korea (hereafter referred to as korea) over the years, their role is not yet as defined and noteworthy compared to other professions because of its unidisciplinary approach. this article investigates how korea has to improve emergency managers' disciplinary approach to ultimately contribute to the goal of effective transnational disaster management. this study uses qualitative content analysis of government policies, college curricula, nongovernmental organizations' (ngos') emergency-manager certification, and mass media coverage to compare emergency managers' unidisciplinary and multidisciplinary approaches. the key tenet is that korea must change its emergency managers' unidisciplinary approach into a multidisciplinary approach because the former is less effective when dealing with complicated disaster management systems. to achieve this change, the stakeholders must carry out their assigned responsibilities under risk-oriented management. as for the study's international implications, developing nations may consider the enhancement of related educational curricula, collaborative learning, continuous evaluation, disaster awareness, and disaster prevention for the emergency managers' multidisciplinary approach. the frequency and impact of large-scale disasters in korea are not decreasing, and the characteristics of such disasters are becoming more complicated than ever before. in addition, disasters have become more heterogeneous. the current structure of korean disaster management is unable to fully address the impacts of disasters, due to political, economic, social, and cultural reasons. to resolve this, a more collaborative, integrated, and comprehensive form of emergency management is required. several sub-areas in korea including firefighting, civil engineering, and other businesses officially proclaim that they have produced emergency managers through their own individual programs, focusing on their specific discipline. also, government institutions at the central government level (being similar to the u.s. federal level) have started to recruit emergency managers as public employees. however, governments have maintained that the capability or knowledge of korean emergency managers is still limited when it comes to dealing with diverse disasters, both natural disasters and manmade emergencies (kim, 2014) . to be professional korean emergency managers, they have to be oriented towards multiple disciplines. such professionals possess specialized training, skill, or education, whereas non-professionals do not. restrictively speaking, professional emergency managers concentrate on their own areas of responsibility, but they clearly need multiple disciplines apart from their own specialization. the premise of this study is that a unidisciplinary approach does not lead to effective disaster planning, whereas a multidisciplinary approach does (doe, 2006) . by depending upon a single aspect or onesided viewpoint, the unidisciplinary model addresses reactive disaster management, which does not consider planning (culwick and patel, 2013; hartkopf, 2003) . on the other hand, a multidisciplinary approach strongly supports disaster planning. note also that similar terms have been used in place of multidisciplinary, such as interdisciplinary, intradisciplinary, crossdisciplinary, and transdisciplinary. among them, interdisciplinary has been used frequently or interchangeably with multidisciplinary. what they all have in common is the need for more than one discipline and the interconnection of one discipline to another. many developed nations have strongly relied upon the multidisciplinary approach for disaster management. when recruiting emergency managers, the united states prefers to employ those who have a multidisciplinary background (waugh and sadiq, 2011) . japan has also implemented the multidisciplinary approach to deal with earthquakes and tsunamis, floods accompanying typhoons, and other complex natural disasters (nazarov, 2011) . the emergency planning college in the united kingdom has traditionally offered multidisciplinary programs, while educating their emergency managers (epc, 2016) . korean emergency managers have unique characteristics. the job itself lacks professionalism and popularity in korea. for advanced nations, their emergency managers are regularly recruited, paid, and thus contribute significantly to efficient disaster management. modern disaster management in korea started 10 years ago, which is 'new' or less experienced when compared with developed nations such as the united states, the united kingdom, japan, and others. this means that korea has much room for improvement in this field and can learn from examples and practices by developed nations such as the whole community approach in the united states, the establishment of integrated emergency management system in united kingdom, the role of small-scale voluntary organizations in japan, among others. a specific area to consider is adopting a multidisciplinary approach for/by emergency managers to widen their exposure in the field. the purpose of this article is to investigate how korea might improve the disciplinary approach of its emergency managers towards the ultimate goal of effective transnational disaster management through mitigating human loss, economic damages, and psychological impacts. we maintain that korea has to change its emergency managers' unidisciplinary status to multidisciplinary status, and given korea's own experience, the international community must address the need to change related educational curricula, collaborative learning, and sustainable evaluation. there have been two kinds of studies on korean disaster management in the past: those within korea, and those outside of it. the majority of korean researchers or korean language researchers have examined how to organize the national disaster management institution (cho and ahn, 2011) . considering that the history of modern disaster management in korea started in 2004 with the establishment of the national emergency management agency (nema), related researchers paid attention to predicting the next head of nema. with the rise of ministry of public safety and security (mpss) at the end of 2014, they continued to study which professions would require the human resources of mpss. in fact, the nema was transformed into the mpss after experiencing the sinking of ferry sewol in mid-2014. outside korea, some english language researchers have looked into how disaster management principles would be applied to the case of korea (park, 2015) . in doing so, they made efforts to examine subjects that korean language researchers had not considered. for example, while disasters have both physical and social impacts, many korean researchers focused only on the physical impacts in the following cases: typhoon maemi in 2003, the sinking of ferry sewol in 2014, the outbreak of middle-east respiratory syndrome (mers) in 2015, among others. conversely, researchers outside korea often delve into the social impact including the psychological impact of disasters, the status of special needs population, and the application of equity to emergency professionals. many researchers have examined the significance of a multidisciplinary aspect on disaster management in the international community (fazey et al., 2014; leonard et al., 2014; quick, 1998; rose, 2007) . in particular, many educators, nurses, and medical doctors have focused on topics within their areas. at the same time, they have identified, promoted, and implemented multidisciplinary status for professional emergency managers, while elaborating on environmental change, holistic problem solving, dynamic change, and case studies, among many others. although some researchers have attempted to create boundaries between their preferred subject and other specialized subjects in the field of disaster management, many researchers have shared basic knowledge or common disciplines (macinnis and folkes, 2010; zhang et al., 2015) . in this context, correlation exists among multidisciplinary subjects and other specialized ones. multidisciplinary approach does not stunt but fuels the advancement of disaster management. further, with a multidisciplinary approach, there is comprehensive planning as part of proactive management. when analyzing that a specific disaster may lead to multiple disasters, disaster management is not oriented for a unidisciplinary but a multidisciplinary model. to illustrate, when a typhoon hits a local area, it usually causes flooding. overflowing water contains a number of chemicals, which need the management of hazardous materials. subsequently, flooding may cause fires due to electric leakage. complex situations such as these scenarios will not be addressed by a linear or single approach. understanding and quick action, looking into alternatives, and applying a multidisciplinary approach have a greater chance of succeeding and in helping to mobilize as many people and organizations as possible to work together to resolve problems. given that disaster management involves a number of interrelated factors and parties, a multidisciplinary perspective is needed to identify and evaluate complicated issues (ali and nitivattananon, 2012) . unidisciplinary disaster plans typically outline actions for emergency managers from a single discipline or common background. those emergency managers share similar language, training, and emergency function. in addition, they are oriented to handle only one specific aspect of disaster management. in contrast, multidisciplinary disaster plans cover those for emergency managers from diverse fields or different backgrounds. to this point, emergency managers from different disciplines or multidisciplinary disaster plan(s) are expected to handle the multi-faceted aspects of disaster management better than unidisciplinary emergency managers. many challenges come with disaster awareness, decision flexibility, adapting to volatile environments, among others, and for this reason, relying on a single discipline is not likely to adequately explain certain complicated aspects of hazards or risks in disaster management nor will it provide comprehensive solutions (doren et al., 2012; jensenius, 2012) . conversely, a multidisciplinary approach may fully address many fragmented issues and concerns towards the goal of effective disaster management, in particular, by comprehensively combining or integrating various knowledge and information. as decision-makers, professional emergency managers in developed nations may get diverse support from their multidisciplinary background (sterlacchini et al., 2007) . whether as part-time or full-time, shared position or not, as they go about making sound decisions, they also utilize their knowledge on preventive measures during dangerous events. as a result, professional emergency managers play a role in maximizing potential benefits despite limited resources, as long as they fully utilize a multidisciplinary approach. on the other hand, professional emergency managers in korea have not played a specific role in managing diverse disasters. rather, they have taken part in many roles in disaster management such as planners, leaders, administrators, trainers, protectors, communicators, and problem solvers, among others. accordingly, the whole community has expected them to carry out many activities such as hazard identification, efficient emergency response, systematic emergency recovery, ethical conduct, and others (fema, 2013-1). in korea, an increasing number of researchers have studied how efficiently the nation has to operate its disaster management. in doing so, some researchers have indirectly mentioned the category of emergency managers while proposing their theories (incheon city council, 2013) . however, when reflecting that the concept of professional emergency managers is a relatively new one to korea, almost no rigorous study has been attempted to delve into the issue (yoon, 2015; yoo et al., 2015) . to the author's best knowledge, this study is the first to systematically investigate korean professional emergency managers. although this study is not a new attempt outside korea, researchers from other nations can also benefit from or adopt the results of this study at a national level, in particular while studying their national disaster management systems. in other words, this study can serve as an example to other nations in terms of learning from and avoiding similar mistakes. korea can also learn from the experience of advanced nations, potentially applying principles that reflect a multidisciplinary approach. with all the above in mind, the scope of this paper includes not only the characteristics of korean disaster management but also many disaster management principles as observed in the international community. it is not easy to have and maintain emergency managers who are multidisciplined. many practitioners, though knowledgeable, may not be readily available or may not have access to relevant networks on account of (geographical) location or other barriers (e.g., language). some educators, trainers, and researchers also have different means of interpreting certain disaster management data or model (gonzalez et al., 2012) . for this reason, it is crucial to discuss and establish appropriate techniques and strategies for better communications including exchange of best practices towards solidifying multidisciplinary approach. we used qualitative content analysis as it is able to provide meaningful insights and generalizations that may not be possible in quantitative analysis. this is particularly helpful in evaluating characteristics of professional emergency managers and how they relate to multidisciplines in disaster management (fig. 1 ). in addition, we used comparative perspective, while focusing on qualitative content analysis. similarly, we used qualitative data in this paper. qualitative data are useful in studying disaster management as they may describe qualities, features, or certain characteristics relevant to disaster management including stakeholders' behavior, human relations, effective strategies, and other information (gorodzinsky et al., 2015) . further, those qualities are helpful in analyzing the disciplinary status of professional emergency managers or in examining the interaction between emergency managers and disaster management. to elaborate, we primarily used several databases for qualitative data collection. in the case of english data, we relied on traditional scholarly journal articles. in the case of korean data, we utilized korean databases to include dbpia, kiss, and government websites. we typed some keywords such as emergency managers, unidisciplinary study, multidisciplinary study, and korean disaster management, among others. in terms of english data analysis, we evaluated data on the u.s. emergency managers that indicate many significant lessons for korea. when thinking that korean data did not directly analyze many things about its emergency managers, we had no choice but to qualitatively interpret them. we maintain that korea has to transform its current emergency managers' unidisciplinary approach into a multidisciplinary approach. in a unidisciplinary setup, the decision-making process is linear whereas in a multidisciplinary approach, inputs come from multiple areas and there is an opportunity to evaluate before concretizing a decision (as reflected by the 'decision box' in the flowchart). to systematically compare two disciplinary approaches, we initiated listing important stakeholders surrounding emergency managers in korea by relying on many qualitative techniques, such as analyzing government documents, discussions with experts, internet searches, and others. the list included the mpss, local governments, disaster management trainers, industries, job applicants, and others. finally, we chose four major stakeholder areas, namely government policies, college curricula, ngos' emergency-manager certification, and mass media coverage. the identified stakeholders and emergency managers are expected to play a number of roles within the field of emergency and disaster management (kim et al., 2015; yo, 2014) . for emergency managers, the exercise of their responsibilities will depend on which stakeholder they deal with at a given time in the (disaster) lifecycle. with all the above in mind, we have attempted to draw international implications for many other nations later. when the sinking of ferry sewol happened around jindo island in 2014, unidisciplined maritime policemen attempted to rescue passengers with minimal success. even though they were accustomed to dealing with maritime accidents, the maritime policemen were unable to consider important issues such as disaster victims' psychological needs, the operation of rapid and complex disaster management, interaction with other institutions, and how to use public information officer(s). after rescuing only 172 out of 476 passengers, the public became angry at the poor disaster management actions of the maritime policemen, causing the president to dismantle the institution, which is the nema (hong, 2016) . the procedures followed by emergency managers during the sewol ferry incident are considered typical of the unidisciplinary approach. only three professionals, namely firefighters, civil engineers, and maritime police make up the mpss, which is a comprehensive disaster management agency in korea (mpss, 2016) . since the ferry sewol sinking in 2014, the mpss has placed most of the emphasis on maritime accidents as well as house fires and flood accompanied by typhoon. therefore, those who are dealing with each hazard have also turned into the emergency managers for those fields or areas. each professional under the mpss has strongly wanted to dominate the field of disaster management in korea. in particular, the competition between firefighters and civil engineers has been fierce in terms of budget allocation. not much collaboration has been observed among the three professionals. further, other professionals such as humanists, natural scientists, mechanical engineers, lawyers, sociologists, and public administrators have not been allowed to work for disaster management. under politics-oriented management, each of the three emergency managers has come to embrace his or her own principles based on their own disciplines or areas of expertise. 4.1.2. college curricula. korean health workers in college hospitals were heavily involved in dealing with the outbreak of the mers in 2015. although health workers knew their responsibilities in terms of medical treatment, they knew relatively little about the phase of medical prevention as part of disaster management lifetime, how to coordinate with other stakeholders to include patients' family members, government officials, and local communities, and other emergency management principles. consequently, because the unidisciplined health workers in college hospitals were not able to consider the other equally important aspects surrounding the situation, the outbreak claimed the lives of 36 patients (ha, 2016a) . many departments in colleges have recently begun offering disaster management programs such as firefighting science, civil engineering, ocean science, medical science, nursing science, public administration, and safety engineering, among others (ha, 2015) . each department has maintained that their own academic subject, which is a unidisciplinary approach, is the key major in the field of disaster management. they have not seriously attempted to incorporate other disciplines into their own areas. when analyzing departmental curricula, we can see that they have not put significance to the concept of emergency managers (kang et al., 2012) . without emphasizing the role of emergency managers, they have tried to describe how each has operated its own disaster management. in general, many departments have not realized the status of emergency managers as a professional in the field of disaster management having such certificates is a requirement for some public institutions' recruitment. nevertheless, many emergency manager certificates have been based on the unidisciplinary approach. it means that they have been taught in only one area of study when a more comprehensive and diverse curriculum/training would be better. certificates from kfsa, kdpa, mrsa, and lsa are oriented on their own disciplines including firefighting, flood accompanied by typhoon, maritime rescue, and maritime search and rescue. although the kbcpa has supported multidisciplined emergency managers via classroom sessions, the program towards certification still lacks the aspect of multidisciplinary training. 4.1.4. mass media coverage diverse mass media including tv, radio, internet, mobile phones, newspapers, and others have exerted efforts to cover the occurrence of a disaster as breaking news. similarly, they have tried to cover the phase of disaster response or that of recovery much more than that of disaster prevention/mitigation or preparedness (choi et al., 2011) . in general, many mass media networks have not clearly recognized emergency managers as entities in the field of disaster management. notwithstanding, few mass media such as arirang tv and ytn tv have just begun to talk about emergency managers. there was realization that with the disasters korea has faced so far, the role of korean emergency managers has been neither extraordinary nor maximized. the discussion about the criticality of the profession has not also touched on the needed multidisciplinary approach. korea has a small number of multidisciplined emergency managers in the field of disaster management. they are those professionals who are open-minded and used to interpreting various disaster management concepts in a more critical manner (macaskill and guthrie, 2014). for example, having a multidisciplinary background helps professional emergency managers to more flexibly interpret diverse issues to include the scientific analysis of complicated evolution, decision making process, the behavior of multiple stakeholders, and others than a unidisciplinary one. without a multidisciplinary background, those emergency managers may not be able to design and implement flexible alternatives quickly during the period of disaster response. there are many reasons why korea has currently had only a few multidisciplinary emergency managers. for example, some stakeholders including governments have politically supported unidisciplinary emergency managers, when reflecting few incumbents' aspiration towards hegemony. in addition, colleges and mass media as well as ngos have not seriously realized the importance of having a multidisciplinary approach on korean emergency managers. in short, either politics or lack of expert knowledge is the fundamental reason for the lack of emergency managers' multidisciplinary approach at present (ha, 2011) . the nation has just partially enhanced its multidisciplinary approach, as far as the field has failed to embody the full extent of addressing risk-oriented management. without considering risks and having appropriate or sufficient knowledge, resulting also from various experiences on past emergencies or disasters, the nation has not moved to the level of multidisciplined emergency managers (ha and ahn, 2009 ). in particular, when assigning resources and priorities, the nation and its emergency managers have not utilized sound principles on disaster management. to elaborate, thanks to the support of international association of emergency managers' (iaem's) certified emergency manager program, korea now has several multidisciplined emergency managers. iaem has played many roles in training emergency managers in the international community. although the number of multidisciplinary emergency managers in korea is not quite big, those certified emergency managers are trying to contribute to the goal of disaster management in the government sector, in colleges, and others. another good case of multidisciplinary emergency managers is that of the association of slope disaster management (asdm). as an ngo in korea, it radically adopted multidisciplinary training and exercise program in 2013 despite lack of management funds that almost closed its business. since that time though, asdm has provided many multidisciplinary courses to the trainees by following important lessons from hong kong' slope management. their program included not only the civil engineering perspective but also other multidisciplinary trainings sessions such as on disaster awareness, climate change, and local history. now, the asdm has been able to recruit many trainees. at the same time, those trainees have played a role in managing slopes around their places by successfully practicing multidisciplinary approach. regarding the differences between unidisciplinary and multidisciplinary approaches, quite a few researchers have tried to empirically prove them, in particular, in the research area of emergency medicine and education (beckett et al., 2012; chen et al., 2009; ferrario et al., 2015) . although the focus of each research has been distinct depending on individual viewpoints, many researchers have indicated that the characteristics of multidisciplinary emergency managers are superior to those of unidisciplinary emergency managers (thomson and black, 2008) . thus, the multidisciplinary model may be evaluated as one of the most innovative solutions for disaster management. certainly, there are different effects between emergency managers' unidisciplinary approach and multidisciplinary approach, see table 1 . the details in the table illustrate that both have benefits. in some aspects, a particular approach is better than the other. in general though, the multidisciplinary approach has more advantages when compared to a unidisciplinary one. in the field of disaster management, multidisciplined emergency managers have traditionally performed better than unidisciplinary emergency managers have. though it is certain that unidisciplinary emergency managers also possess positive characteristics such as their speed of decision making or homogeneity, other aspects still support positive signs for the superiority of multidisciplinary status. in particular, if thinking that the whole community approach is quite necessary in the 21st century, multidisciplinary approach is more suitable for the operation of disaster management than unidisciplinary approach is. similarly, multidisciplinary disaster plan(s) or related planning are more effective than unidisciplinary disaster plan(s) are. effective means that multidisciplinary emergency managers produce results, and thus, may contribute to the goal of disaster management, compared with unidisciplinary emergency managers (martensson et al., 2016) . to elaborate, disaster plan(s) include handling diverse kinds of disaster. while dealing with them, multidisciplinary disaster plan(s) or related emergency managers communicate with one another and then implement a series of evaluation processes on uncoordinated problems. their decisions are credible and thus, may flexibly adapt to the complexity of disasters. in short, multidisciplinary emergency managers are able to produce successful outcomes as initially intended during disaster management planning. when korea fully embodies the multidisciplinary approach for emergency managers, it may have the most appropriate or ideal disaster management style. if thinking that the field of disaster management cannot survive without those who are running it, emergency managers are the key to the efficient operations of disaster management (wooten and james, 2008) . even though dealing with emergency managers is not an easy task, they are considered to be the most valuable resource in the field. while emergency managers have competitive advantages, the korean field of disaster management may develop a new style of its disaster management in particular by breaking down the unidisciplinary approach. not just one or two, but all four stakeholders in korea need to carry out their own assignments for the goal of achieving multidisciplinary approach, following table 2. in particular, many decision-makers (with vested interests) in each area have not been willing to change the disciplinary approach of their emergency managers in korea (saleh and pendley, 2012) . hence, the field including the four stakeholders must expand the aspect of multidisciplinary approach into its culture by getting rid of vested interests of those in politics or by being well-informed, and not ignorant. a disaster may happen to anybody, regardless of national boundary (ha, 2016b) . at the same time, the category of professional emergency managers has risen in the international community. emergency managers in each nation have played their own roles in minimizing the impacts of disasters, although the exact extent of their roles is not fixed but continues to vary. with these in mind, many nations may learn important lessons from the disciplinary approach of korean emergency managers to include mistakes or errors made by the korean emergency managers. other nations, which do not have the category of emergency managers in the field or whose emergency managers lack multidiscipline, must realize why the disciplinary approach does matter for the role of emergency managers in their areas. without knowing the significance of multidisciplinary approach, those nations will not develop or improve the position of their emergency managers (ha and ahn, 2008) . in short, those nations have to consider the multidisciplinary approach as critical to the development of their professional emergency managers. based on disaster awareness, such nations need to diversify their educational curricula for professional emergency managers. when considering that educational curricula provide concepts, principles, instructions, strategies, and tools on disaster management, such curricula as an essential element should be improved by including multiple approaches. while studying multidisciplinary curricula, emergency managers are likely to be equipped with skills to help them quickly create appropriate strategies to address certain aspects of disaster management. it is also necessary for certain nations to utilize collaborative learning among different schools, teams, specialties, communities, and other institutions (alfred et al., 2015) . when a specific educational unit faces its limits on the expansion of multidisciplinary curricula, it may contact neighboring units and then collaboratively develop its curricula. collaborative learning may bring different disciplines into the activity of emergency managers. those nations may continue to set up collaborative networks on the way to stronger collaborative learning. they can start to establish multidisciplinary environments with the cooperation of diverse individuals and institutions within national boundaries (kozucha and sienkiewicz-malyjurek, 2014; noran, 2014) . to this point, various communication channels around them should play an important role in coordinating thorny issues. simultaneously, they may extend collaborative networks internationally by addressing not only different disciplines but also cultural interoperability (ha and park, 2014) . when recruiting emergency managers, authorities from training centers must consider recruiting from a variety of professionals. they need to include not only firefighters, civil engineers, and maritime police, but also public administrators, environmental engineers, chemical engineers, communicators, psychologists, medical doctors, nurses, and others (becker, 2000) . vice versa, diverse trainees may outline how different disciplines can work together towards the goal of disaster management. training and exercise in disaster management are also expected to expose challenges experienced by disaster victims, and thus, facilitate or simulate related experience for trainees (martin and hutchon, 2008) . however, the extent of exposure or experience accruement may not be quite feasible in other nations, due to limited environment such as poor disaster preparedness programs. thus, there is a need to formalize their multidisciplinary training and exercises, and then provide robust training opportunities for professional emergency managers. similarly, it is necessary for other nations in the international community to reflect on diverse knowledge and information during the planning process. by integrating multiple disciplines into emergency operational plans, the competencies of professional emergency managers are expected to be enhanced. in short, multidisciplined emergency managers will be able to efficiently adjust to the demands of multidisciplinary planning process under complicated environments or situations (khorram-manesh, 2015) . other nations may not easily produce professional emergency managers via a single program or tool. rather, they require a series of programs for the goal of developing professional emergency managers (gfdrr, 2012) . thus, those nations have to continue to monitor, evaluate, and then improve relevant programs. in addition, because the scope of disaster management is quite wide, those nations must be flexible in introducing changes to related programs or tools via sustainable evaluation. among the many challenges and alternatives, the major finding is that korea has to transform its emergency managers' unidisciplinary approach to multidisciplinary approach in the near future. in so doing, it is necessary for each stakeholder to carry out their own assigned roles and responsibilities under the name of risk-oriented management. likewise, many nations in the international community may learn important lessons from the korean case regarding why a nation should transition to the multidisciplinary style. accredited researchers have studied the exact role of emergency managers in some advanced nations. however, almost no rigorous study has been attempted to examine the role of korean emergency managers or how to change their disciplinary status under their own environment. by suggesting the importance of multidisciplinary approach, this paper may be considered a pioneer study. in a broad sense, this paper may contribute to the goal of transnational emergency management by highlighting the need for multidisciplined emergency managers in the international community. as a future study, researchers may expand their exploration on the disciplinary approaches practiced by professional emergency managers in the international community. korean researchers may further study specifically how their emergency managers will utilize and benefit from a multidisciplinary approach. various researchers in advanced 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city experience economic resilience to natural and man-made disasters: multidisciplinary origins and contextual dimensions from learning from accidents to teaching about accident causation and prevention: multidisciplinary education and safety literacy for all engineering students gulf oil spill landslide risk analysis: a multi-disciplinary methodological approach an exploratory study of the differences between unidisciplinary and multidisciplinary goal setting in acute therapy services professional education for emergency managers linking crisis management and leadership competencies: the role of human resource development theoretical analysis on integrated emergency management system (in korean) a study on improved emergency management system (in korean) a study on education and training of public servants in the field of disaster and safety management in korea (in koran) a correlation analysis model for multidisciplinary data in research he as an adjunct professor is working for the dept. of public policy and management at pusan national university, korea. he, as certified emergency manager, is serving as the korean representative for the international association of emergency managers. his biography (disaster management researcher) has been selected for marquis who's who in the world key: cord-278083-ut2ssdbz authors: li, juan; zhu, yuhang; feng, jianing; meng, weijing; begma, kseniia; zhu, gaopei; wang, xiaoxuan; wu, di; shi, fuyan; wang, suzhen title: a comparative study of international and chinese public health emergency management from the perspective of knowledge domains mapping date: 2020-10-02 journal: environ health prev med doi: 10.1186/s12199-020-00896-z sha: doc_id: 278083 cord_uid: ut2ssdbz background: at the end of 2019, the outbreak of coronavirus disease 2019 (covid-19) severely damaged and endangered people’s lives. the public health emergency management system in china has played an essential role in handling the response to the outbreak, which has been appreciated by the world health organization and some countries. hence, it is necessary to conduct an overall analysis of the development of the health emergency management system in china. this can provide a reference for scholars to aid in understanding the current situation and to reveal new research topics. methods: we collected 2247 international articles from the web of science database and 959 chinese articles from the china national knowledge infrastructure database. bibliometric and mapping knowledge domain analysis methods were used in this study for temporal distribution analysis, cooperation network analysis, and co-word network analysis. results: the first international article in this field was published in 1991, while the first chinese article was published in 2005. the research institutions producing these studies mainly existed in universities and health organizations. developed countries and european countries published the most articles overall, while eastern china published the most articles within china. there were 52 burst words for international articles published from 1999–2018 and 18 burst words for chinese articles published from 2003–2018. international top-ranked articles according to the number of citations appeared in 2005, 2007, 2009, 2014, 2015, and 2016, while the corresponding chinese articles appeared in 2003, 2004, 2009, and 2011. conclusions: there are differences in the regional and economic distribution of international and chinese cooperation networks. international research is often related to timely issues mainly by focusing on emergency preparedness and monitoring of public health events, while china has focused on public health emergencies and their disposition. international research began on terrorism and bioterrorism, followed by disaster planning and emergency preparedness, epidemics, and infectious diseases. china considered severe acute respiratory syndrome as the starting research background and the legal system construction as the research starting point, which was followed by the mechanism, structure, system, and training abroad for public health emergency management. public health emergencies have increased in recent years and have shown a trend of causing considerable damage [1] . according to the emergency events database (em-dat), the most widely used and influential disaster database in the world, the average number of deaths per major public health event was more than 10,000 [2] . population growth, urban development, migration, and other issues brought about by globalization have sped up the incidence of public health events, such as epidemics [3, 4] . public health events also propelled the process of emergency management, giving top priority to changes in emergency operations. the outbreak of coronavirus disease 2019 in china spread rapidly throughout the world in a short time, which illustrated the need to build a resilient health emergency system that can withstand epidemics [5] . public health emergency management (phem) is a relatively new field that draws on specific sets of knowledge, techniques, and organizing principles found in emergency management [6] . specifically, it includes public health emergency planning, organization, leadership, coordination, control, evaluation, prevention, preparation, and response [7] . for covid-19, china's phem system quickly took the following measures: emergency mobilization measures within the government, lockdown of cities and communities, nationwide medical mobilization, provision of financial support, preferential policies for the medical community and pharmaceutical industry, and the categorical comprehensive publicity to spread prevention and treatment knowledge [8] . these measures effectively reduced the spread of the disease. thus, current recommendations are mostly derived from the reported chinese experience [9] . given the weaknesses and deficiencies exposed by the covid-19 outbreak, people have recognized the need to improve the national phem system [10, 11] . a growing body of research has studied phem from different perspectives, mainly those of institutions, funds, technologies, and laws. the public health emergency was a severe challenge to health institutions such as hospitals, the centers for disease control and prevention (cdc), and governments [7, 12] . the solutions to these challenges were characterized by sustainability, redundancy, and flexibility [13] . monetary and technology resources can merge the roles and responsibilities of public health preparedness and emergency management [14] . severe deficiencies in legal preparedness can undermine effective responses to public health emergencies [15, 16] . these were the essential factors in dealing with public health emergencies. additionally, many countries took corresponding measures to strengthen the emergency management of public health. for example, the usa established phem operations centers either independently in health departments or as a part of the overall command system in the government [17] . china established the phem system from the national level to the local level to be responsible for emergency preparedness and response in 2004 [17] . in march 2018, the ministry of emergency management of the people's republic of china was established, which was an integral part of the state council. thus, we can see that phem is still a timely topic for scholars and governments [18, 19] . however, there are still some problems that need to be solved. to the best of our knowledge, there is little evidence about the differences that occurred between international and chinese phem. moreover, what are the hotspots and trends of phem? what are the main research forces of phem? it is necessary to sort out the characteristics of the development of phem and explore the hotspots of phem research. additionally, we compared international and chinese research on phem. based on this situation, we reviewed the articles on phem that were published over the past nearly 30 years in international and chinese journals. then, we used the knowledge map method to reveal the research strengths, frontiers, and development trends in this field. study conclusions are helpful to draw people's attention to public health emergencies, provide a reference for scholars to understand the current situation and trends of phem, and for government departments to formulate guidance strategies. data were divided into two categories: international and chinese data. according to the relevant authoritative research [20] , the database of bibliometric methods should contain complete documents. a considerable amount of literature has shown that the web of science (wos) is the largest comprehensive academic information resource, covering peer-reviewed journals with high impact factors [21] [22] [23] [24] . accordingly, the international data used for our study were collected from the wos core collection, including science citation index expanded (sci-e), science citation index expanded (ssci), and arts & humanities citation index (a&hci) databases. chinese data were downloaded from the china national knowledge infrastructure (cnki), which had the largest chinese journal full-text database, including the vast majority of chinese journals relating to public health management. more importantly, it has become one of the critical basic data sources for bibliometric research in china [25] . data obtained by inappropriate literature information retrieval strategies could not accurately reflect the content of the research [26] . emergency management is a common term in china that focuses on the occurrence, development, and evolution of emergencies and finding effective ways of responding to them [27] . however, it was not certified internationally. after consulting the experts from the chinese cdc who once worked for the world health organization (who), we learned that the management was refined by preparedness, operation, response, and recovery for an international public health emergency. additionally, this has been mentioned in articles [5, 28] . based on the above points, the international data retrieval strategies were set as: ((ts = public health) and (ts = preparedness or ts = operation or ts = response or ts = recovery) and ts = (emergency)) and language: (english) and document types: (article) indexes = sci-expanded, ssci, a&hci, timespan = 1988-2018. when retrieving chinese data, we choose "public health" and "emergency management" as the theme words, timespan = 1988-2018. we ran the search query of wos and cnki on february 19, 2019. a total of 2759 articles from 1991 to 2018 were retained from wos, while 999 articles from 2003 to 2018 were retained from cnki. after discussing the results with the team members, we further selected the articles based on inclusion and exclusion criteria to ensure that all of the data were closely aligned to the study targets. the inclusion criteria were as follows: (1) occurrence, development, and evolution of phem; (2) prevention, preparedness, response, operation, and recovery of the phem system; (3) planning, organization, leadership, coordination, and control of public health emergencies; and (4) practice and method of phem. the exclusion criteria were as follows: (1) health care, medical record management, or disease treatment; (2) guidelines on the action, proceedings paper or book chapter, interviews, summaries of conferences, and patent abstracts. finally, 2247 international articles and 959 chinese articles were accepted for the analysis after data filtering and removing duplications. the international articles were downloaded in "plain text" format with a full record and cited references for classification and statistical analysis. the chinese articles were downloaded in the "refworks" format. those downloaded data contained the list of authors, the title of the publication, the abstract, keywords, and so on. accordingly, we obtained the data for this study. figure 1 shows the specific search steps. we used citespace 5.5. r2 and microsoft excel 2016 for the data analysis. citespace was a free java-based application found by chaomei chen to analyze the potential knowledge contained in the scientific literature. it has been widely adopted for scientometric analysis in various scientific fields [29] , and has achieved excellent results [30, 31] . the parameters of citespace for this study were set as follows: time slicing (2003) (2004) (2005) (2006) (2007) (2008) (2009) (2010) (2011) (2012) (2013) (2014) (2015) (2016) (2017) (2018) , respectively), years per slice (1), term source (all selection), node type (author, institution, keyword, for chinese and international data; country for international data), selection criteria (top 50), and visualization (cluster viewstatic, show merged network). the corresponding other settings were selected according to different study questions. microsoft excel 2016 was used for temporal distribution and polynomial prediction of the number of articles. it should be noted that the results of the cnki database made by citespace were presented in chinese. to make it easier to read, we translated the chinese results into english. this study involved using bibliometric and mapping knowledge domain analysis methods. bibliometric methods provided an approach to identify the development trends or future research orientations by combining different tools and methods to analyze the articles [32, 33] . it allowed researchers to generate information from historical data and indicators, such as keywords, authors, institutes, and countries [34] . we were mainly engaged in cooperation network analysis (including the network analysis of the authors, institutions, and countries) and co-word network analysis (including keyword co-occurrence network and burst detection analysis) in the mapping knowledge domain analysis. first, we performed a statistical analysis of the temporal distribution of relevant articles. then, we made a polynomial prediction of the number of articles, fitted the trend line of international and chinese study, and predicted it for the next 3 years. cooperation network analysis was used to analyze the contribution to different authors, institutions, and countries in one field. it was obvious that the more an author, a country, or an institution publishes its research findings, the more contributions it will make [35] . betweenness centrality is an index to measure the importance of nodes in the network. the purple circle represents documents with betweenness centrality not less than 0.1, which means that the authors, institutions, or countries occupied an essential position in this field [20, 36] . co-word analysis was a content analysis technique that was effective for mapping co-occurrence relationships and the strength of the relationship between a pair of items existing in the same text, revealing the inner construction of a research field [24] . analysis of the keyword co-occurrence network was meaningful and valuable for exploring timely topics in a specific knowledge domain [37, 38] . in addition, keyword burst detection analysis can clearly grasp articles that receive particular attention from related scientific communities in a certain period. therefore, the frontiers founded by burst detection analysis can provide researchers with upto-date information [39, 40] . the analysis of the highly cited articles in the field can reflect the development of the discipline in a period, examine timely topics, and supplement the above results to provide a reference for topic selection by scientific researchers [41] . temporal distribution analysis countries, yet a large number of chinese scholars participated in this study at the beginning. after the descriptive analysis of the data, we conducted a polynomial prediction analysis of the number of articles and predicted it for the next 3 years. the trend of chronological distribution of articles related to phem in international data can be expressed as follows: y = 0.2790x 2 + 0.7688x−7.7708 (r 2 = 0.9577), while chinese data was y = −0.0345x 3 + 1.5079x 2 −14.142x + 27.273 (r 2 = 0.9251). y indicates the number of articles, and x indicates the years. r 2 > 0.9, indicating a good degree of fit. the chronological distribution of international articles showed a trend of increasing year by year. in 2019-2021, the annual number of articles will exceed that of previous years. at the same time, the trend line of chinese articles, such as a wave line, and the number of articles will continue to decrease over the next 3 years. in addition, as time goes on, the gap in the number of articles in chinese and international journals will be gradually increasing. figure 3 , which shows the international co-author network, shows that there have been many authors writing . however, all three items' centrality was less than 0.1. in fig. 4 , the top-ranked item for chinese scholars by citation count was qunhong wu with a citation count of 22. she was followed by yanhua hao (17), feng han (11), ning (10), yadong wang (10), zheng kang (8), ying liu (6), jincheng ma (6), mingli jiao (5), and libo liang (5) . most of them were teachers at harbin medical university. the top-ranked items by centrality were yanhua hao and ning, with a centrality of 0.02. the third one was qunhong wu, with a centrality of 0.01. their nodes' centrality is also less than 0.1. in terms of the quantity and quality of articles, qunhong wu and yanhua hao were the leaders of phem in china. from the co-author network, we can see that many authors internationally and table s1, table s2 , and figure s1 ). similar to the co-author situation, many institutions have studied phem (figs. 5 and 6). the top-ranked item by international citation count was the centers for disease control and prevention (ctr dis control & prevent.), with citation counts of 255, which means that the institution publishes the largest number of articles in this field. the second one was johns hopkins university (johns hopkins univ.), with citation counts of 92, which means that johns hopkins university had the largest number of articles published among the universities in this field. johns hopkins was followed by harvard university (harvard univ.), columbia university (columbia univ.), and so on. the above analysis showed that the cdc and universities were the leading institutions to study international phem. the centrality ranked item was cdc (0.50). then, johns hopkins university (0.21), harvard university (0.16), university of washington (univ washington., 0.13), university of toronto (univ toronto., 0.10), university of pittsburgh (univ pittsburgh, 0.10), and boston university (boston univ., 0.10) followed. the centrality of all these nodes was no less than 0.1 with the purple circle, which meant that they were the institutions with higher publication quality and the leading institutions in this field. the top-ranked item by citation count in the chinese database was the school of health management, harbin medical university, with a citation count of 20, followed by shanghai publishing and printing college (9) table s3 , table s4 , and figure s2 ). [42] , these were all high-income countries except china. geographically, half of them are centralized in europe. among these countries, the usa was the most productive, far ahead of the rest in this field, and its centrality was the largest. this showed that in the field of phem, the usa carries out the most studies, and their studies were more advanced. although china ranks fifth on this list, its centrality was only 0.03. therefore, these results indicate that chinese scholars could publish some internationally recognized articles in the field, which would offer an advantage in quantity; however, they need to improve their article quality. it is worth noting that although the number of articles from switzerland (44) and sweden (34) was much lower than that of the usa, the articles' centrality of these two countries was more than 0.10, which showed that the quality of the articles was still high. generally, keywords represent the research hotspots, which represent topics of wide concern for researchers in this field. figure 7 shows that the top 10 keywords ranked by citation count for the international database were public health (297), preparedness (215), emergency preparedness ( preparedness and monitoring for public health events, while chinese research mainly focuses on analysis and disposition (additional file 1: table s5, table s6 , and figure s3 ). figure s4 ). to further explain the above research hotspots, the top 8 cited articles are shown in tables 2 and 3 article elevated blood lead levels in children associated with the flint drinking water crisis: a spatial analysis of risk and public health response was the most cited (372) international article [43] followed by the 2006 california heat wave: impacts on hospitalizations and emergency department visits [44] . in terms of the time distribution, the research on international bioterrorism started first [45] , followed by recommendations for health emergency response teams and health incident management [46, 47] . in recent years, the causes and disposal of public health events have been the hotspots of international attention [43, [48] [49] [50] . this was basically consistent with the analysis results of the above research keywords. the top 8 chinese cited articles of phem appeared in 2003, 2004, 2009, and 2011 . table 3 shows us that the most frequently cited chinese article was emergency logistics [51] , written by zhongwen ou, huiyun wang, and dali jiang et al. with a frequency of an astonishing 473. this was followed by kaibin zhong's article review and prospect: construction of emergency management system in china [52] . the next three articles, legislative situation and characteristics of china's emergency international research on phem occurred earlier than the chinese research, and it has been growing over time. this means that international scholars have paid increasing attention to phem. in 1991, the first article on phem was written by richard l. siegel and was titled code 9: a systematic approach for responding to medical emergencies occurring in and around a hospital [56] . it mentioned the need for an organized system to respond to such emergencies involving patients, visitors, local community residents, and hospital employees, both inside the hospital and on the grounds surrounding the building. he recommended the establishment of a systematic emergency response system in all health care institutions. since then, academia has begun to pay attention to emergency management of public health incidents. the number of international articles is increasing gradually, reaching the maximum in 2017, and it is expected to continue to grow in the next 3 years. the development of phem in china shows a fluctuating pattern. the occurrence of public health emergencies in the 10 years from 2006 to 2016 showed a general trend of first rising and then slowly declining. it is likely related to the number of significant events that occur in each year [57] . the severe acute respiratory syndrome (sars) epidemic in 2003 resulted in significant increases in both the amount of research and articles on emergency management [7] . the number of articles reached a small climax in 2008. events such as the wenchuan earthquake and the southern snow disaster occurred in that year. the maximum was in 2013, with human infection from h7n9, the ya'an earthquake, and death from a hepatitis b vaccine occurring that year. moreover, 10 years after the sars outbreak, some authors compared the development of phem in china over the 10-year period. the first chinese article on phem was written by tiewu jia and was titled capacity-building for public health emergency response to disasters (2003) [58] . this article was published during the epidemic of sars. in 2003, china did not establish a network and echelon phem system. the author combined the development of emergency management, reform of health and epidemic prevention institutions, and discussed the capacity building of public health emergency response. it is helpful for the social function orientation of the disease control center and the improvement of disease prevention ability. although the number of chinese articles decreased in the following years, it remained above 48. in summary, the above analysis shows that phem is still a timely topic. from the perspective of cooperative networks, we find that there is more cooperation among chinese authors but less cooperation among authors from different institutions. the cooperation between different research institutions is believed to be highly effective in facilitating high-level and fruitful research, which can also help develop the research field into a more established area [59] . therefore, chinese scholars should strengthen cooperation between different institutions. the research institution focus on phem mainly comes from universities and health institutions, while chinese institutions have regional differences. reasons include the following: the western region had poor fiscal capacity, a limited personnel size, and an inadequate stockpile in terms of working budget, timely reserves, and prompt delivery [60] . as a leader in international phem, the cdc has begun to help other entities strengthen their capacity, recognition, and technical expertise to strengthen their phem capacity [61] . additionally, some other health institutions, such as the who, have promoted development in this field. in 2005, the 58th world health assembly (wha) adopted the revised international health regulations, which instructed the who member states to collaboratively confront public health emergencies of global significance [5, 17, 62] . universities have undertaken the scientific task of phem, and they have conducted in-depth research on it in china. the chinese cdc has carried out more disease prevention and control services, but its scientific research ability is weak. the country network analysis shows obvious differences in regional and economic development levels for phem. those countries with more developed health emergency management systems are the most high-income ones. geographically, most of these countries are concentrated in europe, where the numbers of publications and citations are also significantly higher [60] . the usa, the uk, japan, and other countries have constantly built and improved their phem systems, which have become a comprehensive management network. co-word analysis of phem international research is more complex, extensive, and multidimensional. it reflects some of the major ideas of this research. based on these ideas, scholars mainly focused on emergency preparedness and monitoring of public health events. from the perspective of chinese phem development, it has gone through a process from theory to preparation, disposition, response, evaluation, organization, and discussion. that is, the main contents of china's health emergency management include the prevention and preparation of health emergencies as well as the key links of disposition, evaluation, and management, system construction, personnel training, and so on. the development of the whole discipline is therefore systematic and clear. the keywords with the strongest citation burst for international research on phem started with terrorism and bioterrorism [63] , followed by disaster planning and emergency preparedness. in recent years, epidemics and infectious diseases have become the new research frontier. from the perspective of the whole development context, international research on phem has been related to current affairs hotspots, such as terrorism, which may have originated from the 911 incident, and epidemics, which may be related to the epidemic of infectious diseases caused by viruses and bacteria such as the ebola virus. the study of phem in china is a process from theory formation to practice discussion, involving many links of management. during 2003-2008, chinese scholars focused on health emergency response and disposition. after that, chinese scholars began to learn more about foreign phem models. some new methods have gradually been applied to chinese phem in recent years. the top-ranked articles by citation for the international knowledge domain of phem appeared in 2005, 2007, 2009, 2014, 2015, and 2016 . in 2005, lawrence m. wein [45] developed a mathematical model of a cow-toconsumer supply chain to reduce bioterrorism events. once again, it shows that international emergency management research is based on terrorism and bioterrorism. in 2007, nathalie embriaco focused on the working condition of emergency management personnel [46] . kim knowlton [44] and salim s. abdool karim [47] mentioned the emergency department. the above three articles are all about the factors involved in health emergency management. the remaining articles analyze the specific events involving the mechanism, response, and recovery [43, [48] [49] [50] . from the above analysis, it can be seen that terrorism, emergency response and health incident management, and the disposition of public health events are the hotspots of international attention. legislative situation and characteristics of china's emergency law [53] , legal construction of public emergency response in china: legal construction task proposed by sars crisis management practice [54] , and the realistic subject of administrative rule of law in public emergency management [55] were published in 2003. all three articles discussed the problems existing in the construction of the administrative legal system under the background of sars. after that, three articles were published in 2004, mainly studying the mechanism and structure of phem in china. this research proposed the need to establish the emergency response mechanism for phem and establish emergency structure construction as soon as possible. in 2009, kaibin zhong wrote the article review and prospect: construction of emergency management system in china [52] . he elaborated on the core contents of chinese phem construction, including emergency plans, emergency structures, emergency mechanisms, and legal systems. china's phem integrates emergency systems, emergency mechanisms, and legal systems in an all-round way, which is characterized by comprehensiveness, institutionalization, openness, and guarantees. in 2011, the status quo of emergency management system for sudden public health events in america and japan and its enlightenment [64] was published, showing that china has been learning the theory and experience of phem from some advanced countries. from the above analysis, it can be seen that the legal system, mechanism, and structure, system, and learning from abroad are the theoretical guidance for chinese phem in the past 30 years. admittedly, there are some limitations to this study. first, the conclusions drawn from this study were based on only two large literature retrieval libraries. other databases, such as embase and springer link, were not studied. not being able to search all the literature in this field may lead to incomplete retrieval results. second, citespace has some shortcomings in processing the results of the chinese database; it cannot translate the result from chinese into english directly. third, there is a 1-year or longer time lag between our paper submission and its publication. the database articles may change during this time. fourth, we conducted a comparison between chinese and international databases similar to that performed in many other studies. it should be acknowledged that the two databases had different acceptance ratios, and this difference in data sources might lead to bias in the study results. in addition, we categorized english articles focusing on china as being part of the international database and did not analyze them alone. although only a small part of the total, this may have created some deficiencies. this limitation may constitute an object of future studies, namely, those analyzing the differences between english papers focusing on china vs. chinese papers. in summary, we selected two large retrieval library documents to define the phem domain and detected the research status and the trends related to it from 1991 to 2018. according to the analyses, the conclusions are as follows. in the next 3 years, the number of international phem articles will continue to increase, while the number of chinese articles will decline. chinese scholars show less cooperation among different organizations. there are differences in regional and economic distribution between international and chinese cooperation networks. china focuses on the east regionally, while developed countries and european countries have a more international focus. international research often relates to timely issues, mainly by focusing on emergency preparedness and monitoring of public health events, while china focuses on public health emergencies and their resolution. the international research on phem begins with terrorism and bioterrorism, followed by disaster planning and emergency preparedness, and emerging infectious diseases. china uses sars as the research background and the legal system construction as the research starting point, which is followed by the mechanism and structure, system, and training abroad. oscar: a framework to integrate spatial computing ability and data aggregation for emergency management of public health. geoinformatica the international disasters database complex emergencies of covid-19: management and experience in zhuhai, china robert koch institute: towards digital epidemiology the public health emergency management system in china: trends from the evolution of public health emergency management as a field of practice hospital emergency management research in china: trends and challenges how did chinese government implement unconventional measures against covid-19 pneumonia rapid 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patterns in scientific literature current research trends in traditional chinese medicine formula: a bibliometric review from emerging trends in recent research on motivation in learning contexts evolution of connected health: a network perspective trends and development in enteral nutrition application for ventilator associated pneumonia: a scientometric research study (1996-2018) knowledge infrastructure project in china citespace: text mining and visualization in scientific literature public health emergency management. beijing: people's medical publishing house crisis management: planning for the inevitable how many ways to use citespace? a study of user interactive events over 14 months bibliometric analysis on the association between behavioral finance and decision making with cognitive biases such as overconfidence, anchoring effect and confirmation bias review and exploration of china subtropical climate change research based on scientometric analysis highly cited works in neurosurgery. part i: the 100 top-cited papers in neurosurgical journals bibliometric analysis of fracking scientific literature a bibliometric analysis of research on haze during 2000-2016 a retrospective analysis with bibliometric of energy security in 2000-2017 searching for intellectual turning points: progressive knowledge domain visualization the evolution of intellectual structure in organization studies between 1990 and 2010: a research based on bibliometric analysis indoor air quality: a bibliometric study emerging trends and new developments in disaster research after the 2008 wenchuan earthquake the collaborative networks and thematic trends of research on purchasing and supply management for environmental sustainability: a bibliometric review co-citation in the scientific literature: a new measure of the relationship between two documents elevated blood lead levels in children associated with the flint drinking water crisis: a spatial analysis of risk and public health response california heat wave: impacts on hospitalizations and emergency department visits analyzing a bioterror attack on the food supply: the case of botulinum toxin in milk high level of burnout in intensivists: prevalence and associated factors hiv infection and tuberculosis in south africa: an urgent need to escalate the public health response cross-reactivity, and function of antibodies elicited by zika virus infection social capital and community resilience hiv infection linked to injection use of oxymorphone in indiana emergency logistics review and prospect: construction of emergency management system in china legislative situation and characteristics of china's emergency law legal construction of public emergency response in china: legal construction task proposed by sars crisis management practice the realistic subject of administrative rule of law in public emergency management code 9: a systematic approach for responding to medical emergencies occurring in and around a hospital analysis of knowledge bases and research hotspots of coronavirus from the perspective of mapping knowledge domain capacity-building for public health emergency response to disasters a bibliometric analysis of emergency management using information systems emergency capability construction of institution of disease prevention and control cdc fact sheet public health emergency operations center -a critical component of mass gatherings management infrastructure the nature of disaster: general characteristics and public health effects the status quo of emergency management system for sudden public health events in america and japan and its enlightenment supplementary information accompanies this paper at https://doi.org/10. 1186/s12199-020-00896-z.additional file 1: table s1 . top 10 authors in the published volume and centrality of international database. table s2 . top 10 authors in the published volume and centrality of chinese database. table s3 . top 10 institutions in the published volume and centrality of international database. table s4 . top 10 institutions in the published volume and centrality of chinese database. table s5 . top 10 keywords ranked by citation counts and centrality of international database. table s6 . top 10 keywords ranked by citation counts and centrality of chinese database. figure s1 . co-author network of chinese database. figure s2 . coinstitution network of chinese database. figure s3 . keyword cooccurrence network of chinese database. figure s4 . keywords with the strongest citation bursts of chinese database. authors' contributions jl conceived and designed the study and wrote the manuscript. yz adjusted the retrieval strategy and edited the manuscript. jf collected the international data. wm collected the chinese data. gz and xw performed data processing. kb and dw reviewed the writing problem. fs and sw work orientation and secured funding for this study. all authors discussed the results and reviewed the manuscript. the authors read and approved the final manuscript. publisher's note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. key: cord-346664-ilebaqx3 authors: rahul; verma, alka; yadav, priyank; sharma, vijay kumar; sanjeev, om prakash title: non-covid surgical emergency during the nationwide lockdown due to corona pandemic: a critical appraisal date: 2020-08-10 journal: indian j surg doi: 10.1007/s12262-020-02549-5 sha: doc_id: 346664 cord_uid: ilebaqx3 the world health organization (who) declared corona infection as a pandemic in february 2020. a nationwide lockdown was enforced by indian government on 25 march 2020. separate health facilities were developed to handle the confirmed and suspected cases of covid-19 (coronavirus disease). other than emergency services and care of cancer patients, all remaining healthcare activities were curtailed. through this study, we intend to assess any change in number and pattern of non-covid surgical emergencies during the lockdown as well as the interventions required. this was an observational study which included all patients with surgical emergencies who presented during the study period (25 march to 24 april 2020) after two stage screenings for corona infection (group 2). the results obtained from analysis of prospectively collected database were compared with a similar period (group 1) prior to the onset of pandemic in india using appropriate statistical tests. in group 2, an increase (17%) in number of patients was noted. the need of organ support was more than 4 times the usual period. an upsurge in neurosurgical emergencies was noted, though the number of interventions decreased by 40%. a significant decrease in hospital stay was also documented (7 days vs 12 days). the nationwide lockdown led to an increase and change in pattern of surgical emergencies, though the interventions required were less. effective management entails appropriate preparedness. an outbreak of viral infection emerged in china in december 2019. a novel coronavirus named covid-19 (coronavirus disease) was isolated as the causative agent. despite containment measures taken by china and other countries, the case count soared so high that the disease was declared a pandemic by the world health organization (who) in february 2020 [1] . the first case in india was recorded on 30 january 2020 in the southern state of kerala. the virus spreads through direct contact, fomites, and droplets [2] . a slow but steady increase in the number of cases throughout the country was noted in the months of february and march. to prevent the exponential growth and a sudden outburst of patients, a nationwide lockdown was enforced by the indian government from 25 march 2020, when the case count in the country was 500. the primary intention was social distancing to put a check on the transmission and buy time for preparedness. as compared with the western countries, the early enforcement of lockdown in india diminished the initial rate of progression [3] .the recorded patients of coronavirus and mortality associated with the disease remained substantially low as compared with european and american countries. in order to ensure that the focus of the healthcare system remains undivided in the fight against coronavirus, except for emergency services and care of cancer patients, all remaining healthcare activities were curtailed during the lockdown. the outpatient department activities were put on hold (other than malignancy and end-stage organ disease). hospital admissions and elective surgeries were postponed to safeguard the manpower and resources. the essential emergency services remained functional. at many centers, a separate health facility was created within a span of 1-2 weeks to handle the confirmed and suspected cases of covid-19 [4] . the response to coronavirus outbreak in the province of uttar pradesh with a population of over 200 million was swift, and as the lockdown was enforced, a 3-tier triage system was introduced [4] . the trauma cases during the lockdown were expected to be low. the trauma center at our institute was converted to a corona hospital within 2 weeks. all non-covid emergency services continued to be delivered by the department of emergency medicine in the main hospital. during the lockdown period in india, the services to patients who were not at imminent risk took a serious toll [5] . the lack of standard guidelines and dearth of eloquent personal protection equipment for screening and management of patients in the first month impeded the healthcare services offered by the nursing homes and private practitioners, a trend that mimicked the one seen in italy earlier [6] . as a result, many patients who would not normally come to the emergency department at a government center were forced to do so. the increased load on emergency during a contagious pandemic conjures efficient screening system of covid suspects and triage to bestow maximum benefit to the patients. organizing separate traffics for the epidemic patients and non-covid casualties entails huge redistribution of manpower. in the period of crisis, it is prudent to judiciously utilize the limited resources. the available staff members need to be trained and reorganized to manage increasing number of concurrent emergencies. with limited number of operation theaters and available anesthesia support, it is pragmatic to learn about changes in number and type of surgical emergencies. this will aid in formulating effective plans. through this study, we intend to highlight the difference in patterns of patients who presented as a surgical emergency during the lockdown period (covid outbreak). the primary end points of the study were (a) to assess any change in number and pattern of patients with surgical emergency during the lockdown and (b) to assess the impact of lockdown on the duration of symptoms before reaching the emergency. the secondary endpoint of the study was to assess any change in the number of interventions. this was an observational study conducted in the department of emergency medicine at a tertiary care center in northern india. institute's ethical committee approval was obtained to conduct the study (iec code: 2020-134-ip-exp-20). the emergency department (ed) has 30 beds which cater to both surgical and medical emergencies. during the lockdown period, the patients were admitted to the department only after thorough screening with questionnaire (symptoms and travel history) and temperature probes for suspicion of corona. the suspected cases were evaluated at corona center in a holding area. patients who were not suspected to be positive for corona and hailed from a low transmission area were directly admitted at the ed in the main hospital. all patients were tested for corona before any radiological or surgical intervention or before being shifted to their respective wards. in this study, we intended to evaluate the patients with surgical emergencies visiting the ed (in the non-covid hospital) during the first month of national lockdown (25 march 2020 to 24 april 2020). patients who were brought dead were excluded. the data was collected retrospectively from the prospectively maintained hospital records. the management of the patients was not altered by the study. the data of patients during the lockdown period was compared with the profile and outcomes of patients referred to the respective departments over a similar period (1 month) prior to the onset of the pandemic in india. any change in the characteristics of patients and their management were recorded and compared using appropriate statistical tests. sample size estimation to detect the 0.8 effect size (≥ 0.8 effect size between two independent groups is considered large effect) between two independent groups, at minimum two-sided 95% confidence interval and 80% power of the study, calculated sample size of the two groups came out to be 26 each. in this study, we have included 29 patients in group 1 (pre lockdown) and 34 in group 2 (during lockdown). sample size was estimated using software g power version 3.1.9.2 (düsseldorf university, germany). statistical analysis normality of the continuous variables was tested, and a variable was considered normally distributed when z score of the skewness was ± 3.29.continuous variables were presented in mean ± standard deviation/median (interquartile range), whereas categorical data was presented in frequency (%). to compare the mean, median, and proportions between two groups, independent sample t test, mann-whitney u test, and chi-square test/fisher exact test were used respectively. error bar graph was used to present the distribution of means. a p value < 0.05 was considered statistically significant. statistical package for social sciences version-23 (spss-23, ibm, chicago, usa) was used for the analysis. the differences in the profile and management of the patients (surgical emergencies) who were managed in the ed of the non-covid hospital during the first month of the lockdown period and a similar period in the non-pandemic era (before january 30th in india) have been highlighted in tables 1 and 2 . there was a marginal increase (17%) in the total number of surgical emergencies during the lockdown period, and the average distance covered by the patients to reach the hospital was around 25 km more (13% more) than the pre-covid era, though the differences were not statistically significant. the duration of symptoms before reaching the hospital was on an average 6 days in group 2 against 5 days in group 1. though the most common complaint with which the patients were admitted in both the groups was pain in the abdomen, there was significant decrease in the number of patients with acute abdomen overall (82% vs 58% with significant decrease in group 2, p value 0.039). the type of abdominal emergencies was also different. in group 1, the majority of cases included perforation peritonitis, biliary peritonitis following cholecystectomy, necrotizing pancreatitis, liver abscess, or intestinal obstruction necessitating surgical/radiological intervention. in group 2, mild acute pancreatitis, biliary colic, and advanced malignancy with jaundice or ascites were the commonest abdominal emergency. most of them could be managed conservatively. two patients required surgery: one underwent nephrectomy for renal cell carcinoma with intractable hematuria, and another underwent percutaneous nephrostomy for obstructive uropathy. a significant increase in the number of patients with neurosurgical emergencies (most commonsubarachnoid hemorrhage) was noted. all patients had severe headache and altered sensorium. they were stabilized, resuscitated, preferably tested for covid, and taken up for intervention. two patients required craniotomy and three underwent coiling for aneurysm. no differences in groups 1 and 2 were recorded in terms of number of patients managed successfully and number of blood transfusion required or mortalities. the major difference noted was in the status of patients at arrival to the ed: more than 4-fold increase in requirement for organ support in group 2 (9 vs 2 in favor of group 2), though the difference was not statistically significant. six patients with neurosurgical issues required intubation with due precaution. an increase in number of radiological evaluation was noted in group 2. this was because all the patients referred to neurosurgery underwent cross-sectional imaging of the head. the major difference in groups 1 and 2 was the median hospital stay (12 days vs 7 days with significant decrease in group 2, p = 0.007; fig. 1 ). the covid-19 pandemic has made a true global footprint and has strained the healthcare facilities across the world including india [7] . knowledge regarding the presentation and possible management of the covid infection is improving constantly. new corona hospitals are being set up in every city. the hospital staffs including doctors, nursing personnel, and supporting crew managing these patients are being rotated frequently. the constantly rising number of cases has engaged more than one-third of the workforce in care of the infected. during the lockdown period, we observed a certain change in the patient load in ed at our center. a minor rise (17%) in the number of surgical emergencies was noted. the patients had to travel a longer distance (13% more) to avail the health facilities. the most important difference was increase (4-fold increase) in number of seriously ill patients requiring organ support. majority of patients with neurological complains required ventilatory support. the increase in requirement of vasopressor support among the patients may be due to various reasons. in pre-lockdown period, the patients were referred to our center by peripheral centers after providing primary care and initial resuscitation, but in the pandemic era, majority of the patients directly came to tertiary care centers. moreover, the average time to reach the hospital from the start of illness was greater during the lockdown. the health facilities extended by the peripheral private setups remained non-functional due to lack of personal protection equipment and the fear of pandemic in the first month of the lockdown. in group 2, majority of patients who arrived with abdominal complaints could be managed conservatively. the number of interventions needed was less (26% vs 65%). this was again because majority of the patients came with symptoms of biliary colic or mild pancreatitis which resolved on medications. in normal circumstances, they are usually treated at peripheral centers and need not travel distance to avail health facilities. further, the strict lockdown also affected the diet habits and social behavior due to isolation that could partially explain the reduction in the incidence of bowel obstruction, severe pancreatitis, and perforation. similar findings were documented by patriti et al. in their study [6] . in the pre-lockdown period, many neurosurgical emergencies would be operated in smaller hospitals across the city and the state. in the country, neurosurgery units run in trauma centers which take care of the non-traumatic neurosurgical emergencies as well. with the start of the pandemic, trauma centers in the city were converted into covid care facilities. this added to the load of neurosurgery cases in the ed which was very visible in the limited duration of the present study. they were managed successfully by the neurosurgery team. at our center, the patients treated in the ed were all low risk for covid infection admitted after thorough 2 stage screenings (detailed history and thermo scan). none of them tested positive for the virus during the stay. all the patients requiring intervention were first tested for covid antigen, and those requiring early ventilation were intubated with all due precautions. the overall emergency and hospital stay in group 2 was significantly less as the decision to shift to respective units and intervene were swiftly taken. the upsurge in medical and surgical emergencies necessitated prompt treatment. moreover, majority of the patients (with mild abdominal complains-biliary colic and mild pancreatitis) improved with conservative management over a short period. the substantial decrease (40%) in the requirement of intervention was responsible for reduced hospital stay. the present study points towards the likelihood of upsurge in emergencies presenting to the ed, especially the neurosurgical emergencies. with the ease in travel restrictions, the number of emergencies (including trauma) is set to rise, and this will add to the burden of ed. it is important to make periodic appraisal of the hospital services and the changing patient load in order to apprise the concerned authorities regarding the changing needs. the lacunae need to be highlighted and necessary adjustments made. this will also help to reactivate and coordinate with the local healthcare centers for mutual support and mitigate the undue load on a tertiary care center. the use of referral and counter-referral systems can help to efficiently distribute the work load, provide home care (with the help of local hospitals), and avoid unnecessary admissions in the hospital. hospital emergency management plan during the covid-19 epidemic feng z (2020) early transmission dynamics in global comparison of changes in the number of test-positive cases and deaths by coronavirus infection (covid-19) in the world ministry of health and family welfare government of india (2020) updated containment plan for large outbreaks novel coronavirus disease 2019 (covid-19) lockdown deals deadly blow to kidney patients, the hindu what happened to surgical emergencies in the era of covid-19 outbreak? considerations of surgeons working in an italian covid-19 red zone an interactive web-based dashboard to track covid-19 in real time publisher's note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations conflict of interest the authors declare that they have no conflict of interest.ethics approval this study was approved by the institute's ethics committee and patient consent was waived off (iec code: 2020-134-ip-exp-20). key: cord-303861-qn8yifcd authors: wang, chongjian; wei, sheng; xiang, hao; xu, yihua; han, shenghong; mkangara, ommari baaliy; nie, shaofa title: evaluating the effectiveness of an emergency preparedness training programme for public health staff in china date: 2008-05-31 journal: public health doi: 10.1016/j.puhe.2007.08.006 sha: doc_id: 303861 cord_uid: qn8yifcd summary background the severe acute respiratory syndrome (sars) crisis of 2003 provided a new urgency in china in terms of preparing public health staff to respond effectively to public health emergencies. although the chinese government has already carried out a series of emergency education and training programmes to improve public health staff's capability of emergency preparedness, it remains unclear if these training programmes are effective and feasible. the purpose of this research was to evaluate an emergency preparedness training programme and to develop a participatory training approach for emergency response. methods seventy-six public health staff completed the emergency preparedness training programme. the effectiveness of the training was evaluated by questionnaire before training, immediately after training and 12 months after training (follow-up). additionally, semi-structured interviews were conducted throughout the training period. results the emergency preparedness training improved the knowledge levels and increased attitudinal and behavioural intention scores for emergency preparedness (p<0.01). the results at follow-up showed that the knowledge levels and attitudinal/behavioural intention scores of participants decreased slightly (p>0.05) compared with levels immediately after training (p<0.01). however, there was a significant increase compared with before training (p<0.01). moreover, more than 80% of participants reported that the training process and resources were scientific and feasible. conclusions the emergency preparedness training programme met its aims and objectives satisfactorily, and resulted in positive shifts in knowledge and attitudinal/behavioural intentions for public health staff. this suggests that this emergency training strategy was effective and feasible in improving the capability of emergency preparedness. summary background: the severe acute respiratory syndrome (sars) crisis of 2003 provided a new urgency in china in terms of preparing public health staff to respond effectively to public health emergencies. although the chinese government has already carried out a series of emergency education and training programmes to improve public health staff's capability of emergency preparedness, it remains unclear if these training programmes are effective and feasible. the purpose of this research was to evaluate an emergency preparedness training programme and to develop a participatory training approach for emergency response. methods: seventy-six public health staff completed the emergency preparedness training programme. the effectiveness of the training was evaluated by questionnaire before training, immediately after training and 12 months after training (follow-up). additionally, semi-structured interviews were conducted throughout the training period. results: the emergency preparedness training improved the knowledge levels and increased attitudinal and behavioural intention scores for emergency preparedness (po0.01). the results at follow-up showed that the knowledge levels and attitudinal/behavioural intention scores of participants decreased slightly (p40.05) compared with levels immediately after training (po0.01). however, there was a significant increase compared with before training (po0.01). moreover, more than 80% of participants reported that the training process and resources were scientific and feasible. since the 9/11 disaster, anthrax bioterrorism, 'mad cow' disease, severe acute respiratory syndrome (sars) and avian influenza outbreaks, public health emergencies have become an important threat to communities worldwide. managing these emergencies and the threats they pose is part of the longterm government development plans in many countries, and expensive resources are being invested into preventing and responding to public health emergencies. 1 in china, surge capacity is one of the most urgent problems regarding public health emergency response at the present time, 2 along with the lack of equipment and the low efficiency of the public health emergency information system. recognizing this, the chinese government carried out a series of emergency preparedness education and training programmes to improve the capability of public health staff to respond to emergencies nationwide. however, it remains unclear if these training programmes are feasible and effective in improving emergency preparedness. investigation has revealed that the emergency response of the public health sector was insufficient, especially the emergency preparedness of public health staff, such as not knowing the emergency response protocols and management procedures, and how to collect and analyse the relevant data during the sars outbreak. 2, 3 therefore, in order to change the current situation and improve the capability of public health staff in china to respond to emergencies, a pilot study was developed and supported by the ministry of health of the people's republic of china (moh) and the world health organization (who). the study was carried out by tongji medical college in hubei province from 2004 to 2006. the training was completed in 2005, and the follow-up survey was conducted 12 months later. like any other successful health education programme, the emergency preparedness training programme should be subjected to a process of continuous monitoring, control, evaluation and, if needed, relevant modifications. [4] [5] [6] [7] [8] the comprehensive evaluation of an emergency training preparedness programme should include its various aspects (contents, aims and objectives, training resources, methods, effects and impact), and it should also answer questions about the efficiency and impact of training on the participants. [9] [10] [11] this study highlighted the procedures used in the evaluation of an emergency preparedness training programme, and focused on its most important aspects: training resources; training process; and effectiveness of training (before training, immediately after training and 12 months later). seventy-eight trainees from the centers for disease control and prevention (cdc) in 18 cities in hubei participated in the emergency preparedness training programme in 2005. two participants did not complete their training and were not part of the evaluation (n ¼ 76). trainers were selected based on their expertise in the field of public health emergency response, related training programmes and their involvement in continuous consultations on health service programmes, both educational and promotional. trainers came from the moh, who, chinese cdc, health department of hubei province, fudan university, wuhan university and huazhong university of science and technology. the aims and objectives of training were designed carefully by educational and training experts with an intimate knowledge of the public health emergency response plan and the training programme, in consultation with public health personnel who did not participate in the training. the training programme was based on the us cdc's emergency preparedness core competencies for all public health workers. [12] [13] [14] in brief, the training consisted of: (1) the definition of public health emergency; (2) the public health workers' role during emergencies; (3) the responsibilities of local, province and government agencies during emergencies; (4) the role of the cdc during emergencies; (5) the cdc emergency response chain of command; (6) emergency communication strategies and use of special equipment; (7) emergency response protocols; and (8) management procedures, including the management of necessary supplies and equipment. the training contents and objectives were subjected to continuous monitoring and evaluation throughout the training period. various training methods were used, including case studies, workshops, tutorials, seminars, group discussions, role playing, drilling and fieldwork. formal lecturing was the least used method. the training centre was equipped with modern audiovisual aids designed for training purposes. as well as the training logistics, other facilities and general services, such as transportation and accommodation, were provided free of charge to the participants. individual basic information, knowledge levels, attitudes and behaviours regarding emergency preparedness were investigated by questionnaire, which was designed by experts in the field of training programmes and continuous consultation on emergency management. in order to assess the questionnaire, a pilot test was undertaken among other public health personnel who did not participate in the training, and modifications were made by experts based on the feedback. thirty questions assessed the participants' knowledge of public health emergency competencies, which consisted of basic public health science knowledge, emergency management knowledge and emergency analytical/assessment skills (10 questions). if the correct answer was given to these questions, the participant received one point, whereas incorrect answers received no points. eight items were designed to assess the staff's attitudinal and behavioural intentions related to the 'eight core competencies for public health services'. 15 each of the eight items asked respondents to rate their attitudinal and behavioural intentions, as well as the frequency of their use of each of the competencies. responses were rated on an ordinal scale (1 ¼ very low, 2 ¼ low, 3 ¼ middle, 4 ¼ high, 5 ¼ very high). participants completed the first measurement (pre-test, baseline) on the first day of training. the post-training measurement (post-test) was conducted at the end of the last day of training. for the follow-up test, the participants were mailed a copy of the survey, with a self-addressed return envelope, 12 months after the training had been completed. the training process and resources were subjected to continuous monitoring and evaluation by semi-structured interviews. the inclusion of the trainees in the evaluation process was extremely helpful in updating and modifying the programme. the items addressed in the semi-structured interviews were as follows: (1) the scientific methods offered; (2) the technical material presented; (3) the performance of the trainer; (4) the benefits derived by the participant; (5) the use of the audiovisual aids; (6) the strengths and weaknesses of the session; and (7) final critical comments and remarks. the forms were distributed at the end of each session to be completed anonymously by each participant. the forms were analysed immediately and the results were shown to the trainer who had conducted the session. if any defects were revealed, the necessary rectifications were made immediately. evaluation of workshops and fieldwork was carried out in a similar fashion. feedback of the results of the evaluation was given to the participants. most data were reported as scores. frequency and confidence scores were derived for each domain by participants' responses to the frequency questions and the self-efficacy questions. repeated-measures analysis of variance was used to test differences between pre-test, post-test and follow-up test. the data from semi-structured interviews were categorized independently by three authors using the triangulation method, and the individual results of the analysis were compared and discussed until consensus was reached. all results were expressed as mean7standard deviation. data were analysed by one-way analysis of variance using statistical package for the social sciences for windows, version 12.0 (spss. inc., chicago, il, usa). seventy-six of the study participants completed the entire training programme and represented public health staff from the cdc of 18 cities (97.44% response). most respondents were male (n ¼ 57, 75%) and over half (n ¼ 42, 55.26%) had earned a bachelor's or master's degree, of which one-sixth possessed masters of public health degrees. additionally, most participants (n ¼ 62, 81.58%) had more than 5 years of experience as public health staff. some trainees (n ¼ 50, 65.79%) had participated in inter-related training approximately 12-24 months previously. the results of reliability assessment showed that test-retest reliability and the internal consistency of questionnaires was accredited to some extent (test-retest reliability of pretraining ¼ 0.83, cronbach's alpha 40.61). the results of related analysis indicated that the construct validity of the questionnaire was of high quality (related coefficient fluctuated between 0.35 and 0.79, po0.05). 16, 17 knowledge levels the investigation revealed that knowledge levels of public health emergency preparedness were relatively low before training. after training, a significant increase in the mean knowledge scores was observed (pre-test: 19.7972.41; post-test: 24.4970.86; followup test: 24.2471.58) (po0.01). basic public health science knowledge and emergency management knowledge scores decreased slightly (p40.05), but the mean scores for emergency analytical/assessment skills were increased dramatically in the follow-up test compared with the post-test (po0.01). furthermore, there was a significant increase in overall knowledge scores between the follow-up test and the pre-test (po0.01) (fig. 1 ). descriptive statistics on attitudinal and behavioural intentions at pre-test, post-test and follow-up test are presented in table 1 . as mentioned above, the responses ranged from high (5) to low (1) . the results showed that participants reported a significant improvement in their attitudinal and behavioural intentions in all eight core competencies in the post-test compared with the pre-test. twelve months later, there were slight decreases in participants' attitudinal and behavioural intentions in some core competencies, but the mean score for emergency analytical/assessment skills was significantly increased compared with the post-test (4.35 vs 3.69), and mean scores for policy development/programme planning skills (2.94 vs 3.95) and financial planning and management skills (2.66 vs 3.47) were decreased compared with the posttest (po0.05). the results of the semi-structured interviews showed that most participants (n ¼ 73, 96.05%) thought that the training methods were excellent/very good, and the training contents were clear and easy to understand. the remaining participants (n ¼ 3, 3.95%) indicated that the training methods needed to be improved/further developed. however, all of the participants recognized that the training was innovative. analysis showed that 80.26% (n ¼ 61) of participants were satisfied with the trainers' performance, and 19.74% (n ¼ 15) of participants thought that the trainers' performance needed to improve. however, no participants indicated that resource personnel were incompetent. additionally, most participants (n ¼ 72, 94.74%) were very satisfied with the venue, training logistics and services, and only four participants (n ¼ 4, 5.26%) thought that logistics and services needed improvement. continuous medical education and training is a process of updating knowledge, developing skills, bringing about attitudinal and behavioural changes, and improving the capability of participants to perform their tasks efficiently and effectively. 18 effective training methods are key to the success of an emergency training programme. a number of studies have shown that the training methods recommended by the present study educators were effective because different participants learn by different training methods, and methods of active training are especially helpful for adult learning. [19] [20] [21] formal lecturing was the least used training method because trainees do not participate actively in the learning process and the outcome is inferior to methods of active learning. the results of the evaluation suggested that up-todate training of public health staff should focus on the development of effective training methods, and interactive training methods may help to increase the quality of training and improve retention of knowledge through immediate reinforcement of learning. 22, 23 furthermore, comprehensive evaluation and feedback about the training programme were of vital importance for the participants and trainers as it helped participants to identify their limitations while monitoring their performance during the training period. also, trainers tended to improve their performance as they were aware that it was being monitored and evaluated. feedback of the results of evaluation of the training sessions to the trainers was found to be helpful in rectifying the weaknesses of sessions. 24 in addition, the mean scores of emergency analytical/assessment skills increased rather than decreased by 12-month follow-up. this is similar to results found by qureshi et al. 14 for this type of phenomenon, one must consider the experience of the public health staff at the end of 2005. before the follow-up survey, the majority of trainees had participated in avian influenza emergency response activities, thus providing practice and increasing perceived relevance of the training. as such, this probably had a positive effect on the effectiveness of training. nevertheless, the increased overall knowledge score and the positive change in attitudinal and behavioural parameters suggested that training programmes on emergency preparedness resulted in gaining knowledge and shifts in attitude and behaviour. this study had a few potential limitations. the analysis was limited to staff who were primarily engaged in disease monitoring and control, and epidemiological investigations in the cdc. in addition, evaluations were based on changes over time without the use of a horizontal comparison group. thus, it was not possible to fully determine which changes were due to the emergency preparedness training programme and which were the result of other factors. these results, however, remained constant throughout, which provides support that these changes were due to the training programme. the effectiveness of any educational training programme depends on its continuous monitoring and evaluation, which should include appropriate and varied methods. moreover, trainers and trainees should be actively subjected to the process of monitoring and evaluation, which was helpful in monitoring their overall performance. immediate feedback with results analysis of the continuous monitoring and evaluation should be available to those involved so that necessary improvements can be made. the results of the evaluation suggested that the emergency training strategy was effective and feasible in improving the capability of public health staff to respond to an emergency. a preliminary framework to measure public health emergency response capacity evaluation of the performance of responding to public health emergency for the workforce in cdc in hubei report of the system construction on disease control and prevention. hubei measuring effectiveness of tqm training: an indian study emergency preparedness: one community's response the road map to preparedness: a competency-based approach to all-hazards emergency readiness training for the public health workforce primary health workers in northeast brazil evaluation of health impact assessment workshop. criteria for use in the evaluation of health impact assessments business and public health collaboration for emergency preparedness in georgia: a case study responsive evaluation of competencybased public health preparedness training programs emergency preparedness training for public health nurses: a pilot study emergency preparedness core competencies for all public health workers public health worker competencies for emergency response council on linkages between academia and public health practice. core competencies for public health professionals psychometric considerations in evaluating health-related quality of life measures psychometric theory training objectives, transfer, validation and evaluation: a srilankan study what matters most? predictors of student satisfaction in public health educational courses applying educational gaming to public health workforce emergency preparedness relative effectiveness of worker safety and health training methods emergency preparedness and bioterrorism response: development of an educational program for public health personnel evaluating health impact assessment evaluation study of the training programs for health personnel in al-qassim, saudi arabia the authors thank all of the participants and trainers for their hard work, and all of the coordinators for their support and help. in addition, the authors would like to thank c.k. lee for his critical reading of the manuscript. not required. world health organization. none declared. key: cord-335550-l7opl6b1 authors: coronini-cronberg, sophie; john maile, edward; majeed, azeem title: health inequalities: the hidden cost of covid-19 in nhs hospital trusts? date: 2020-05-14 journal: j r soc med doi: 10.1177/0141076820925230 sha: doc_id: 335550 cord_uid: l7opl6b1 nan socioeconomically disadvantaged people are more frequent users of healthcare, 5 as are the elderly. 6 in particular, those in the most deprived decile access emergency services more than twice as often as the least deprived, 7 and the emergency department is often used for routine care by marginalised groups who find it difficult to access general practice and other community services. 8 therefore, disruption to elective or emergency care will have disproportionately large negative impacts on these marginalised groups. in order to release capacity for patients with covid-19, hospitals in england were instructed to suspend non-urgent clinical services. 9 for example, one london teaching hospital has reduced activity by 80%, affecting numerous services including gynaecology, sexual health and paediatrics, 10 as well as restricting access to diagnostics such as ultrasound. concurrently, there has been a sharp drop in emergency department attendances, with a decline of almost 44% during march 11 (see figure 1 ), compared to an 11% increase in march last year 12 (see figure 2 ). while the reasons for this are unclear, it is possible that patients are being deterred by increasing covid-19 hospitalisations and death rates, associated fear of nosocomial covid-19 infection and sensitisation to concerns about overburdening nhs services. public messaging may also have played a part, for example: 'to protect others, do not go to places like a gp surgery, pharmacy or hospital. stay at home'. 13 the steep decline suggests that some patients genuinely in need of medical attention are no longer attending emergency departments, in which case they are jeopardising their health. furthermore, specific concerns have been raised that children and families may not be accessing medical advice and review. 14 both the restriction of non-urgent clinical services and the precipitous decline in emergency department attendances will affect marginalised groups disproportionately by restricting access to care 6 and therefore exacerbating health inequalities. hospitals are attempting to mitigate the impact of service reduction by replacing clinic appointments with telephone or video consultations and by offering enhanced support to general practitioners through remote specialist advice from hospital consultants. however, people with a poorer grasp of english or lower health literacy levels may not have their needs met adequately through these methods when compared with traditional face-to-face consultations. 8 we therefore propose that innovative methods are considered to facilitate access during the pandemic, such as the clean sites being established for cancer patients, 15 and that non-urgent clinical services are restored as soon as it is safe to do so. in terms of public messaging, although some channels are beginning to nuance advice, such as 'for lifethreatening emergencies, call 999 for an ambulance', there is an urgent need to communicate clearly and in lay language so that those with emergency health needs should continue to attend emergency departments or use other nhs services such as general practices and urgent care centres. a vital part of our response to covid-19 is minimising staff absence. despite this, testing is only just becoming available and in a recent survey one in five staff reported being off work for coronavirus-related reasons, with the same proportion unable to access appropriate personal protective equipment. 16 to address this, nhs employers have been mandated to increase testing to support staff retention, 17 provide more comprehensive personal protective equipment 18 and clearly communicate pay arrangements for instances of self-isolation. this includes that any absence due to self-isolation should be treated as an absence related to compliance with infection control guidance and should not contribute to sickness absence policy triggers. 19 while welcome, these approaches fail to recognise the likely inequality in protection for critical workers who are not directly employed by the nhs. while the focus has been on ensuring availability of clinicians, emergency departments aʃendances hospitals need many other support staff in areas such as security, cleaning, portering and catering. these workers access the same clinical areas, may have significant patient contact and without them it would be impossible to deliver health services. however, many nhs trusts do not directly employ these staff groups, who are usually in the lowest pay bands and are more likely to be migrants. as a result, they often do not enjoy equality in pay or terms of employment, 20, 21 and in particular many outsourcing firms do not provide sick pay for the first three days. 22 a consequence of this may be that staff with mild symptoms or who have a symptomatic household member may feel they have no option but to attend work, thereby undermining infection control efforts. this may make the terms of employment unsafe for staff, their families, nhs colleagues and, critically, patients. these concerns are supported by evidence that nosocomial infections are higher in hospitals that have contracted out cleaning services, than those that have not. 20 nhs england have instructed that all staff, including outsourced workers, receive full pay during self-isolation, 23 but there are concerns that this has not been comprehensively implemented. there is therefore an immediate need to review contractors' staff policies and processes with regards to covid-19 testing, personal protective equipment and absence arrangements. in england, there are well-established smoking prevalence gradients across genders (males, 16.8%; females, 13.0%) and deprivation decile (most deprived, 18.1%; least deprived, 10.4%). 24 early data from china show a threefold difference in poor outcomes: while 12.4% of hospitalised smokers were admitted to intensive care, mechanically ventilated or died, among nonsmokers this was only 4.7%. 25 although not yet conclusive, it is plausible that smoking is a risk factor for covid-19 considering higher infection rates in people who smoke for other respiratory illnesses such as influenza. 26 potential infection mechanisms are the repetitive fingers-tomouth action when consuming tobacco, and sharing smoking materials, e.g. waterpipe mouthpieces. 27 in addition, once a patient who smokes has contracted covid-19, the many adverse effects of smoking on respiration, circulation and other physiological functions are likely to affect outcomes. the precautionary principle would therefore support raising awareness of smoking cessation services, which in turn may reduce inequalities in infection rates and disease progression. 24 official guidance advises postponing face-to-face smoking cessation clinics during the pandemic, 28 but we encourage providers to provide alternative remote services and to promote these tenaciously. for those that continue to use tobacco products, there should be clear targeted messaging about avoiding smoking indoors during either self-isolation or lockdown periods, particularly when others are present and to observe social distancing rules, including not smoking in public groups. 29 finally, younger women and those living in more deprived areas are more likely to smoke during pregnancy. 30 self-reported status results in underestimated smoking prevalence, and carbon monoxide screening is mandated. 30 however, to minimise covid-19 infection risk, carbon monxide screening of pregnant women has been temporarily suspended. 31 nonetheless, it remains vital that maternity services continue to ask women (and their partners) if they smoke or have recently quit, and continue to refer those who smoke for specialist cessation support. disease incidence and progression for many conditions can vary by ethnicity and covid-19 may be no different. it is therefore imperative that we rigorously capture baseline data so that we understand the impact of key risk factors on disease prognosis. while ethnicity data are generally accurately captured for white british patients, for minority groups only 60-80% of hospital records capture ethnicity correctly, 32 so we risk reaching incorrect conclusions based on flawed data. we also need to consider nhs staff: with 1 in 5 nhs staff from ethnic minority groups, and 2 in 5 doctors, 33 this is disproportionately high compared to the general population. 34 as the first deaths among clinicians are announced with a disproportionate number of deaths in health professionals from minority ethnic backgrounds, there will be intense post hoc scrutiny of systematic differences between groups and whether the nhs adequately protected its staff. how and whether we measure ethnicity matters and it is critical for trusts to do so accurately -both among patients and staff -using nationally recommended categories so that data are meaningful and comparable. 35 moreover, smoking is not currently considered a risk factor for more severe covid-19 infection. 36 this is despite a plausible hypothesis that inhaling chemicals could be associated with lung damage and subsequently poorer covid-19 outcomes. many uk hospitals have joined the global recovery trial, 37 which could provide a rare insight into the impact on lung health of not just combustible tobacco products but also electronic cigarettes, but only if this is rigorously captured in health records. we support the development of mechanisms to routinely capture such data, such as the one below which is being developed by an nhs hospital in london (see figure 3 ). an advance decision allows people to specify that they refuse a specific type of treatment sometime in the future. critically it lets people involved in care and treatment -including family members and healthcare professionals -act upon a patient's wishes if capacity has been lost. nonetheless, the prevalence of advanced decisions in england is estimated at just 4%, 38 perhaps due to a belief it is unnecessary if family members or clinicians have been informed of a patient's wishes. data from italy show that consistently between 9% and 11% of covid-19 patients are admitted to intensive care units. 39 early data of confirmed cases admitted to intensive care units in england show inequalities, with patients overwhelmingly older (median age 61 years) and male (7 in 10 patients). 40 nearly 60% were mechanically ventilated within 24 h of admission and of those with recorded outcomes, 871 (51.6%) had died and were 818 discharged from the intensive care unit alive. 40 many marginalised groups, including certain faith groups, prisoners and those experiencing homelessness, experience disadvantage in their end-of-life journey. 41 while frontline clinicians will undoubtedly be striving to deliver patient-centred care under extremely difficult circumstances, whether to accept life-sustaining treatment remains a deeply personal decision: time on an intensive care unit is gruelling and can leave survivors, even previously fit-and-well patients, with long-term effects. not all eligible patients would want to be admitted to intensive care or receive mechanical ventilation. there is an urgent need for a compassionate national conversation, focussed on those from marginalised groups with and without covid-19, so that their wishes are formally understood in case they become critically ill or lose capacity. this would allow more patients to be cared for according to their wishes and reduce the intense pressure on frontline clinicians which results from making these decisions in acute settings. we do not underestimate the threat posed by covid-19 and we commend the nhs on the swift action taken to expand capacity and reorganise services to help ensure that it can cope. we recognise that difficult choices have been required and that some unintended consequences are inevitable. however, policymakers, managers and clinicians should take pause during this accelerated work to protect the most vulnerable from negative unintended consequences and avoid worsening health inequalities. we believe that hospitals are uniquely placed to support this agenda. competing interests: none declared. ethical approval: not required. guarantor: sc-c. contributorship: sc-c and ejm wrote the article. ejm finalised the manuscript. sc-c and am revised the draft and provided critical feedback. the final manuscript was approved by all authors. what are health inequalities? the king's fund monitoring equality and health inequalities: a position paper guidance for nhs commissioners on equality and health inequalities legal duties socio-economic inequalities in health care in england the wider impacts of the coronavirus pandemic on the nhs. london: institute for fiscal studies why do patients seek primary medical care in emergency departments? an ethnographic exploration of access to general practice important and urgentnext steps on nhs response to covid-19 nhs foundation trust. covid-19 response from guy's and st thomas' nhs foundation trust -gp communications (issue two the royal college of emergency medicine self-isolation if you or someone you live with has symptoms delayed access to care for children during covid-19: our role as paediatricians -position statement clinical guide for the management of essential cancer surgery for adults during the coronavirus pandemic royal college of physicians. covid-19 and its impact on nhs workforce covid-19 testing to support retention of nhs staff covid-19 personal protective equipment (ppe) nhs-staff-council-guidance-for-covid-19-feb-20.pdf? la¼en&hash¼70c909da995280b9fae4bf6af291-f4340890445c cheap and dirty: the effect of contracting out cleaning on efficiency and effectiveness at last our hospital's cleaners, caterers and porters work for the nhs again. the guardian coronavirus: nhs trusts must ensure sick pay for outsourced staff self-isolation statistics on smoking clinical characteristics of coronavirus disease 2019 in china cigarette smoking and the occurrence of influenza -systematic review world health organization regional office for the eastern mediterranean. tobacco and waterpipe use increases the risk of suffering from covid-19 rcgp guidance on workload prioritisation during covid-19 staying at home and away from others (social distancing health of women before and during pregnancy: health behaviours, risk factors and inequalities. london: public health england, 2019. 31. national centre for smoking cessation and training. protecting smokers from covid-19 ethnic group, national identity and religion guidance on social distancing for everyone in the world's largest trial of potential coronavirus treatments rolled out across the uk. see public policy institute for wales. increasing understanding and uptake of advance decisions in wales. public policy institute for wales covid-19 and italy: what next? intensive care national audit & research centre. icnarc report on covid-19 in critical care. london: intensive care national audit & research centre care quality commission. a different ending: addressing inequalities in end of life care a&e attendances and emergency admissions 2019-20 key: cord-016840-p3sq99yg authors: bales, connie watkins; tumosa, nina title: minimizing the impact of complex emergencies on nutrition and geriatric health: planning for prevention is key date: 2008-09-09 journal: handbook of clinical nutrition and aging doi: 10.1007/978-1-60327-385-5_29 sha: doc_id: 16840 cord_uid: p3sq99yg complex emergencies (ces) can occur anywhere and are defined as crisis situations that greatly elevate the risk to nutrition and overall health (morbidity and mortality) of older individuals in the affected area. in urban areas with high population densities and heavy reliance on power-driven devices for day-to-day survival, ces can precipitate a rapid deterioration of basic services that threatens nutritionally and medically vulnerable older adults. the major underlying threats to nutritional status for older adults during ces are food insecurity, inadequate social support, and lack of access to health services. the most effective strategy for coping with ces is to have detailed, individualized pre-event preparations. when a ce occurs, the immediate relief efforts focus on establishing access to food, safe water, and essential medical services. the most common issues impacting on the nutritional well-being of elderly persons are comprehensively addressed in the preceeding 28 chapters of this edition of the handbook of clinical nutrition and aging. this chapter focuses on a different type of concern, one that can overshadow all other threats to health when a serious disaster strikes. that subject is the welfare of aged persons when catastrophic events pose a direct (or indirect) threat to nutrition and health (1, 2) . while there is a large body of literature on the health impact of natural and man-made disasters (e.g., droughts, floods, military conflicts) and associated long-term food shortages in the third world, surprisingly little information is available about the short and intermediate-term consequences of emergency situations in developed countries. in these situations, high population densities and heavy reliance on power-driven devices for day-to-day survival (e.g., electrical power for mass transit, elevators to reach living quarters, medical devices, and refrigeration of foods and medicines) can accelerate the speed with which a catastrophic, health-threatening situation develops. in 2005, the plight of the elderly evacuees from new orleans (pre-storm population approaching 485,000) following hurricane katrina provided a dramatic demonstration of how essential services can rapidly deteriorate in a well-developed, highly populated urban environment following a major disaster and place older individuals in eminent mortal danger. in order to lay the foundation for this discussion, we begin with some definitions (see table 29 .1). while terms like ''disaster relief'' and ''humanitarian crisis'' may be any of a number of crisis situations that greatly elevate the health risk of individuals in the affected area; examples are natural disasters like floods and earthquakes; urban health emergencies like fires, epidemics, and blackouts; and terrorist acts like massive bombings or poisonings of food or water supplies. resolution of these emergencies requires collaboration between multiple groups. acute protein/calorie malnutrition (pcm) pcm or ''wasting'' is associated with recent rapid weight loss, i.e., as in emergency situations (as opposed to chronic malnutrition). chronic energy deficiency (ced) an intake of energy that is below the minimum requirement for a period of several months or years. in order to achieve energy steady state, the energy expenditure must drop to match the low intake, ultimately leading to underweight and low levels of physical activity. nutritional rehabilitation restoration of weight and healthy nutrition through the provision of appropriate foods based on established protocols. food rations a shelf-stable pre-packaged dry ration that meets minimum daily intake recommendations for calories and other nutrients. used to temporarily meet critical nutritional needs when food supply is inadequate. examples: meals ready to eat or mres (1,250 kcal) are often distributed in complex emergencies in the united states; general food rations or gfrs (2,100 kcal) are distributed in many countries in sub-saharan africa. (continued ) more familiar, the most broadly acceptable term for these threatening situations is ''complex emergency'' (2) . complex emergencies (ces) can occur anywhere and are defined as any of a number of crisis situations that greatly elevate the risk to nutrition and overall health of individuals in the affected area. examples include natural disasters like floods and earthquakes, urban health emergencies like fires, epidemics and blackouts, and terrorist acts like massive bombings or poisonings of food or water supplies (see table 29 .2). ces were originally associated with wars, genocide, and political strife, where innocent civilians were forced to endure loss of access to shelter, food, appropriate clothing, and timely medical care. such emergencies have traditionally been associated with populations in developing nations, not those in the so-called developed countries. however, with increasing a complementary ration to the general food ration is sometimes provided. typically, it consists of fresh fruit and vegetables, condiments, tea, etc. it is especially appropriate when the population of concern is completely reliant on food assistance. ''wet'' feeding food rations prepared and cooked on-site as opposed to rations that are taken home for preparation in the household (dry rations). typically, fortified foods have had supplemental vitamins and/or minerals added. hunger the uneasy or painful sensation caused by lack of food. malnutrition the medical condition caused by an improper or insufficient diet that can refer to undernutrition resulting from inadequate consumption, poor absorption, or excessive loss of nutrients. malnutrition results from an inappropriate amount or quality of nutrient intake over a long period of time. the inability to obtain nutritionally adequate and safe food; or the inability to obtain it in socially acceptable ways food insufficiency inadequate amount of food intake due to a lack of food. epidemics and pandemics an epidemic is a disease outbreak that affects numbers of the population in excess of what would normally be expected in a defined community, geographical area, or season. a pandemic refers to this type of disease outbreak that is occurring over a wide geographic area and affecting an exceptionally high proportion of the population. source: borrel, a. addressing the nutritional needs of older people in emergency situations in africa: ideas for action. helpage international africa regional development centre, westlands, nairobi, 2001. globalization of the world's societies and economies and news coverage documenting world events, it has become clear that ces can and do occur in both developed and developing world locations. nutritional risk is commonly elevated in ces and is most likely to occur when the crisis is protracted or recurrent. table 29 .1 includes definitions for factors related to inadequate food intake (e.g., food insecurity, hunger), the resulting nutritional problems (e.g., malnutrition, acute protein/calorie malnutrition), and terms used to discuss interventions for undernutrition (e.g., food rations, nutritional rehabilitation). even in the absence of a crisis, older persons are well recognized to be at greater risk than the remainder of the adult population for food insecurity and hunger. some of the many factors that contribute to increased nutritional vulnerability of older adults are listed in table 29 .3. in 2001, food insecurity and hunger affected at least 1.4 million households in the united states that contained older members (3) . people in 20% of those households also experienced hunger, in addition to food insecurity. most of these older persons are suffering from food insecurity due to lack of income or due to their place of residence. residents of the south are more apt to experience food insecurity, as are residents of cities and all elders who live alone (3). recognizing the day-to-day nutritional vulnerability of its poor and elderly citizens, the u.s. government has a number of programs in place to provide assistance to elders at risk for food insecurity and hunger. mandated by the older american's act, the elderly nutrition program (enp) provides a minimum of onethird of the daily calories required by recipients through daily meals and nutrition services to people aged 60 or older in group settings, such as senior centers and churches, or in the home, through home-delivered meals. the enp provides an average of 1 million meals per day to older americans. these meals are targeted toward highly vulnerable elderly populations, including the very old, people living alone, people below or near the poverty line, minority populations, and individuals with significant health conditions or physical or mental impairments. on an average the meals generously meet the rda requirements, supplying more than 33% of the recommended dietary allowances (rdas) for key nutrients, thus significantly increasing the dietary intakes of enp participants. the meals are also ''nutrient dense'', that is, they provide high ratios of key nutrients per calories. the most recent evaluation of the enp program occurred in 1996 and was conducted by mathematica policy research, inc. (www.mathematica-mpr.com/nutrition/ enp.asp). the resulting report clearly confirms that the enp program recipients are at nutritional risk. it was found that between 80 and 90% of participants had incomes below 200% of the poverty level (twice the rate for the overall elderly population in the united states). more than twice as many title iii participants lived alone, compared with the overall elderly population. approximately, twothirds of the participants were either overweight or underweight, placing them at increased risk for nutrition and health problems. title iii home-delivered participants had more than twice as many physical impairments, compared with the overall elderly population. although (and perhaps because) the success of the enp program is well recognized, 41% of title iii enp service providers have waiting lists for home-delivered meals, suggesting a significant unmet need for these meals. it would appear that even in times of relative calm and prosperity for most americans, there are elderly citizens who are persistently in a state of nutritional crisis. when nutritionally and medically vulnerable older persons encounter a complex emergency, there is an increase in morbidity and mortality rates. this is due to both short-term insufficient nutrition and the resulting long-term increased mental stress and disability, decreased resistance to infection, and exacerbation of chronic diseases (4), all of which make obtaining proper nutrition more difficult in a cyclic pattern. many different types of ces produce similar challenges. the consequences of a shortage of edible food and/or potable water, regardless of the type of emergency that produced that shortage, are multifold and can lead to increased physical and mental harm to older people (5) . reduced access to essential medical care heightens the immediate risk. a more extensive listing of the immediate impact of various complex emergencies and the resulting nutritional and health consequences is shown in table 29 .4. the likelihood of having to provide care for older persons during a ce is greater than one might think at first. as previously noted, table 29 .2 provides a list of common ces that have the potential to cause nutrition-related health risks. the impact of these crises on the nutritional state and overall health of older adults is discussed in more detail in the following sections. the 2005 hurricane season in the united states, most notably hurricanes rita and katrina, left no doubt that older persons continue to be disproportionately affected by hurricanes (6,7) just as they were with hurricane andrew in 1992 (8). older floridians who were affected by hurricane charley in 2004 found that the hurricane not only disrupted their quality of life but also disrupted their medical care (9) . persons with pre-existing conditions such as diabetes mellitus, heart disease, and physical disabilities were especially affected. approximately onethird of the older residents in the area had a worsening of their conditions posthurricane, including a lack of access to prescription medicine and loss of routine medical care for pre-existing conditions. medically related deaths were linked to the loss of power (resulting in loss of access to oxygen) and to exacerbation of cardiac disease. hurricane iniki in hawaii and the great hanshin-awaji earthquake in japan were associated with an increase in the rate of diabetes mellitus-associated deaths for a year following the disaster (10, 11) . in a study of residents in the high-impact area of hurricane andrew, one-third of persons had high levels of ptsd (12) , which was attributed to variables such as property damage, exposure to life-threatening situations, and injury. tornadoes, while typically more limited in the size of the area affected than a hurricane, are often even more physically destructive. although no research has been published on their specific effects on physical and mental health, it is well recognized that tornadoes can lead to many of the same dangers noted for hurricanes; the disruption of home care services and meal delivery to homebound elderly persons are of concern. the situation can become life threatening not only to the older persons who are critically dependent on these services but also to their dedicated care providers who often risk much to ensure the delivery of food and medical care to their clients (personal communication from area agency on aging of southwestern illinois grantees to nt). floods are a relatively common disaster and are often associated with earthquakes or hurricanes. besides trauma and drowning, the most common conditions associated with floods are an increase in gastrointestinal symptoms. increased preventable conditions following the crisis include gastroenteritis (13), acute respiratory infections including asthma (10), and increased post-traumatic stress which can persist for years after the event (14). in the aftermath of an earthquake, as with the other natural disasters already mentioned, access to basic life-sustaining nutrients and hydration as well as to basic and specialized medical care may be partially or completely disrupted. due to the magnitude and scope of the destruction that occur with a major earthquake, the restoration of infrastructure to fully support the inhabitants of the region may take months or even years to be accomplished. earthquakes result in a three-fold increase in deaths from myocardial infarction, a doubling of the frequency of strokes, increased blood pressure levels, and increased coagulability of blood (15, 16) . increased rates of cardiac arrests occurring after loss of power (17) and deaths due to increased incidence of coronary heart disease (18) and myocardial infarctions (19, 20) are also reported. deterioration of mental health occurs and post-traumatic stress is also prevalent (21, 22) . emotional stress can persist for months (23, 21) . in particular, the displacement of elderly persons from their places of residence and their social and medical supports can have a dramatic negative effect on health and quality of life (see fig. 29.1 ). displacement following a ce has been linked with a significant increase in mortality rates (15, 16) . the confusion of the displacement, as well as loss of access to appropriate diet and medications, prevents older individuals from monitoring and treating their medical conditions. inappropriate diet has been directly linked to decreased glycemic control and increased mortality in diabetic patients following an earthquake (11). the type of naturally occurring ce that is most threatening for older persons in terms of numbers affected each year comes during periods of temperature extremes, especially heat waves, claiming about 400 lives annually in the united states alone, more than the deaths caused by all other disasters combined. at greatest risk are poor persons who live in inner cities, those with chronic illnesses, and those homebound. heat disasters are often aggravated by power outages, which prevent people from keeping cool, bathing properly, and storing food at proper temperatures (24) . in the 1993 heat wave in philadelphia, there was a 26% increase in total mortality, with a 98% increase in cardiovascular deaths, particularly in those persons over 65 years of age (25) . in france, during the period 1971-2003, there were six major heat waves, resulting in thousands of deaths; the mortality ratios increased with age after 55 years and in the over age 75 years cohort; the death rate was higher for women than for men (26) . although little research has been published about the health effects of ice storms and blizzards, the loss of power leaves older persons stranded at home, increasing the risk for ingestion of inadequate calories and inappropriately prepared food and/ or spoiled food. the risk of exposure combined with the risk of house fires or carbon monoxide poisoning due to use of unsafe heating devices pose serious threats at a time when emergency services may not available due to the extreme weather conditions. fires increase the extent of cardio-respiratory problems, which results in exacerbation of chronic diseases (27) . people who already suffer from mental health problems or medically unexplained physical symptoms (28) and gastrointestinal morbidity (29) can develop an exacerbation of these problems (16,29) once they become a victim of a fire. even when no injuries result, fires almost certainly force displacement of their victims, adversely affecting quality of life and manifestation of chronic diseases. a serious infectious global pandemic is one of the most threatening of all complex emergencies, and calls back memories of the most devastating infectious disease outbreak on record, the great flu epidemic of 1918-1919, which killed an estimated 20-40 million people worldwide. the spread of this epidemic was linked to the trans-global transportation of soldiers during world war i. today, world travel and the importation of foods and other products are very common. thus, in the event of a serious epidemic in one country, there is a high likelihood of quick transmission to others. the outbreak of sars, a severe acute respiratory illness caused by a coronavirus, was first reported in asia in february 2003 and spread to more than two dozen countries in north america, south america, europe, and asia (sickening 8,098 and killing 774) before the global outbreak was contained (http://www.cdc.gov/ncidod/sars/factsheet.htm). in recognition of the severe strain that a major disease outbreak can place on health systems, the world health organization (who) advocates for an ''integrated global alert and response system for epidemics and other public health emergencies'' that allows for ''a collective approach to the prevention, detection, and timely response'' for these emergencies (http://www.who.int/csr/en/). the who is currently coordinating the global response to human cases of h5n1 avian influenza (bird flu) with regards to the threat of a future influenza pandemic. a widespread illness or intoxication from a food source could also threaten nutritional and overall health. while these outbreaks are typically limited in scope and short lived, the potential for more widespread and dangerous effects exists due to the centralized nature of the us food distribution chain and the clustering of very large populations into a small geographical area. (see more on this topic in section 29.2.2.3.) while other complex emergencies produce far more damage and deaths each year than are caused by terrorism, the destruction of the twin towers in new york city and a portion of the pentagon in washington dc on september 11, 2001 , focused the attention of americans upon the potentially devastating effects of an intentional man-made disaster. the development of the department of homeland security was a tangible product of the national response to implied threats of bio-terrorism. a terrorist attack such as one causing explosions and collapse of buildings would result in the interruption of basic living functions in a manner similar to previously discussed emergencies like earthquakes, tornadoes, or fires. disruptions to necessities of daily living and loss of power and access to medical care would be major concerns. a bioterrorist attack would have very different potential consequences for the well-being of the elderly, potentially causing widespread illness and/or hunger and dehydration. the propagation of an illness over a wide geographical area could be lethal for a substantial number of older adults, who are typically among the most medically vulnerable. during the anthrax attacks in 2001, all emergent cases involved adults over 50 years old, with the one fatal case affecting a 94-year-old woman (30) . intentional contamination of food or water supplies with a toxin or infectious agent also has the potential to cause an outbreak of poisonings or illness over a wide geographical area. in this situation, the outbreak could be slow and/or diffuse and the cause difficult to ascertain, delaying the recognition and treatment of the problem. for example, in 2006, bagged spinach contaminated (unintentionally) by escherichia coli infected over 200 americans (killing three) in 26 states before the strain was isolated and eradicated. similarly, intentional waterborne diseases or toxins would be difficult to detect and could impact a vulnerable population more severely than a healthy population, due to delayed recognition and reporting of the contamination (31). in the case of deliberate food/water contamination, nutritional health is affected directly (by reducing the availability of safe food and water) as well as indirectly (by the symptoms of illness and the reduced access to an over-burdened medical care system). in fact, the deliberate poisoning of food has already occurred in the united states, when in 1984 members of the rajneesh religious cult contaminated salad bars in the dalles, oregon, with salmonella typhimurium. though it was only a trial run for a more extensive attack that was planned to disrupt local elections later that year, the contamination caused 751 people to develop salmonellosis in a 2-week period. other isolated examples of intentional food contaminations have also been reported in the united states and canada (32) . coping with complex emergencies due to terrorism is for the most part a new challenge, at least in the united states. despite considerable effort to prepare for these scenarios, our experience in dealing with the aftermath is limited, yet, unfortunately, our experience is likely to grow in the future. experts warn that a major terrorist attack on the united states is very likely (29-50%) to occur within the next 10 years (cfr online debate). heat, cold, hurricanes, tornadoes, floods, fires, illness, terrorism, and other disasters endanger health and claim elderly lives. sometimes the effects are immediate, but more often an increase in morbidity and mortality occurs progressively after the disaster as survivors experience a continued decrease in the quality of life and increased nutritional risk due to displacement and a loss of basic resources. these events result in increased disability, which further impairs the ability of older persons to maintain access to safe food and water and sustain proper nutrition and hydration, and so the spiral continues downward. recovery from food insecurity and poor nutrition is more difficult for persons who are poor, socially isolated, cognitively impaired, and/or old. the more risk factors people possess, the faster their decline. all of the disasters described in this chapter threaten nutritional and metabolic health because they disrupt access to food, water, and vital medical treatment (33) . older persons with pre-existing chronic conditions are particularly vulnerable to these disruptions. preparation for and resolution of the aftermath of these emergencies require collaboration between multiple stakeholders and takes time. there are no easy fixes to ces. the underlying causes of malnutrition in older adults during ces are (1) insufficient household food security, (2) inadequate social and care environments, and (3) poor public health and inadequate health services (2) . the basis for current governmental and humanitarian responses to nutritional crises builds on lessons learned in the earliest organized relief efforts (circa 1940-1950) . during the 1970s, guidelines began to be published following experiences with relief efforts in places like biafra and ethiopia (2). in the subsequent decades, the experiences of various crises have progressively shaped what are, today, the characteristic challenges, and avenues of support available to older adults who are caught in ce situations in any given country. with increasing recognition that the elderly are uniquely vulnerable to ces, efforts are underway to develop specific recommendations and resources for this population group. table 29 .5 lists some of the resources available, along with web links. helpage international (www.helpage.org) is a global network of more than 70 not-for-profit organizations in 50 countries who are working for improvements in the lives of older people. this group has published a manual of guidelines for best practice during disasters and humanitarian crises (see table 29 .5). the sphere project minimum standards in disaster response project (http://www. sphereproject.org/content/view/27/84) advocates for the use of community-based systems to implement the care of older individuals in these circumstances. in the united states, a number of national organizations, including the federal emergency management agency (fema), the american red cross, and various branches of the military take responsibility for rescue and relief efforts following a major ce but the contribution of the private sector to the relief effort is traditionally also a substantial one. this type of broad-based support is necessary but makes it more difficult to consistently implement age-related guidelines for relief efforts once they are in the field. coordinating the advance preparation efforts for ces, however, is a more tangible goal. as is true for almost all health issues, the best way to address the nutritional and related health risks that accompany ces is to take preventive measures. in the case of nursing homes and assisted living facilities, many states require that these institutions have a substantial reserve food and water supply and that they have a welldelineated disaster and evacuation plan. the specifics of these requirements vary on a state-by-state basis. however, attention to the development of specialized parish, louisiana, due to a failure to comply with evacuation orders during hurricane katrina, and the bus accident in which 24 houston, texas, nursing home residents being evacuated from hurricane rita died in a fire that was sparked by mechanical problems and fed by the explosions of the passengers' oxygen tanks. beyond the obvious need for institutions and organizations like long-term care and hospice agencies to have detailed plans for evacuations and emergency conditions, there is also a need to identify ''at risk'' older adults living in the community. this would involve developing registries of ''vulnerable populations'' of elders based on degree of factors like contact need, predominant special impairment, and predominant life-support supply need, if any. by doing so, vulnerable elders could be easily identified in the event of a disaster and better supplied with assistance. such registries are currently implemented in some instances (examples are available in california, www.aging.ca.gov, and florida, www.broward.org/atrisk), but a more systematic approach has yet to be employed. these registries will most likely need to be local in origin and maintenance in order that control of sensitive health data would remain confidential. however, it would be preferable for the structure of the databases to be developed in a uniform format in order to facilitate the sharing of important data across local and regional entities. once successful programs and examples are created, their implementation by all interested parties should then be straightforward. emergencies require flexibility and the ability to survive changes in regular routines. this flexibility can be easier to achieve if people have a few necessary and familiar objects with them to assist with performing certain everyday chores, such as eating properly, taking medications, and changing into clean clothes. in order to assist people in getting prepared for the disruptions that inevitably occur during an emergency, the fema and the american red cross recommend that every family have an emergency preparedness kit that contains food, water, clothing, medical supplies, flashlight, and other supplies that will aid their survival for 3-5 days. by the time recommended objects are placed in a backpack, the entire kit weighs between 45 and 50 pounds. this is clearly too much weight for an older person to handle safely. of emergency kits for elders the health resources and services administration (hrsa) provided funding to the gateway geriatric education center of missouri and illinois (grant number d31hp70122) for train-the-trainer programming to teach 150 health-care professionals in the spring of 2006 how to create an emergency preparedness kit that was light, compact and specific for older adults. this kit consisted of a small satchel, a flashlight, a photo album (to store copies of prescriptions, insurance cards, evacuation plans, contact phone numbers, and family pictures), a pill box and a pamphlet introducing the fema web site. the trainees were then taught what other materials should be added to the kit to make it appropriate for a particular individual (table 29 .6). upon completion of this training each of the 150 trainees received two complete kits, one to use as an example during their subsequent training sessions of other health-care providers and the other to be given to a disadvantaged older person whom they deemed at risk during an emergency. each participant provided an e-mail address in order to be contacted 1 year following their training to determine the outcomes of their training. one year after training, the 150 trainees were contacted by e-mail. twenty-three of the e-mail addresses were no longer valid. of the remaining 127 trainees, 67 filled out and returned the survey within 2 weeks (53% response rate). an additional 18 surveys were returned after a second e-mail blast (85/127, for a final response rate of 67%). the survey asked if, as a result of their training, had the trainees: 1. given the extra kit to an older adult? 2. determined if that kit had been used during an emergency? 3. used their own emergency kits for training, and if not, why? 4. used their own emergency kits during an emergency? responses to the quality improvement survey are summarized in table 29 .7. the majority of the trainees (94%) had given the extra kit to an older person and many 23 (18) 104 (82) of the respondents indicated that the person was either an older relative or a neighbor. however, few respondents (15%) had provided any training to other health-care providers on how to create these kits. barriers cited included lack of money to purchase kit contents, lack of commitment or permission from supervisors, lack of time to provide the training, and lack of time for their colleagues to receive training. the percentage of older adults that were reported to have used their emergency kits by the time of the end point survey was higher than expected (46%), especially given that only 18% of the (younger) trainees reported using their kits. however, a review of the disruptive weather patterns in the 11 counties in eastern missouri and southwestern illinois where the trainees (and therefore, presumably of the older adults receiving the extra kits) lived, indicated that three area-wide power outages had occurred between august 2006 and january 2007. all of these three power failures lasted 1-3 weeks, with the rural areas in southwestern illinois being the last to get power restored each time. each of these power failures affected at least a half million citizens each time. numerous cooling or heating stations were set up for older adults, thereby allowing them to evacuate from their homes during the days in august and to receive warm meals during the november and january power failures. multiple public service announcements encouraged people to evacuate their homes completely until power was restored, so many older adults either moved in with relatives who did have power or went to hotels. under those conditions, it is reasonable to expect older persons to take their emergency kits with them. many of the health-care provider trainees reported that they had gone to work daily. a brief second query to 10 trainees who had used their kits and 10 trainees who had not used their kits indicated that both sets had gone to work daily and returned home at night, even if they had no power at home. (these health-care providers worked in facilities with working generators.) several of those that took their kits with them indicated that the kits provided them with some measure of safety while traveling icy roads in november and january. those that had not used their kits indicated no perceived change in their normal safety. this quality improvement study shows that emergency kits for older adults are used during an emergency. community-dwelling older adults appear to be more vulnerable to weather emergencies than are the health-care providers who care for them, as evidenced by the differences in usage rates of the kits by both groups through three lengthy power outages. upon review of the barriers that prevented trainees from providing training to other health-care providers, it is possible that it would have been more appropriate to provide train-the-trainer programs to older adults rather than to health-care providers. peer-to-peer training might have had the added advantage of motivating trainers to find community funding to make kits for distribution because of a greater perceived personal need for the kits. because every emergency event presents a unique challenge, this section offers general information about coping with the major nutritional concerns, namely shortages of food and water and overall loss of access to social support and health-related resources. optimal public health and nutrition relief includes a broad range of interventions and needs to utilize strong programmatic interconnections to meet the aforementioned needs. in the immediate aftermath of a ce, the supplies of food and water may be extremely limited. in this event, food can be more safely rationed than water. a general guideline is that the minimum adult ration be one well-balanced meal per day, with the utilization of vitamin/mineral supplements, protein drinks, ''power bars'', or other fortified foods as meal extenders if available. however, water should not be rationed due to the very rapid effects of dehydration. individuals are advised to drink what is needed today and search for more water on a daily basis. indicators of dehydration in the elderly differ from those in younger individuals; increased thirst, reduced skin turgor are not reliable markers. better indicators include tongue dryness, longitudinal tongue furrows, dry mucous membranes of the nose and mouth, eyes that appear sunken, upper body weakness, speech difficulty, and confusion (34) . when there is a loss of power to the home, perishable foods are to be consumed first, followed by foods from the freezer. frozen foods should be safe to eat for at least 2 days following the power loss. at this point, nonperishable, staple foods would be the only safe source of nutrients. as conditions stabilize, food aid will begin to become available. the recommended actions to be facilitated for older adults include (1) achieve/improve access to food aid (rations, supplemental feeding programs, etc.); (2) ensure that the rations are easy to prepare and consume; and (3) assure that the rations being used meet the nutritional requirements of older adults (35) . the usda's food and nutrition service (fns) coordinates with state, local, and voluntary organizations to provide food for shelters and also distributes food packages and authorizes states to issue emergency food stamp benefits to individuals. as part of the national response plan, fns supplies food to disaster relief organizations such as the red cross and the salvation army for mass feeding or household distribution. these organizations, along with other private donors, support the supply of water and food rations to affected areas. there are several concerns related to the access and appropriateness of food aid for elderly individuals (again, see resources listed in table 29 .5). access to the aid is a concern because disabilities and medical problems may prevent elderly individuals from reaching the distribution centers. another concern is the composition of the food rations, which may not be appropriate in consistency for persons who have dentures or who lack teeth and that may not be adequate in nutritional composition. food rations vary in composition; not all are developed for the primary purpose of post-ce relief. in the united states, the meal, ready-to-eat (mre), although first developed for use in the space program and now widely used by the armed forces, is one form of ration that is commonly distributed to civilians who need food following ces. having been designed for soldiers in a high activity situation, the mres are much higher in sodium (5,500 g) and fat (136 g) than is optimal, especially for older adults (36) . likewise, the texture, packaging, and preparation of mres were not developed with the intention of use by older adults. in an effort to supplement the nutritional needs of elderly citizens and to meet federal recommendations for increased emergency preparedness, the administration on aging (aoa) sought and received special funding to provide shelf stable meals that could be delivered to participants of the home-delivered-meal programs. these meals, which have a shelf life of approximately 16 months, are delivered with instructions to consume them during emergencies when regular home-delivered meal service is disrupted. the program is new so, to date, no evaluations have been done to determine what becomes of those meals (e.g., are they saved for emergencies or eaten to supplement other meals). no policy has been created to determine liability for any sickness caused by consumption of meals that are beyond their expiration date (personal communication from area agency on aging of southwestern illinois and the mideast area agency on aging to nt). obtaining adequate food and water is only one step on the road to recovery where elderly persons are vulnerable to food insufficiency. once food is obtained it must then be stored properly, prepared properly, and then ingested without health risk. in each of these steps, older persons are also at increased risk, compared to the rest of the population. this is because these older persons have additional risk factors for poor nutrition such as functional impairments, social isolation, reduced ability to regulate energy intake, greater susceptibility to depression, decreased ability to taste and smell, poor dentition, and poor health. all of these items (listed in table 29 .3) can lead to malnutrition, if not starvation, in older persons. following a ce, the speed with which basic services such as heating/cooling, shelter, and water supply can be restored will be a major factor in the recovery of older persons. past experience has shown that cold, loss of mobility, access to services, and psychological stress and trauma are some of the most important factors contributing to undernutrition in older people following a ce (37, 38) . in particular, the loss of social networks and support systems increases the vulnerability of these individuals (2) and needs to be corrected as soon as possible to prevent further deterioration as the days following the event go by. the best approach is to utilize programming strategies that address the needs of older adults without undermining their independence and discouraging their ability to support themselves (39, 2) . the restoration of medical facilities and the provision of transportation to appropriate medical facilities in unaffected areas are not under the control of the individual clinician or caregiver. these efforts are usually dependent on the local police and military forces who take charge post-ce. additionally, medical facilities will vary in their ability to handle the ce, depending on the type of emergency. for example, the response to a ce such as a hurricane (which would probably slow down access to the facility) would be very different than that required for an infectious disease epidemic (when admissions might very quickly exceed capacity) (40) . the challenge for the clinician on the front line is to stabilize the older patient until access to more formal support can be restored. thus, the aforementioned preparedness efforts are key in preventing the acceleration of medical conditions from chronic to life threatening. the availability of medical records and prescription medicines, as recommended for the evacuation kits of older adults, can play a critical role in this regard. in summary, the long list of complicated and threatening ces that can affect the nutritional status and overall medical welfare of older adults underscores the fact that all older adults and their care givers, as well as administrators of structured living facilities, should plan for and be physically and psychologically prepared for the event of a serious ce. 1. home-dwelling elders should be prepared for a ce by stocking a 2-week safety supply of food, water, and medications, having a carry-away disaster pack with medicines and other essential supplies, and having a delineated evacuation plan. 2. administrators/medical directors should ensure that nursing homes and assisted living facilities are prepared with food and water supplies and an alternate source of power and have detailed, individualized evacuation plans for each resident. ideally, a multidisciplinary team should utilize age-specific guidelines to design and implement a ce-preparedness plan. 3. in the future, there is a need for conceptual advances in understanding the causes of undernutrition in older adults during a ce and the development of better advance preparations and response mechanisms. the public health aspects of complex emergencies and refugee situations public nutrition in complex emergencies food security rates are high in elderly households hunger and food insecurity in the elderly food biosecurity morbidity surveillance after hurricane katrina -arkansas public health response to hurricanes katrina and rita -louisiana 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disease mortality after the hanshin-awaji earthquake among the older community on awaji island. tsumna medical association heart attacks and the newcastle earthquake increased acute myocardial infarction mortality following the 1995 great hanshin-awaji earthquake in japan psychological impact of the hurricane mitch in nicaragua in a one-year perspective psychiatric morbidity and post-traumatic symptoms among survivors in the early stage following the 1999 earthquake in taiwan disaster severity and emotional disturbance: implications for primary mental health care in developing countries heat-related deaths -philadelphia and united states, 1993-1994 cardiovascular mortalitythe hidden peril of heat waves the impact of major heat waves on all-cause and cause-specific mortality in france from 1971 to cardiorespiratory hospitalizations associated with smoke exposure during the 1997, southeast asian forest fires health problems presented in general practice by survivors before and after a fireworks disaster: associations with mental health care health problems of victims before and after disaster: a longitudinal study in general practice bioterrorism: from threat to reality water and bioterrorism: preparing for the potential threat to u.s. water supplies and public health threat of a biological terrorist attack on the us food supply: the cdc perspective public health issues in disasters clinical indicators of dehydration severity in elderly patients addressing the nutritional needs of older people in emergency situations in africa: ideas for action. westlands, nairobi, helpage international africa regional development centre military preventative medicine: mobilization and deployment. p. w. kelley, office of the surgeon general, department of the army nutritional risk factors for older refugees who is nutritionally vulnerable in bosnia-hercegovina? ageism: a factor in the nutritional vulnerability of older people? the initial hospital response to an epidemic identifying nutritionally vulnerable groups in case of emergencies: experience from the athens 1999 earthquake acknowledgments the authors thank caroline friedman for researching the historic and current events cited here. key: cord-300080-l0fyxtva authors: venkat, arvind; wolf, lisa; geiderman, joel m.; asher, shellie l.; marco, catherine a.; mcgreevy, jolion; derse, arthur r.; otten, edward j.; jesus, john e.; kreitzer, natalie p.; escalante, monica; levine, adam c. title: ethical issues in the response to ebola virus disease in us emergency departments: a position paper of the american college of emergency physicians, the emergency nurses association and the society for academic emergency medicine date: 2015-03-10 journal: j emerg nurs doi: 10.1016/j.jen.2015.01.012 sha: doc_id: 300080 cord_uid: l0fyxtva the 2014 outbreak of ebola virus disease (evd) in west africa has presented a significant public health crisis to the international health community and challenged us emergency departments to prepare for patients with a disease of exceeding rarity in developed nations. with the presentation of patients with ebola to us acute care facilities, ethical questions have been raised in both the press and medical literature as to how us emergency departments, emergency physicians, emergency nurses and other stakeholders in the healthcare system should approach the current epidemic and its potential for spread in the domestic environment. to address these concerns, the american college of emergency physicians, the emergency nurses association and the society for academic emergency medicine developed this joint position paper to provide guidance to us emergency physicians, emergency nurses and other stakeholders in the healthcare system on how to approach the ethical dilemmas posed by the outbreak of evd. this paper will address areas of immediate and potential ethical concern to us emergency departments in how they approach preparation for and management of potential patients with evd. the 2014 outbreak of ebola virus disease (evd) in west africa has presented a significant public health crisis to the international health community and challenged us emergency departments to prepare for patients with a disease of exceeding rarity in developed nations. with the presentation of patients with ebola to us acute care facilities, ethical questions have been raised in both the press and medical literature as to how us emergency departments, emergency physicians, emergency nurses and other stakeholders in the healthcare system should approach the current epidemic and its potential for spread in the domestic environment. to address these concerns, the american college of emergency physicians, the emergency nurses association and the society for academic emergency medicine developed this joint position paper to provide guidance to us emergency physicians, emergency nurses and other stakeholders in the healthcare system on how to approach the ethical dilemmas posed by the outbreak of evd. this paper will address areas of immediate and potential ethical concern to us emergency departments in how they approach preparation for and management of potential patients with evd. in march 2014, an outbreak of ebola virus disease (evd) was confirmed in the west african nation of guinea with subsequent rapid spread to the neighboring countries of liberia and sierra leone. given the underdeveloped health infrastructures in the 3 primary affected nations and the high transmission and mortality rate of the disease, domestic and international public health agencies called for aid and personnel to be rapidly deployed to the affected nations to treat infected patients and prevent further spread of the ebola outbreak. yet despite significant efforts from the international community, evd continues to represent a significant challenge in the region. as of january 2015, the centers for disease control and prevention (cdc) reports that the total case count stands at 21,689 with 8,626 deaths and continues to rise. 1 in the united states, the transfer of ebola-infected healthcare workers from the outbreak zone to us hospitals raised public awareness and fear of spread of the disease. this fear was heightened after the initial missed diagnosis in a us emergency department of a patient with evd who later died, 2 the transmission of ebola to 2 nurses who cared for this patient 3 and a subsequent case of an emergency physician who traveled to west africa to care for patients with evd and required hospitalization after returning to the united states. 4 these cases raised significant concerns that us emergency departments and hospitals were not adequately prepared to diagnose and treat patients with evd. in addition, the infection of healthcare personnel created the specter of a more widespread outbreak in the general population due to poor infection control guidelines, inadequate training and management protocols in us medical centers and initially absent mechanisms to identify potentially infected individuals arriving through us ports of entry. 5 a subsequent controversy surrounding a nurse who returned from west africa without symptoms of evd and was held in quarantine highlighted concerns about how personal liberty and public health should be appropriately balanced. 6 in response, both emergency medicine and emergency nursing organizations and federal agencies have issued guidance on the nature of evd, approaches to identification, isolation and treatment of potential patients and standards for use of personal protective equipment (ppe) by healthcare providers. [7] [8] [9] while the number of cases in the united states remains low to date (10 total patients, 4 diagnosed in the us and 2 deaths), the outbreak of evd has raised ethical issues relevant to us emergency departments and hospitals, emergency physicians and emergency nurses. issues artic-ulated in the medical literature and by the press include the following: how resources should be used in preparation for the likely rare event of an undiagnosed patient with evd who presents to a us emergency department, 10 whether there should be a different standard for care of ebolainfected patients than for other patients with less contagious and lethal diseases 11 and whether healthcare providers are obligated to place themselves at a significant degree of risk while caring for these patients due to their professional status. 12 to address these concerns, the american college of emergency physicians (acep), the emergency nurses association (ena), and the society for academic emergency medicine (saem) developed this joint position paper to provide guidance to us emergency physicians, emergency nurses and other stakeholders in the healthcare system on how to approach the ethical issues posed by the outbreak of evd. this paper will address areas of immediate and potential ethical concern to us emergency departments in how they approach preparation for and management of potential patients with evd. since the outbreak of evd, numerous articles have been published on the epidemiologic characteristics of this condition and the microbiological details of the causative organism. [13] [14] [15] [16] however, particular characteristics of evd are worth highlighting to provide the factual basis for addressing the ethical questions raised in this outbreak for us emergency departments. first, it is well recognized that individuals with evd will often have relatively non-specific symptoms, common to many viral infections, in their initial stages of presentation (eg, fever, headache, myalgias). 15, 17 such non-specific presentations make unrecognized infection with ebola a realistic concern. lack of prompt identification of potential patients by emergency department staff can increase the risk of spread of the disease and mandates a heightened awareness of the risk factors for the disease. second, the pathophysiology of contagion is related to contact with blood or bodily fluids from an infected individual, with rising viremia in the late stages of disease presenting a particular risk for human-to-human transmission. however, even a low level of viral inoculation can lead to evd. 18 this recognized pathway of spread aids in evaluating the risk of transmission from patient to healthcare providers or the general public. at the same time, knowledge of how the ebola virus is transmitted heightens the ethical concerns posed by the potential presentation of highly symptomatic and contagious patient(s) to an emergency department, especially if to a center without specialized experience in the care of evd patients. finally, the lack of specific effective treatment and the high mortality rate posed by evd exacerbates public fears, may create irrational panic relative to the actual risk and lead to unexpected institutional consequences such as the avoidance of the use of healthcare facilities where evd patients are being or have been treated. the emergency department in the united states, and increasingly worldwide, serves as the primary gateway to the acute healthcare system. it is estimated that 50% of admissions to hospitals in the us are initially assessed and treated in emergency departments. 20 the emergency department is also the only access point in the us acute healthcare system available to patients 24 hours per day-7 days per week. in the us there is a legal obligation under emtala to provide a medical screening exam for an emergency medical condition and treatment until the emergency medical condition is resolved or stabilized to the extent of that hospital's capability (until appropriate transfer) regardless of insurance status or other socioeconomic factors. 21, 22 finally, the emergency department is the primary location for the initial evaluation, diagnosis and treatment of the acutely ill undifferentiated patient. these facts together help define the ethical construct of emergency medical practice where access to quality emergency care is a right of all patients in the us. as noted in the acep code of ethics, "emergency physicians shall respond promptly and expertly, without prejudice or partiality, to the need for emergency medical care." 23 the ena code of ethics states that "the emergency nurse works to improve public health and secure access to health care for all." 24 the society for academic emergency medicine, through its mission statement "to lead the advancement of emergency care through education and research, advocacy, and professional development in academic emergency medicine," 25 also supports the ethical mandate for all patients in the united states to have access to quality emergency medical care regardless of disease process, ability to pay or other characteristics. while the above ethical framework emphasizes the critical importance of the availability of emergency care to all, it is clear from both published codes of ethics and the literature on the "duty to treat" that there are rare circumstances in which risk to the individual healthcare provider and institution should be weighed in determining the treatment plan for a patient who poses significant risk to providers or the general public. the acep code of ethics notes the requirement of the adequacy of in-hospital and outpatient resources in the provision of emergency care. 23 the american medical association code of ethics states that "because of their commitment to care for the sick and injured, individual physicians have an obligation to provide urgent medical care during disasters. this ethical obligation holds even in the face of greater than usual risks to their own safety, health or life. the physician workforce, however, is not an unlimited resource; therefore, when participating in disaster responses, physicians should balance immediate benefits to individual patients with ability to care for patients in the future." 26 the american nurses association code of ethics specifically states, "the nurse owes the same duties to self as to others, including the responsibility to preserve integrity and safety." 27 within the larger ethics literature, explorations of whether there is a duty to treat on the part of healthcare providers at risk to themselves also indicates that codes of ethics, historical references and theoretical analysis do not mandate an absolute obligation. rather, particular factors of disease process, availability of resources and training, countervailing responsibilities outside of the professional realm, personal viewpoints on the virtues of courage and resilience as well as relational ethics perspectives and obligations imposed by professional status have guided the evaluations of the obligations of healthcare providers in the face of outbreaks of infectious disease. [28] [29] [30] [31] for emergency departments, emergency physicians and emergency nurses, there is a need to weigh all of these considerations against the special role played by emergency departments in the us healthcare system and the duties that accompany the professional status of emergency physicians and emergency nurses. with this background, we will present an ethical framework that has potential application for emergency departments, emergency physicians and emergency nurses along with other health system stakeholders in the particular response to evd in the united states. this framework will address questions relevant to us emergency departments and separate consideration of the current situation (few confirmed cases within the united states with a relative abundance of resources to respond) versus 2 potential scenarios (increasing number of potential and confirmed domestic cases of evd in a variety of locations due to spread in the us and widespread number of potential and confirmed domestic cases that would strain existing resources and creates a necessity of disaster triage response) where appropriate. what in the current outbreak of evd, as of january 1, 2015, there are no extant active cases in the united states. as such, the most immediate issue is how to contain the spread of the disease from its present locus in west africa and end the current epidemic there. with the underdeveloped nature of the health infrastructure in the primary affected nations and the declaration of a public health emergency of international concern by the world health organization, 32 there is widespread recognition that ending the epidemic does and will continue to require the volunteering of healthcare providers to serve in the outbreak zone. under the ethical principle of reciprocity, which calls for acting in a manner that one would want others to act in return, there is an obligation to support emergency physicians and nurses who volunteer to serve in the nations primarily affected by the current ebola epidemic, just as we would welcome support or available expertise in a time of health crisis in the us. yet as a practical matter, support of volunteerism needs to be weighed against the special logistical concerns faced by most emergency departments, where local staffing levels must be maintained to provide safe patient care. an application of the principle of reciprocity in this outbreak would include support of emergency physician and nurse volunteerism in the current outbreak through the covering of shifts and other professional obligations in the volunteer's absence and acceptance by volunteering emergency physicians nurses of any potential risk of contagion on return to the us and the resultant need for monitoring for signs of the disease and possibly prolonged isolation. we would propose that in considering the support of volunteerism by emergency physicians and nurses, the specific background, training and education of the provider is a key decision making factor. education and training are essential components of preparation prior to disaster or disease outbreak response. medical volunteers should be appropriately trained in disease management, including rendering effective supportive care within the resource constraints in the primary outbreak zone, prior to travel to infected areas. they should ensure to the extent possible that malpractice, health and life insurance are in place to cover potential events, likely with the assistance of the non-governmental organization or other agency sponsoring their volunteer efforts. they should be willing to undertake the risks of volunteerism, including infection or threats to individual safety and security. [33] [34] [35] volunteers should be prepared to ensure appropriate infection control practices in their international work and to follow recommended protocols upon return for monitoring for symptoms of evd and the isolation that might result. [36] [37] [38] without this preparation, volunteering emergency physicians and nurses may be a liability rather than a benefit to the resource-poor countries primarily affected by the ebola outbreak and a risk to the domestic population upon their return to the us. it is appropriate for emergency departments and hospitals to query volunteering staff on their willingness to undergo the necessary training to be effective in the primary outbreak zone. with the continuing spread of the disease in west africa, those volunteering emergency physicians and nurses with existing experience in ebola and disaster response should be given priority over those without such training. specific decisions regarding support for volunteer efforts should also include the number of volunteers and impact on ed staffing and potential impact on public health domestically (i.e., will the loss of experienced providers adversely affect the care of patients in the local area served by the emergency department?). if the current outbreak were to spread significantly within the us, the ethical evaluation of the appropriateness of supporting volunteerism overseas would likely change since this could result in the expertise on the management of evd being shifted out of the country rather than being available domestically. this emphasizes the importance of supporting present efforts of containing and ending the current epidemic in west africa, including with the volunteerism of trained emergency physicians and nurses, as the most effective means of preventing the spread of evd to the us and other countries. some emergency departments have supported the volunteerism of emergency physicians in particular through altruistic coverage of shifts to allow staff to travel to the primary outbreak zone. 39 in addition, private foundations have provided grant funding to alleviate the financial burden of volunteerism of emergency department staff in the outbreak zone. 40 while these novel approaches have been largely confined to academic settings, they do suggest that there may be methods for individual centers to address the logistical difficulties that can arise when us emergency department providers volunteer in the primary outbreak zone. the application of these options to individual centers is one that is best judged on a case-by-case basis based on the factors noted above. finally, emergency departments, emergency medicine and nursing professional societies, non-governmental organizations and government agencies can aid volunteer efforts by educating health care providers and the lay public using published evidence on the pathophysiology of ebola and its transmission to alleviate the stigma that returning volunteer staff may experience after their efforts. at the same time, as noted above, volunteering emergency physicians and nurses have an obligation to adhere to monitoring and isolation protocols upon return to the us as a reciprocal ethical obligation for the support their efforts have received. what 41 it is anticipated that patients with a confirmed evd diagnosis will be transferred to these hospitals which will have enough ppe and other treatment requirements (isolation rooms, dedicated equipment and designated physicians, nurses and other necessary health care professionals and staff with proper training under cdc guidelines) to manage patients for at least 7 days, after which governmental agencies would assist in acquiring more supplies and expertise if needed. 42 however, not every state or locality has such a facility, nor is it likely that an undiagnosed patient would necessarily present to one of these centers. therefore, the cdc has provided guidelines for so-called frontline (any emergency department or acute care facility) and ebola assessment hospitals, which can safely isolate, treat and transfer patients with suspected or confirmed evd. to meet these standards, the cdc has called for all emergency departments to have protocols in place for the recognition of potential ebola patients and training for the proper isolation and assessment of these individuals. 42 the hierarchy of treatment facilities for evd codifies the reciprocity-based obligations that hospitals have to each other in the current state of the outbreak. such reciprocity should extend to the sharing of ppe, trained staff and other necessary equipment as needed to care for a suspected or confirmed ebola patient until transfer can be effected to a designated treatment center. hospitals and emergency departments should consider and develop relevant protocols for rapid credentialing of staff and transfer of equipment to allow resources to be brought to bear should there be additional cases in the us. if the current epidemic were to spread significantly in the us, hospitals should consider whether and how they can upgrade their capabilities to meet the needs of rising numbers of patients, presumably with the assistance of government resources. another ethical consideration is the reputational impact upon hospitals caring for ebola patients. as has been reported in the press, hospitals have expressed concern that the potential costs and risks accrued in treating an ebola patient along with the public fear generated by the disease may have an adverse impact on volumes and financial results for medical centers. the facility in dallas that treated a recent case reported that afterward emergency department volumes dropped and still have not returned to their expected level. 19 it is therefore imperative, in the face of a disease such as ebola that has generated such public scrutiny and at times hysteria, for hospitals to be cognizant of their ethical responsibility to support the efforts of designated treatment centers as well as frontline facilities that might encounter ebola patients and potentially be perceived adversely by the public. we affirm that the principle of reciprocity extends beyond physical means of support (equipment, personnel) to reputational support in the setting of an outbreak of evd. such support could, where appropriate, take the form of publicly confirming the safety and quality of other healthcare facilities with ebola patients, educating other facilities on effective policies and procedures in caring for evd patients and avoiding messages that implicitly suggest a competitive advantage from not treating patients with this highly infectious disease. through such support, hospitals ensure that the public is aware and reassured of the unified response the medical system will take towards both the existing epidemic and the potential for worsening if the outbreak spreads from west africa. without such reputational support and cohesion in the healthcare system, should the epidemic worsen, it is conceivable that public doubt and panic may lead to untenable consequences such as facilities avoiding the care of at-risk patients and the public fearing certain hospitals as being sites of contagion rather than medical care. trainees (nursing students, medical students, residents, and fellows) routinely care for patients with infectious diseases in the ed and should understand and use proper measures to protect themselves while caring for patients with potential or confirmed contagious diseases. both the accreditation for graduate medical education program requirements in emergency medicine and guidance on ebola affirm that trainees should know how to recognize, treat and isolate patients with infectious disease in general and ebola specifically. 43, 44 the 2013 model of the clinical practice of emergency medicine goes further by listing within the domain of emergency medicine "understand[ing and apply[ing] the principles of disaster and mass casualty management including preparedness, triage, mitigation, response, and recovery." 45 additional content areas in the model relevant to ebola response include the following: personal protection (equipment and techniques); universal precautions and exposure management; and emerging infections, pandemics and drug resistance. 45 together, these raise the issue of whether the current evd outbreak should be viewed as an opportunity for trainees in emergency medicine and emergency nursing to care for patients during an international infectious disease epidemic. few health care professionals in the united states have experience with the diagnosis and treatment of ebola or the infection control precautions required to safely care for patients with this disease. yet some such individuals may include trainees either with specific backgrounds in infectious diseases or previous experience with the ppe utilized in caring for such patients. historically, the outbreak of an unknown or uncommon infectious disease has led to initial concerns by health providers about risk to self that ultimately give way with time and knowledge to acceptance of an affirmative duty for trainees to learn to treat patients with these conditions. for example, the early fear and stigma surrounding hiv-infected patients in the 1980s gave way to a widely recognized duty to treat these patients and instill the same ethic in trainees. 46 as knowledge of the pathophysiology and epidemiology of evd and its implications for healthcare providers become more widely disseminated, a similar evolution may take place. however, based on the current conditions of the ebola outbreak, it is likely that very few of these professionals will need to be called upon to fulfill this duty. as long as the ebola incidence in the united states remains low, each institution can and should manage its burden of suspected ebola cases with a cadre of nurses and physicians highly trained in ebola treatment and prioritize infection control. the ethical justification to restrict the number of caregivers who come in contact with ebola-infected patients is that, given the limited experience with the disease in the united states, unnecessary exposure to infected patients would increase the risk to providers, other patients and the public. it is prudent to limit the potential chain of infection when possible. because experienced or specially-trained nurses and attending physicians can effectively manage suspected or confirmed ebola cases, trainee involvement is not required and would entail unnecessary risks to trainees and their patients. trainees should, however, be fully prepared in case they find themselves in a position where their duty to treat an individual patient outweighs a duty to the public to limit exposure to the disease. 44 however, if not trained or equipped properly, their duty to reasonably protect their own safety should not be superseded. non-participation of trainees in the care of ebolainfected patients is then an instance of exclusion, rather than exemption. institutions exclude trainees as an infection control strategy; trainees do not opt out. some trainees may object to these policies, as they may feel ethically compelled to care for ebola-infected patients as a function of their professional role and view their exclusion as a restriction of their own moral agency and liberty (to fulfill their commitment to treat the sick). 39 however, this restriction is justified by the greater good of protecting public health. ensuring trainee well-being and availability to care for other ed patients as well as limiting contagion are ethically justifiable reasons to exclude trainees. exclusion of trainees from the care of ebola-infected patients is not simply paternalistic because the primary aim is to protect patients and the public and represents a proportional response relative to the professionalism and moral agency consideration of trainees. 47 at the same time, a blanket exclusion of trainees from the care of ebola patients in the primary outbreak zone may be ethically inappropriate. if the trainee has the relevant experience and is able to meet the other requirements outlined above for volunteerism in the countries most affected by ebola currently, a case-by-case evaluation would seem appropriate for supporting the participation of volunteering trainees in the international response where there is a desperate need for available healthcare providers. 39 such support would have the added benefit of growing the cadre of individuals with the relevant expertise in caring for patients with evd should the current outbreak spread to the us. however, it is worthy of consideration whether academic medical centers can appropriately manage the risk to their trainees in the conditions posed by the outbreak in west africa. there are additional reputational risks should a trainee contract ebola or the public adversely view institutions where a large cadre of providers, including trainees, have traveled to care for patients in the primary affected countries. 39 as such, we affirm the ethical appropriateness of academic medical centers to consider on an individual provider basis whether a trainee should be supported in volunteering to travel to africa rather than endorsing a policy of automatic exclusion or support of providers in this regard. such individualized evaluations should take specific account of the level of training, previous background, experience with ebola and the ppe required to care for patients with this disease, the ability to undergo the necessary preparation for functioning effectively in the primary outbreak zone and the willingness to comply with monitoring and isolation protocols upon return to the us. under the current state of the ebola outbreak, it is anticipated that cases in the us would be scattered and readily managed at designated treatment centers. 41 at the same time, it is recognized that suspected patients may present to frontline emergency departments without specialized expertise in the management of evd, 42 and, as seen in the case of the patient in dallas, this may pose a risk to health care providers, including emergency physicians and emergency nurses. 3 as a result, various health care providers have expressed reluctance to care for patients with ebola. [48] [49] [50] [51] historically, such provider reluctance has often arisen with the emergence of unknown infectious diseases. 29 a 2008 survey of thousands of healthcare workers in new york found that half would hesitate or refuse to report to work during a severe acute respiratory syndrome (sars) outbreak (though 84% would report to work during a mass casualty situation). most cited concern for family, followed by concern for self, as reasons not to report to work during a sars epidemic. 52 individual conscience then, rather than professional tradition, seems to be the main force that compels nurses and physicians to risk their lives in service of patients. 29, 46 with this background, it is fair to ask whether there are circumstances under which emergency department providers could opt out of the care of ebola patients. under us law, nurses and physicians have a legal duty to treat patients with whom they have entered into a therapeutic relationship. once undertaken, the duty continues until the patient and professional mutually agree to end the relationship or the care is transferred to another professional. 53 nurses and physicians have special duties in service of the sick, and since this obligation holds even in face of greater than usual risks to one's own safety, healthcare professionals consequently accept greater risks than ordinary, balancing immediate benefits to individual patients with the professional's own health and ability to treat future patients. 54 but there is no consensus on the specific limits of this duty. 30, 55 emergency nurses and physicians are front line in an outbreak and, implicit in their specialty choice, accept additional risk beyond what is typical for many of their colleagues. as noted above, this is acknowledged in professional codes of ethics and statutory mandates (e.g., emtala). [21] [22] [23] [24] 26 there are potential additional penalties for those health care professionals who refuse to work or treat patients during a pandemic, including reduction in pay, termination and, in some states that have adopted variations of the model state emergency health powers act (mhehpa), the possibilities of licensure actions, fines or imprisonment. 56, 57 though the legal foundations of the duty to treat and its consequences are significant, the most compelling ground for these obligations is that health care is a moral enterprise. 29, 58 "all its efforts converge ultimately on decisions and actions which are presumed to be good for some person in need of help and healing." 58 nurses and physicians have a professional commitment to heal the sick. they are morally accountable to this commitment and are expected to demonstrate the virtues that it entails-such as courage, compassion and fidelity. 29, 59 this virtue-based ethic is independent of the patient's right to access to healthcare and the contract between the patient and physician. rights-based and contract-based accounts of the duty to treat would allow nurses and physicians to opt out of caring for patients in an epidemic as long as others were willing to take their place. 28 but nurses and physicians who opt out in such cases still fall short of their moral commitment. 29 emergency nurses and physicians, therefore, have a duty to care for ebola-infected patients and, in most instances, accept the associated risks. 30, 60 but the duty is not unlimited. an "abstract limitless duty" obscures the discussion about reasonable risk acceptance among nurses and physicians. 60 allowing for reasonable and practical limits to the duty to treat-applied equitably to all clinicians-may increase the likelihood that nurses and physicians will live up to their individual obligations during an outbreak. 30 the limit is illustrated by an account of a physician who, during the 1995 ebola outbreak in the democratic republic of the congo, "found 30 dying patients in an abandoned hospital, left to care for themselves amid rotting corpses, sometimes in the same bed." 30 a nurse or physician should not be expected to treat patients in a context where the risks are extraordinarily high and the potential benefit to patients extremely low. 30 indeed, the first duty of emergency nurses and physicians in the current ebola outbreak or other emerging infectious disease is to protect themselves in the care of patients, if for no other reason than to ensure their availability to treat subsequent patients. 61 by contrast, care of ebola-infected patients in a us hospital with the proper ppe and training would fall well within the duty to treat. 15 in the current state of the ebola outbreak, establishing cadres of highly trained clinicians at well-resourced institutions may be the best way to deliver uniform care under a duty to treat and limit potential spread of infection in the us. 42 under the above noted virtue and professionalism-based ethical framework, 23, 24, 26, 58, 59 emergency nurses and physicians may also volunteer in place of colleagues who they see experiencing exceptional moral or emotional distress over caring for ebola-infected patients-for example, as a result of unusually severe consequences for loved ones should they become ill. but as the burden of ebola-infected patients rises, the duty to treat is a responsibility of all emergency nurses and physicians who have the necessary training, skills and experience. while the duty to treat is intrinsic to health care professionals, institutions may also hold emergency nurses and physicians accountable to this standard. however, institutions may not invoke the duty to treat to coerce hospital employees into accepting unnecessarily dangerous conditions: for example, to expect them to deliver care to ebola-infected patients without proper ppe or training. institutional leaders have an ethical responsibility to prepare for outbreaks, ensure that the providers who risk their lives in the service of patients do so with as much protection and support as possible and make available appropriate channels for emergency physicians and nurses to communicate concerns about the adequacy of the training and preparation they receive. preparation includes, but is not limited to, making high quality ppe readily available, ensuring that all relevant staff are educated and trained to use it properly (especially proper donning and doffing) and limiting exposure to only those individuals needed to care for patients and prevent the spread of infection. experience with the 2003 sars epidemic in canada suggests that hospital leaders owe even more than merely providing equipment and training to nurses and physicians who fulfill their duty to treat under hazardous conditions. some healthcare workers died from sars, and some spread the disease to their families. 55 healthcare workers have moral obligations to their families, and institutions should make it possible for them to care for patients without abandoning their responsibility to their families or risking their families' lives. institutions should, for example, assist with child care and provide temporary living quarters to reduce the risk of disease transmission to family members and the associated anxiety and moral distress. 62 institutions, as well as public health agencies, may also consider additional acts of reciprocity toward healthcare workers who fulfill their duty to treat, such as insurance to protect them and their families should they become ill or die as a result of caring for ebola-infected patients. ultimately, however emergency nurses and physicians care for the sick primarily out of personal moral obligation; financial incentives alone are not likely to increase the likelihood that they will discharge their duty under epidemic conditions. 63 the protections that institutions and society provide healthcare workers-for themselves and their families-are ethically required. just as emergency nurses and physicians may not generally opt out of caring for the sick, institutions and communities may not opt out of caring for healthcare professionals and their families. in sum, the duty to treat patients with infectious diseases, including ebola, is both a legal responsibility and an ethical obligation of the healthcare professions. the duty should be borne equitably by professionals, who in turn, should be adequately supported by institutions and society as a whole. given the expected low number of us cases, there is a role for institutions to ask healthcare providers to volunteer to serve on treatment teams for suspected ebola patients as a means of limiting training efforts, time and expenditures (eg, credentialing of the ability to perform invasive procedures with ppe), reducing the potential risk of infection and ensuring relevant personnel and expertise are available to provide care. however, such volunteer-based plans do not address the special role of emergency departments where patients may present in an undifferentiated manner and potentially in acute distress, and where alternative providers may simply not be available. for emergency physicians and nurses, who through their choice of profession knowingly accept the above circumstances of patient care, 23,24 the current state of the ebola outbreak does not justify opting out of the care of suspected or confirmed ebola patients who may present to the emergency department, but this obligation is contingent upon institutional and governmental resources that provide adequate training and equipment to fulfill this duty. there also needs to be a recognition by healthcare personnel, hospitals and other public health and legal authorities as well as patients that the duty of emergency physicians and nurses to treat must be absolutely contingent on first ensuring personal safety through the proper use of ppe. 61, 64 should ebola rise in prevalence in the us, contingency planning to meet the duty to treat should move beyond training and equipment to mechanisms to support the weighty obligations of emergency physicians and nurses to protect themselves and their families while caring for affected patients. with the high mortality rate, lack of specific treatment and need for specialized ppe in order to prevent transmission, there have been legitimate questions whether the goals of care should change in patients critically ill with evd. specifically, in the circumstance where a patient requires procedural interventions (central venous access, intubation, dialysis, etc) to provide intensive care level support, is the risk posed to providers too high compared to the low potential of benefit, if any, to a patient whose illness may have progressed to a point where such interventions are unlikely to be successful? furthermore, given the time needed to don ppe-an absolute requirement prior to any procedural intervention on an evd patient-should cardiopulmonary resuscitation during an arrest event be considered futile due to the potential delay in its initiation and again the likely prognosis of the patient? 11, 64, 65 since the initial posing of these concerns about the risk versus benefit posed by critical care and resuscitation interventions in patients with evd, case reports have appeared showing that aggressive, intensive care level interventions, including intubation, central venous access, large volume and blood resuscitation and dialysis, can be successful in treating critically ill individuals with this disease and do not pose an automatic risk to providers if ppe is properly used. 66, 67 while anecdotal and representative more of what is possible in idealized circumstances (specialized care units with previous expertise and training in care of evd patients and a high number of dedicated providers), these cases imply that utilizing the full panoply of critical care resources for this patient population may be appropriate treatment. however, the highly contagious nature of evd and the need for specialized ppe, along with the experience in africa of rapid transmission to family members caring for ill patients, makes it appropriate for hospitals to not allow family presence during such procedures as is allowed in other critical care or resuscitation circumstances. with respect to cardiopulmonary resuscitation, to our knowledge, no published report has indicated the successful or unsuccessful use of cardiopulmonary resuscitation in an arrest event in an ebola patient, though resuscitation success in a us healthcare facility may be similar to other infectious diseases at similar stages, from initial manifestations to overwhelming sepsis. at this time, consideration of do-not-resuscitate status in a late-stage evd patient is best determined on a case-by-case basis, taking into account potential benefit to the patient, any limitations of interventions imposed by the disease and the potential risks to the treatment team. however, the circumstances described for the above patients are not typical of that seen in most emergency departments in the us. while the current state of the outbreak would likely lead to a typical ed encountering a patient early in their evd process, if at all, and being able to isolate such an individual until transfer to a higher level of care, should the number of cases rise due to spread of the disease, it is conceivable that emergency departments could encounter patients in a variety of stages of ebola with the risk-benefit calculation on procedural interventions being highly relevant. unlike the above cases, should the current outbreak spread, emergency departments would encounter patients with fewer resources (less isolation facilities, lower ratios of providers to patient) than those expended in the above reported cases and having to simultaneously care for other patients with a variety of conditions. here there is need to refer to the special role played by emergency physicians and nurses in the healthcare system. the assumptions that accompany the choice of these professional roles (exposure to acutely ill, undifferentiated patients) and the specialized training and skills that emergency physicians and nurses possess impose a higher obligation than other medical professionals to be prepared to treat an acutely ill ebola patient in the emergency department setting. 23, 24 at the same time, as we note above, the duty to treat is not absolute. there is no obligation for an emergency physician or nurse to implement treatment measures in an acutely ill ebola patient without training in the use of ppe, the availability of such supplies and, at a minimum, simulated experience with performing critical care procedures while utilizing ppe. 15, 28, 61 without such minimum standards, the social contract that accompanies the professional standing and obligations of emergency physicians and nurses breaks down. this social contract calls for a rational person to expect an emergency physician or nurse to apply their skills to aid an acutely ill patient but at the same time for those professionals to have the requisite training and equipment to provide such aid in an appropriate manner. 68 all emergency departments and hospitals should therefore consider that protocols for ppe training and isolating suspect patients, as called for in the current interim cdc guidelines, 42 are likely inadequate should the current epidemic spread more prominently to the us. to fulfill the ethical obligations imposed by the duty to treat should the current outbreak become more prevalent domestically, more robust training with ppe and the performance of procedures with such equipment will be necessary for a wider cadre of emergency physicians and nurses to appropriately treat acutely ill ebola patients in intermediate or late stages of the disease while ensuring the maximum feasible protection of the healthcare provider. weighing when such expanded training may be warranted should take into account the continued status of the outbreak, the cost of such preparation and the availability of appropriate resources to be effective. in the unexpected scenario where the number of patients with evd overwhelms existing resources, more traditional disaster triage protocols would be applicable. such protocols attempt to apply resources in a manner to benefit the largest number of patients. in the case of ebola, where the evidence to date is that an overwhelming amount of critical care resources are required to effectively treat a late-stage patient, disaster triage protocols would need to weigh at what point in the treatment spectrum such resource expenditure would become untenable. such protocols, to be ethically appropriate, would need to be transparent, proportionate and accountable to oversight along with having a legal imprimatur to be effective in the emergency department and acute care setting. 69 to avoid such a crisis situation, the devotion of resources now to end the epidemic in the primary outbreak zone in africa is vital. the outbreak of evd in west africa has presented a significant challenge to the health systems of the primary affected nations and, even with a low case count, raised concerns about the preparedness of the us healthcare system to respond to uncommon infectious diseases. in some ways, ebola is a unique test for us emergency departments, emergency physicians, emergency nurses and other stakeholders given its rarity in the us, high mortality rate, high risk of transmission to healthcare staff and non-specific presenting symptoms that can make initial diagnosis more difficult. however, as shown with other unanticipated infectious disease outbreaks (hiv, sars, mers), emergency departments will almost certainly be a key location for patient identification and treatment. the ethical concepts applied in this paper are relevant, especially reciprocity, duty to treat and grounding in the specific facts of the disease process in question, when considering how acute care facilities should prepare for likely future outbreaks of infectious disease. we propose that preparation for future emergency department responses to unanticipated infectious disease outbreaks should include ethical as well as logistical and medical factors. 69 given the multiple stakeholders represented in emergency department practice, the model shown here of multi-disciplinary and organizational consideration of the ethical issues involved would likely have application when considering the approach to future infectious disease challenges. the outbreak of evd in west africa and the presentation of patients to us acute care facilities has raised a series of intertwined logistical and ethical issues of relevance to us emergency departments, emergency physicians and emergency nurses. while the current state of the epidemic has not led to a large number of evd patients presenting to us facilities, consideration of ethical questions that are relevant now and of potential relevance in the future will allow emergency physicians, emergency nurses and other stakeholders to prepare appropriately for the challenges posed by ebola and consider its implications for future epidemic infectious disease events. an emphasis on the principle of reciprocity, the obligations imposed by and underlying assumptions of the duty to treat and the specific characteristics of the disease process will aid in addressing the ethical challenges posed in the current outbreak of evd. er doctor discusses role in ebola patient's initial misdiagnosis, : dallas morning news nurse's discharge leaves one ebola case in u.s., though larger battle continues plenty of hugs as craig spencer, recovered new york ebola patient, goes home. n y times hospitals prepared for the next ebola case? sci am ebola quarantine questioned american college of emergency physicians. healthcare resources for suspected ebola 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powers act potential penalties for health care professionals who refuse to work during a pandemic ethics and the moral center of the medical enterprise toward a virtue-based normative ethics for the health professions physicians' duty to participate in pandemic care ebola triage screening and public health: the new "vital sign zero clinical review: sars-lessons in disaster management survey of hospital healthcare personnel response during a potential avian influenza pandemic: will they come to work? responding to ebola: questions about resuscitation a case of severe ebola virus infection complicated by gram-negative septicemia clinical care of two patients with ebola virus disease in the united states the idea of a social contract: the elements of moral philosophy crisis standards of care: a systems framework for catastrophic disaster response the drafting authors wish to thank the acep ebola expert panel and saem global academy of emergency medicine for their critical review of the manuscript during preparation and the leadership of acep, ena and saem for their sponsorship of this effort. key: cord-265633-s3kbdxdu authors: tušer, irena; bekešienė, svajonė; navrátil, josef title: emergency management and internal audit of emergency preparedness of pre-hospital emergency care date: 2020-10-01 journal: qual quant doi: 10.1007/s11135-020-01039-w sha: doc_id: 265633 cord_uid: s3kbdxdu one of the negative components of international travel is the higher likelihood of emergencies that affect a large number of people (mass negative impact on health), for example the transmission of infectious diseases, as e.g. sars cov-2 pandemic. the frequency and sources of mass-casualty incidents are currently changing dynamically, especially with the onset of terrorist attacks and large-scale natural disasters. health services and emergency medical service (ems) take part in addressing these emergencies. for this reason, this paper deals with the ems emergency preparedness in the czech republic for an emergency events with a large number of affected people. ems in the czech republic are not provided by the state but by individual regions. ems in the czech republic do not have central management, nor do they use uniform data documentation. the investigation of the current situation has shown that the attitudes of ems in individual regions of the czech republic to the tasks of emergency preparedness for mass casualty incidents are not identical. the current method of evaluating improvements in the quality of ems emergency preparedness lacks consistency and is not comprehensively supervised. to tackle this, the paper presents an internal audit methodology for assessing the level of emergency preparedness of the emergency medical services. the authors therefore defined the decisive criteria and indicators assessing the quality level of ems emergency preparedness at major disaster with multiple victim incident. when developing the methodological procedure of the preparedness evaluation, an algorithm was chosen, based on the gradual verification of the evaluation criteria and indicators by an expert group. some findings and recommendations based on a research carried out in ems in individual regions of the czech republic are presented. international tourism is an integral part of the development of contemporary society, which also contributes to the growth of the national economy. transport, accommodation, catering and other services that support the mass travel of people are key factors for its development and functioning. a negative aspect of international travel is the higher probability of emergencies. in countries that attract the most tourists, the number and stay of foreign nationals is increased at a certain time. these foreigners bring with them respect for a different culture, religion, respect for different legal norms, and a different state of health. their different behaviour and visit in a foreign country can be a potential factor in the emergence of an emergency, such as the transmission of infectious diseases, a higher number of mass traffic accidents, or even the possibility of a terrorist attack. examples of the above-mentioned serious incidents of the "widespread type" may be the shootings in mumbai in 2008 or the paris attacks of 2015 (roy et al. 2011; hirsch et al. 2015) . health services and emergency medical service (ems) take part in addressing these emergencies. for this reason, this paper deals with the ems emergency preparedness in the czech republic for an emergency event with a large number of affected people. the standard of the emergency preparedness (ep) of individual rescue teams units (fire rescue service, fire rescue service units, emergency medical service, police of the czech republic, non-governmental non-profit organizations, etc.), which form the integrated rescue system (irs) of the czech republic, significantly affects the success with which emergency events are handled. the irs in the czech republic is not an institution, it is a system. in fact, it is a coordinated procedure of its rescue teams in the preparation and solution of emergencies, in the implementation of rescue work and elimination of the consequences of an emergency situation. an emergency event (ee) is, in accordance with czech law act no. 239/2000 sb. on the integrated rescue system and on the amendment of certain laws, defined as "detrimental action of forces and phenomena caused by the action of man, natural effects and accidents that pose a threat to life, health, property or the environment and that demand the performance of rescue and clearance work". a mass-casualty incident is defined by czech regulation 240/2012, which implements the law on the emergency medical service, as an event to which it is generally necessary, in view of the nature or extent of the incident, to send five and more deployment groups of a provider of emergency medical services at the same time to provide urgent pre-hospital care or a place at which more than 15 injured persons are found. a typical mass-casualty incident (mci) is characterised by a single action and a single site of incidence (šín et al. 2017) . a specific type of mass-casualty incident is an event of the "widespread type", which does not involve a single defined event, but rather a larger number of events with a single cause, though occurring at different times in different places. the resolution of mass-casualty incidents demands of medical personnel not merely a change of attitudes, approaches and thinking and targeted lifelong education in the area of catastrophe medicine, but also the need to increase the standard of emergency preparedness in individual segments (šín et al. 2017 ). the emergency medical service is organised differently in individual regions in individual areas stipulated by the law. differences can be seen both in the organisational structure, communication systems, economic aspects, and technical and material equipment for resolving emergency events, and in the sphere of education, training and the performance of training. the actual state of preparedness of workplaces is influenced by a number of factors. it is dependent not only on real experience, but also on the number and focus of tactical and verification exercises performed. tactical and verification exercises are such exercises in the czech republic that focus on a specific type of emergency. this verifies the skills and knowledge of rescue teams and their cooperation in the field. the number of training exercises implemented is one of the factors that influences the state of preparedness of the emergency medical service, though the qualification, competence and level of engagement of all persons contributing to the handling of mass-casualty incidents and the quality of crisis planning documentation is a no less important factor (šín et al. 2017) . attention is devoted around the world to the assessment of the ep of organisations for emergency events. assessment programmes are applied that focus on the documentation of crisis and emergency planning from the viewpoint of a given state or region. methods of assessment are generally drawn up by international accreditation organisations. a dominant position among them is held by the independent company emergency management accreditation program (emap), which assesses plans focusing on emergency management. ep is assessed on the basis of answers to a set of 64 standards (criteria) in the area of administration and the operational and logistical preparedness of rescue teams operating in the given region. the given standards for the assessment of emergency management are a tool for continual improvement to local and state programmes within the scope of the management of emergency events (emap standards 2010). the standardisation of processes and planning in the area of ep is demanded from the viewpoint of medical facilities. these standards and services are provided by various international professional organisations such as, for example, the international society for quality in health care (isqua 2018). the principal aim of this global organisation is to manage improvements to quality and safety in healthcare by means of education, knowledge sharing and external assessment of safety systems in healthcare. the international accreditation programme (iap) is used for external assessment of healthcare organisations and their standards. it is comprised of criteria focusing on the main structure, processes and outputs of healthcare facilities, and not merely in the area of safety management. in practice, the iap realises an investigation in the form of qualitative research. the stipulated indicators take the form of questions with possible yes/no answers. these questions focus on, for example, organisational planning or the management of risk and preventative measures for its minimisation (isqua 2018). the world health organization (who), which has drawn up the manual "toolkit for assessing health-system capacity for emergency management" (who 2012) is a key partner to the isqua. this manual contains indicators associated with the assessment of emergency management plans in healthcare, again in the form of questions with the required answer yes/no. attention is devoted to individual aspects that can be used ex ante for the assessment of ep. in practice the assessment of emergency preparedness is generally performed in two directions. in the first direction the preparedness of the emergency medical service is assessed in individual segments of its activity following mass-casualty incidents (tušer and navrátil 2020; svarcova et al. 2016) . shortcomings are subsequently identified and proposals for increasing the quality of the preparedness of the emergency medical service implemented. in the second direction, a number of papers focusing on the preparation of solutions to a specific emergency event are published, and the overall preparedness of the emergency medical service system assessed, possibly in connection with urgent hospital care. the study of jama and kuisma (2016) , which maps out the level of preparedness of the ems for chemical incidents associated with mass impacts on health or persons, can be stated as an example. this study assesses co-operation between the ems and hospitals during the transport of exposed patients and the provision of means of decontamination. also studies of bekesiene and hoskova-mayerova maps accidents and emergency events in railway transport while transporting dangerous items (bekesiene et al. 2016 (bekesiene et al. , 2017 navrátil et al. 2019) . similarly, sanders (2014) considers the issue of deployment interoperability between the police, firefighters and paramedics. it states that the quality of co-operation between deployed units is positively influenced by the unified information technology introduced. solutions for increasing the ep of the system in two stages are presented at assessing community and region emergency-services capabilities by shoemaker et al. (2011) . the first stage is intended to lead to an improvement to the soft skills of paramedics, including teamwork, co-operation, team leading, self-reflection, flexibility, interpersonal relations, conflict resolution, communication, planning, etc. the second stage takes in hard skills, including the measurable capabilities of the individual such as knowledge of technological, operational or financial procedures, capacity, stamina and recovery. the united accreditation commission, which focuses, first and foremost, on medical facilities, has been one of the certified evaluators of quality and safety in healthcare in the czech republic (cz) since 2012. it implements its stipulated goal by means of activities such as, for example, the "issuing of accreditation standards for medical facilities, including a detailed methodology or assistance for medical facilities preparing for accreditation, specification of a methodology according to types of medical facilities, consultation on the drawing up of internal standards for a given facility, etc." (uac cr 2016). accreditation standards for the emergency medical service, including rules of assessment, are set, first and foremost, for the areas of urgent pre-hospital care in daily operations, though they give less consideration to requirements for the preparedness of the emergency medical service for mass-casualty incidents. from the viewpoint of the united accreditation commission, shortcomings in the preparedness of medical facilities frequently occur in areas of processes and regulations. for example, persons responsible are not stipulated in regulations-definitions of risks may be given, though without specific measures, while a connection to actual conditions and risks is lacking, and knowledge and updating of regulations remain unchecked. procedural acts are often uncompleted, contracts with suppliers are not always properly updated, the resolution of specific risks is unclear (who, where, how?) and tests of substitute sources are often performed without load (tušer and navrátil 2020) . analysis of the issue of evaluation of emergency preparedness has revealed that the evaluation tools used abroad and in this country do not always give due consideration to all the specifics of ep activities in urgent pre-hospital care. neither non-governmental organisations nor international accreditation programmes interpret this issue in a comprehensive manner (tušer and navrátil 2020). unfortunately, the aforementioned methods and procedures in the cz are not used in the field of emergency events with multiple victim incidents. a key role in the preparation of the emergency medical service of the cz for emergency events is played by emergency preparedness units. basic criteria for an objective assessment of the standard of the emergency preparedness of an organisation for emergency events have not, however, yet been stipulated. one of the reasons for this is the fact that the structure and work of these units is not entirely identical in the individual regions of the cz. therefore, the aim of the research and also this paper is to propose evaluation criteria and indicators that will be capable of providing relevant information on the state of preparedness of emergency preparedness units and the entire organisation for emergency events. the main goal is to stipulate obligatory necessary minima to which regional specifics can be linked. to verify the proposed method of evaluation of the prehospital emergency care, the authors identified the following research question: does the ems in individual regions of the czech republic meet the specified level of emergency preparedness for a major disaster with multiple victim incidents? the ep of the emergency medical service is influenced by a number of factors and the selection of criteria and indicators is not rigid. the basis for the proposal for evaluating ep was the definition of decisive criteria and indicators assessing the standard of the quality of the ep of an organisation for mass-casualty incidents. during the creation of this methodology for assessing preparedness, the authors of the paper selected, with a view to procedures used in this country and abroad, an algorithm based on the progressive verification of assessment criteria and indicators by an expert group (a group of evaluators) (talhofer et al. 2019) . the members of this expert group were selected on the basis of their institutional employment, erudition and reputation. the expert group included representatives of selected ep units of the emergency medical service, the pertinent departments of regional authorities, departments of defence of the population and emergency management of the fire rescue service, the faculty of military health sciences, the united accreditation commission and the society of emergency preparedness in healthcare. the group of experts consisted of a total of 32 members (tušer and navrátil 2020) . starting point for the determination of evaluation metrics were legislative regulations (czech law act no. 239/2000 and czech act 374/2011 coll., on emergency medical services) that stipulate the obligations of the emergency medical service for ep and other areas. the authors studied the legislation of the czech republic concerning the ep ems and based on it identified 8 basic criteria determining the level of emergency preparedness of the emergency medical service. these eight criteria were presented to each member of the above-mentioned group of experts individually, at a personal meeting, to assess their relevance. experts evaluated the significance of the order of individual criteria by the scoring method. from the submitted 8 criteria, the expert team determined the three most important criteria (a, b, c). using the method of brainstorming with an expert group, indicators determining the fulfillment of these criteria were assigned to these criteria. all members of the expert group had the same opportunity to express themselves (tušer and navrátil 2020) . the evaluation procedure is based on determination of the level of fulfilment of the individual indicators that are stipulated for basic areas characterising ep in the form of assessment criteria a, b and c: a-collaborative preparedness with other units of the integrated rescue system; b-the preparedness of emergency medical service forces for emergency events; c-means of communication during an emergency event (švarcová and navrátil 2017) . the relevance of the individual indicators was obtained with the use of invention methods (brainstorming, brain-pool-writing). the expert group determined the value of the weightings of individual indicators for the selected criteria "appendix 1" (tušer and navrátil 2020) . assessment scales for the given criteria and rules of evaluation for the overall evaluation of the current state of ep at selected emergency medical services were subsequently created. the basic scheme of the methodology for the assessment of the ep of the emergency medical service for mass-casualty incidents is depicted in fig. 1 , which is divided into three parts: 1. the actual wording of the evaluation criteria; 2. description of the evaluation criteria; 3. evaluation criteria, indicators and questions, as qualitatively assessed viewpoints whose fulfilment weighting is assessed during the survey tušer and navrátil (2020) . during assessment of the ep of an entity in practice, the evaluation committee determines the fulfilment of indicators in the form of stipulated questions with possible yes/no answers. each indicator is assessed, its real value calculated according to the relationship (1) and the level of fulfilment of the criterion characterising the given area of ep determined as the overall sum of the values of the indicators. the assessment of fulfilment of criteria and determination of the resultant level of emergency preparedness proceed in accordance with the "rules for the evaluation of criteria and their indicators" is given in the fig. 1 . where w ki the actual weighting of the indicator, w ki the weighting allocated to the ith indicator within the kth criterion, n p the number of positive answers, n n the number of negative answers (weathington et al. 2012) . the resultant evaluation of each criterion and the overall evaluation of fulfilment of the level of ep is defined by the evaluation range in individual intervals. the range of intervals was set by the expert group and in collaboration with the united accreditation commission (uac cr 2016). (1) the methodology was also transformed into a computer utility for immediate acquisition of the results of evaluation of the level of ep at an assessed unit. during implementation of the procedure in practice, the evaluation commission enters into the computer utility merely the number of positive answers to partial questions for individual indicators of the given criterion. the sum of the values of individual indicators of the given criterion expresses the level of fulfilment of the criterion. an assessment scale is given for the resultant assessment of each criterion: 1. the criterion is met if the total values w k lie within the closed interval ⟨0.9;1.0⟩; 2. the criterion is met in part if the total values w k lie with the interval ⟨ 0.6;0.9); 3. the criterion is not met if the total values w k lie within the interval ⟨ 0.0;0.6)). two conditions have to be met for the overall evaluation of the fulfilment of the desired level of ep of the emergency medical service for mass-casualty incidents: 1. each criterion is met at least within the interval of values w k ⟨0.6;0.9); 2. the sum of values for criteria w k is met at least within the interval ⟨2.6;3.0⟩. the relevance of the assessment scale may be further considered and verified during discussion with the trade community at the conferences urgent medicine and catastrophe medicine (oulehlová et al. 2017) . the proposed methodology was applied to selected emergency medical services in all regions (14 regions) of the cz. an evaluation of the level of ep of emergency medical services in all regions of the cz, according to the methodology put forward, is given in table 1 . the answer to the research question is that 8 regions in cz did not meet the stipulated level of criteria. further verification, e.g. supplementation of the methodology, is possible in the resolution of mass-casualty incidents arising or during exercises focusing on similar issues. the application of the methodical assessment procedure in practice from the viewpoint of an emergency manager can also be understood as a tool of self-assessment (internal audit) for determination of the standard of ep of a given funded organisation without the intervention of an external entity. the purkyně, 2009) . some regions do not follow the recommended procedure for card unification. the cooperation of physicians, rescuers from more regions in dealing with a major emergency can thus be negatively affected. the above findings shortcomings persist even today as reconfirmed at the international conference of disaster medicine 2019 in hradec králové, cz, by the deputy minister of health of the cz (prymula 2019). for the above reasons, the following recommendations and measures to improve emergency preparedness of ems in the case of mass casualty incidents are proposed. harmonization of competences and activities of all emss operating in individual regions of the cz can be achieved by: • amendments to legal regulations; • implementation of accreditation standards; • a larger number of staff involved in the preparation and solution of emergencies and/or emergency situations (svarcova et al. 2015 ); • harmonization of resources needed for emergencies and/or emergency situations, including compatibility and reliability of the means of communication with core and external organizations in the irs and with other healthcare facilities; • systematic and continuous (lifelong) education of emergency management staff (emergency management) hoskova-mayerova (2016) ; ; • the willingness and ability of inter-ministerial effective communication and interoperability (ministry of health vs ministry of the interior), but also between partly statefunded organizations and other irs agencies. the application of the above measures is fundamenta.lly affected by financial resources and the degree of professionalism of the stakeholders (kudlák et al. 2020 ). the basic principles leading to an increase in the quality of the emergency preparedness of the emergency medical service consist of the elimination of shortcomings determined following analysis of interventions at mass-casualty incidents, evaluation of tactical and verification exercises and the implementation of the relevant knowledge and experience from published analyses of previous mass-casualty incidents in this country and abroad. processes of evaluation of the quality of the emergency preparedness of the emergency medical service for possible emergency events must also proceed continually alongside this process. at the present time, however, the assessment tools used do not give the necessary consideration to all the specifics in the activities of emergency preparedness in urgent prehospital care, and the accreditation standards do not provide comprehensive assessment of the emergency preparedness of the emergency medical service for the handling of masscasualty incidents. the current method for increasing quality and assessing the emergency preparedness of the emergency medical service is also disparate and is not subject to comprehensive control. expert discussion focusing on consideration of the suitability of the application of a uniform methodical procedure, system harmonisation, deployment of units and means, and progressive introduction of evaluation criteria, which would allow comprehensive assessment and comparison of funded emergency medical service organisations, is highly necessary. the article presented here, focusing on a methodology for the evaluation of ep, accepts these facts and is one contribution to the discussion as to how to proceed in the assessment of the ep of the emergency medical service. the methodological procedure described here can also be used in internal audits performed by emergency managers, who can thus assess for themselves the fulfilment of preparedness criteria for mass casualty incidents. benefits of the application for practice: • makes it possible to assess and compare the level of ep of the ems in individual regions of the cz for coping with mass casualty incidents with a higher degree of objectivity; • will allow for a systematic introduction and management of changes in the organization of ems and in the coordination of activities with irs units; • strengthens the cooperation between ems from different regions during their joint interventions at mass casualty incidents; • proposes a set of measures that will contribute to increasing the crises preparedness of the ems already at the pre-intervention stage (ex ante); • conversion of the methodology for evaluating emergency preparedness of ems to the electronic format-mobile application enabling evaluations being made in institutions concerned; • helps to make a realistic assessment of the current state of ems preparedness of ep units in all regions for coping with emergencies; • application of the methodical procedure in the organization allows for the assessment of the level of preparedness of ems for coping with emergencies and critical situations involving mass casualty incidents with a higher degree of objectivity. the stipulated set of criteria and indicators and the proposed procedure for the assessment of the ep of the emergency medical service need not be definitive. they can be exactified or modified with a view to the type of emergency event, and may be expanded to take in additional areas associated with the required standard of intervention or otherwise adapted in connection with regional specifics. emergency cases on railways at transport of hazardous substances in the czech republic in 2010-2016 accidents and emergency events in railway transport while transporting dangerous items the medical response to multisite terrorist attacks in paris education and training in crisis management the international society for quality in health care preparedness of finnish emergency medical services for chemical emergencies determination of the financial minimum in a municipal budget to deal with crisis situations health risk assessment of combustion products from simulated residential fire risks evaluation in preparation of crisis management exercise ministry of health mass casualty response in the 2008 mumbai terrorist attacks need to know vs. need to share: information technology and the intersecting work of police, fire and paramedics assessing community and region emergency-services capabilities disaster medicine. galén possible approach to assess emergency preparedness for emergency services psychological intervention as support in disaster preparedness. in: crisis management and solution of the crisis situations crisis management and education in health method of selecting a decontamination site deployment for chemical accident consequences elimination: application of multi-criterial analysis the development of education in emergency management evaluation criteria of preparedness for emergency events within the emergency medical services the united accreditation commission of the czech republic: rules for the evaluation of accreditation standards understanding business research world health organization: toolkit for assessing health system capacity for crisis management. part 1, part 2. who regional office for acknowledgements irena tušer thanks her ambic college, prague for its support. conflict of interest the authors declare that they have no conflict of interest. see table 2 . key: cord-348614-im7qtr9k authors: yánez benítez, carlos; ribeiro, marcelo a. f.; alexandrino, henrique; koleda, piotr; baptista, sérgio faria; azfar, mohammad; di saverio, salomone; ponchietti, luca; güemes, antonio; blas, juan l.; mesquita, carlos title: international cooperation group of emergency surgery during the covid-19 pandemic date: 2020-10-13 journal: eur j trauma emerg surg doi: 10.1007/s00068-020-01521-y sha: doc_id: 348614 cord_uid: im7qtr9k purpose: the covid-19 pandemic has changed working conditions for emergency surgical teams around the world. international surgical societies have issued clinical recommendations to optimize surgical management. this international study aimed to assess the degree of emergency surgical teams’ adoption of recommendations during the pandemic. methods: emergency surgical team members from over 30 countries were invited to answer an anonymous, prospective, online survey to assess team organization, ppe-related aspects, or preparations, anesthesiologic considerations, and surgical management for emergency surgery during the pandemic. results: one-hundred-and-thirty-four questionnaires were returned (n = 134) from 26 countries, of which 88% were surgeons, 7% surgical trainees, 4% anesthetists. 81% of the respondents got involved with covid-19 crisis management. social media were used by 91% of the respondents to access the recommendations, and 66% used videoconference tools for team communication. 51% had not received ppe training before the pandemic, 73% reported equipment shortage, and 55% informed about re-use of n95/fpp2/3 respirators. dedicated covid operating areas were cited by 77% of the respondents, 44% had performed emergency surgical procedures on covid-19 patients, and over half (52%), favored performing laparoscopic over open surgical procedures. conclusion: surgical team members have responded with leadership to the covid-19 pandemic, with crisis management principles. social media and videoconference have been used by the vast majority to access guidelines or to communicate during social distancing. the level of adoption of current recommendations is high for organizational aspects and surgical management, but not so for ppe training and availability, and anesthesiologic considerations. in december of 2019, the world learned about the emergence of a new coronavirus outbreak, this time in wuhan, hubei province, china. initially termed 2019 novel coronavirus (2019-ncov), it would be known worldwide as the severe acute respiratory syndrome coronavirus 2 (sars-cov-2) [1] . this new disease was termed as covid-19 and spread rapidly worldwide. on march 11, 2020 , the world health organization (who) declared the disease caused by the sars.cov-2 a worldwide pandemic [2] . the high transmissibility of the sars-cov-2 and the overwhelming magnitude of this pandemic forced surgery teams to reexamine workflow, organization, and management for surgical emergency cases [3] . these unprecedented challenges imposed swift changes to avoid the collapse of the health system and the workforce's compromise [4] . to prepare surgical teams for this infectious mass casualty scenario, several international surgical and anesthesia societies produced guidelines on emergency surgery, focusing on preventing the infection of its workforce and guarantee the best response [5] [6] [7] [8] [9] [10] [11] [12] [13] . these covid-19 dedicated protocols addressed surgical team organization, operating room (or) preparation, rational use of personal protective equipment (ppe), considerations on anesthesiology, and intraoperative management of emergency surgical pathology. several articles have been published focusing on the technical surgical aspects during the pandemic and surgical ward preparations [14] [15] [16] [17] . however, fewer have put the spotlight on individual countries' responses [18] , and none that we know have assessed the level of adoptions of current recommendations at an international level. this study aimed to obtain a global snapshot of the level of implementation of these new recommendations by the members of the international emergency surgery community during the covid-19 pandemic. an international cooperation group of emergency surgery during the covid-19 pandemic was formed with surgeons from brazil, chile, italy, portugal, and spain to study the pandemic's impact on emergency surgery teams at the international level. the group used the surveymonkey ® platform to develop a five-section structured questionnaire in english that assessed the adoption of updated recommendations for emergency surgery during the covid-19 pandemic. no specific identifying data were requested, six questions queried about demographic information, seven about team organization, 25 regarding ppe, 21 or adequation, anesthesia considerations, and surgical management. the questions were presented in such a way that respondents could agree or disagree with the specific statements. the online survey was issued prospectively, anonymously and voluntarily, from the 1st to the 14th of april 2020, to 680 members of emergency surgical teams from over 30 countries. the survey target population was selected using a non-probability method consisting of a convenience sample of five significant surgeons' associations, which included professionals ascribed to the spanish surgical association, european society for emergency and trauma surgery, international association for trauma surgery and intensive care, american college of surgeons, and the panamerican trauma society. subjects were invited through email invitations, mailing lists of some participating societies, and posted via personal networks and social media. survey results were analyzed using the surveymonkey ® online platform (svmk inc, san mateo, usa), calculating frequencies and percentages of the collected data. a total of 134 valid responses from 26 countries were obtained from 680 (20%) of the issued invitations, of which 119 (88%) were surgeons, 9 (7%) surgical trainees, and 6 (4%) anesthetists. the vast majority were males (72%), with ages ranging from 25 to over 60. respondents worked in 26 different countries, mostly from europe, with 85 responses from 8 different countries, followed by 42 responses from 12 american countries, five from four countries in the middle east, and two countries from asia, with one response each fig. 1 . 81% of the respondents got involved with the covid-19 surge planning taskforce, 93 (71%) developing clinical protocols, 91 (69%) implementing safety precautions, and 67 (51%) performing task management. social media and other online resources were employed by 122 (91%) respondents to obtain relevant covid-19 clinical guidelines fig. 2 . modification of shift handover routines and the use of video conference tools, to maintain communication while promoting social distancing within the working place, was reported by 88 (66%) of them fig. 3 . continuity performing their regular tasks was reported by 73 (54%) of the respondents, in contrast with the rest, whose newly assigned duties were to the emergency department covid-19 triage (25%), the intensive care unit (icu) activities (13%), or had to manage mechanically ventilated patients in the surgical ward (7%). another modification to their routines was in shift duration, as reported by 80 (60%), and over half of the total (52%) worked continuously for extended periods of 24 h or more. about half (51%) of the respondents had not received training in the use of ppe for airborne infectious risk while performing emergency surgical procedures before the pandemic, and roughly over one-third (37%) had it during the studied period. of all the respondents, 105 (78%) used surgical masks, and 38 (28%) wore n95/fpp2/3 respirators always in the ward, even without covid-19 hospitalized. over half (56%) had a specific area assigned for donning/ doffing the ppe, 53% employed checklist, and 60% performed routine buddy checks. three-fourths (75%) made mask fit tests while donning, one-third (34%) reported that fitting issues due to facial hair (beard), and out of these, half (51%) shaved it to obtain an adequate fit. the reported ppe used for emergency procedures was face shield (74%), double gloving (71%), surgical goggles (68%), long sleeve disposable gown (63%), and water-resistant shoe covers (35%) fig. 4 . data about the shortage of ppe (73%) and n95/fpp2/3 (77%), as well as the re-use of ppe components (55%), were collected fig. 5 . reuse or extended use of n95/ fpp2/3 beyond the lapse they were designed for was commented by 55% of the respondents fig. 5 . scarcity or even absence of parts of such equipment was reported by 53% fig. 6 . when asked if using ppe gave a sense of protection during the surgical procedure, less than half (48%) of the respondents felt protected with ppe. over three-fourths (77%) of the participants had covid operating areas (coa), or facilities prepared or modified for performing emergency surgery in covid-19 patients, and over two-thirds (69%) had a designated covid-19 trauma or. the vast majority (80%) cleared out unnecessary equipment form the or when performing surgery on covid-19 patients, and 78 (60%) protected monitors and other electronic equipment, including anesthesia machine, with plastic wraps; 70% used or alert signs during the procedure in covid-19-positive or suspected cases. however, only over one-fourth (26%) had surgical smoke evacuation systems available, and above two-fifths (43%) had to improvise such a device. when asked about the transport of emergency surgical cases to the or, almost two-thirds (64%) answered that covid-19 emergency surgical cases were escorted directly to the or, not stopping in the preoperative-postoperative anesthesia care unit (po/pacu). regarding anesthesiologic equipment preparations, less than half (40%) had a covid-19 resource box available for general anesthesia procedures (including cheat sheets and alert signs). only one-fourth (25%) said to have a specific covid-19 airway trolley at their institution, and of these, 27% had access to a printed intubation guideline. over one-third (38%) responded that the anesthesia team routinely used video laryngoscopy for orotracheal intubation (oti), and almost two-thirds did not know if rapid sequence induction (rsi) was the induction protocol used. almost two-thirds used a covid-19-specific checklist before surgery, and an equal number of respondents entered the or after patient intubation. less than half (44%) had performed emergency surgical procedures on covid-19 patients during the study, and only over one-fourth, 26% had performed emergency laparoscopic surgery on these patients. however, when asked which approach was preferred for acute appendicitis or cholecystitis, over half (52%), preferred the laparoscopic approach. when asked for preoperative screening methods, only one-third (32%) systematically performed covid-19 screening before emergency surgery. 50% of these used the reverse transcriptase-polymerase chain reaction (rt-pcr) test, the rest recurred to radiological screening, either thoracic ct scans (14%) or lung us (1%). when asked for the number of emergency cases evaluated in the emergency department, the vast majority (82%) perceived a lower frequency of emergency surgical emergencies during the studied period. while the novelty of this pandemic has generated many published papers on management recommendations [19] [20] [21] [22] [23] , few assess the degree of guidelines implementation by emergency surgical teams. this study provides an international snapshot of the level of adoption of the guidance for surgical team organization, adequacy of ppe availability and usage, or preparation, anesthesiologic considerations, and intraoperative management of emergency surgical cases during 2 weeks of the covid-19 pandemic. it should be noted that the study tried to capture the initial response when there was a steep curve of newly reported cases, but while that was the case in europe at the time of the survey, the american surge came weeks later. the study analyzed the recommendations for emergency surgical management of covid-19 suspected or confirmed cases, which may differ significantly between countries due to the variability of the number of newly diagnosed cases, resources available, and healthcare policies. increased awareness and adoption of international societies' recommendations for emergency surgical management with greater exposure to covid-19 were expected amongst surgeons with higher case exposure, but the study design did not allow this assumption. nonetheless, the study can help identify weaknesses in the surgical team response and areas of improvement, which could be useful to face the latest news that brings up attention like the possibility of a second wave of the pandemic [24] [25] [26] . regarding the surgical teams' organization, most of the published literature focuses on reducing the risk of infection by limiting the number of workforce members on each procedure [2, 27] . furthermore, the emphasis is made on rescheduling elective surgical procedures to rationalize hospital bed capacity. however, few mention surgical teams' leadership organizing the response to the pandemic [28] . we found out that over 80% of the teams' members have been doing so, either developing protocols (71%) and implementing safety precautions (69%), which confirms the capacity of emergency surgical to rapidly adapt to complex crises, organizing proactive medical responses when facing natural or human-made disasters [29] . the 2009 h1n1 pandemic revealed that communication dynamics are vital for crisis management, and the use of practical tools for the transmission of health recommendations increases compliance [30] . social media and online resources are now used by more than 3.8 billion, twitter, and other social media channels can be a reliable source of health-related information [31] . the covid-19 pandemic has demonstrated that emergency surgical teams and healthcare bodies could use online tools to disseminate guidelines and maintain communication in times of uncertainty [32] . our study reveals the use of these tools by 91% of the respondents and the utilization of video conferences by 66% to improve communication between team members during social distancing. they also had to adapt to new roles when they were assigned to the emergency department triage, icu, or the management of mechanically ventilated patients, 60% had to endure long working shifts, and 52% had 24 h or more in extremely stressful situations. focusing on ppe, current literature reports that there are four essential elements regarding ppe: training, availability, adequate use, and re-use strategies in case of shortage [33] [34] [35] [36] . our study reflects that following ppe recommendations had been a significant issue among respondents; over half expressed concerns for insufficient training, 71% have reported shortages, and 53% improvised part of their protective equipment. training of proper donning/doffing techniques is essential, it will lower the probability of selfcontamination, and educational campaigns must emphasize biosafety breaches to reduce surgical team members' exposure to it [37] [38] [39] [40] . a critical shortage of n95/fpp2/3 respirators was reported. this can be explained by the underestimation of equipment needs, coupled with the abrupt increase of its global demand. a recent survey about ppe supplies in the us reported that 91% of the 213 queried cities had inadequate face mask supplies, and 88% did not have enough ppe for medical personnel and first responders [41] . tabah et al. in a recent international survey among 2711 intensive care unit healthcare workers, reported widespread shortage and adverse re-use [42] . another aspect that stands out in our study is that over half (53%) of the population had to improvise ppe, undermining front-line workers' trust and confidence with their employer institutions [43] . additionally, equipment shortage, re-use, and improvisation elevate the risk of infection, adding to the sense of hazardous exposure, and increasing work-associated stress. concerning the operating conditions, 71% had prepared coa and most followed guidelines to adapt the existing conditions to the suggested recommendations [3] . information regarding negative pressure or suites was not addressed in the survey, but if available, negative pressure ors should be used to reduce the risk of viral spread and minimize infection risk [44] . one element that should be pointed out is the management of surgical smoke during the pandemic. at the beginning of the covid-19 outbreak, many guidelines recommended avoiding laparoscopy due to the possibility of viral aerosolization and team infection due to smoke inhalation. current publications have downsized these risks with measures of smoke/aerosol containment and proper smoke evacuation. however, only 26% reported to have purposed design smoke evacuation systems, and almost half had to improvise them using standard filters, and waters seal devices [45] , which could be useful for smoke and vapors generated electrosurgical and ultrasonic devices until more evidence-based research in this field is available. reported results of anesthesiologic protocol adoption by the emergency surgery teams reflect a significant lack of implementation of the official recommendations promoted by international anesthesia societies [46, 47] . our results suggest that improvements must be addressed, especially with equipment preparation during airway manipulation. the importance of having prepared an individual covid-19 airway trolley with printed airway guidelines should not be underestimated. we consider these elements essential since the use of ppe in the or has been associated with communication interference and visibility impairment [47] . using a specific trolley with printed instructions would help avoid errors and reduce team members' risks. because of the limited number of questions in this area and the reduced number of anesthetists participating in our study, we consider our finding as limited and that further analysis is needed. answers received about the operative management reflect the existing differences in the number of new covid-19-positive registered cases in the participating countries during the studied period. during april 2020, the number of new cases was counted by the thousands in several european countries, with spain and italy among them, while in america, it was only starting to be diagnosed. despite these differences, 44% of the respondents had performed emergency surgery on covid-19-positive patients. it is essential to highlight the need to use aerosol-generating procedures (agp) checklists in all emergency surgical procedures. soma et al. describe how an operative team checklist can potentially reduce risks, but above all, it reduces anxiety and helps maintain the team focused on the task [48] . results reflect the concerns with the laparoscopic approach and the risks of viral aerosolization. in our study, only 26% had performed laparoscopic procedures [49] . the low level of reported preoperative covid-19 screening (32%) is of serious concern, and efforts should be made to perform some screening for all emergency surgical cases. our study had some limitations that must be noted. first, the 2-week period studied reflected a global snapshot of the pandemic, and the number of newly reported cases between asia, europe, and america has not been homogeneous. second, the level of the reported adoptions of the continually changing recommendations reflects respondents' perceptions and opinions, which may not accurately represent actual practices. confirmation of the reported findings should be audited in future studies. this is particularly important with ppe since the massive demand worldwide had generated a global shortage of some equipment. also, the survey design might have introduced some bias and had a relatively small sample size. only 20% of the contacted participants; this is especially important regarding the small number of anesthetists included in the study (n = 6). finally, our sampling strategy recruited mostly european and american respondents, with very few emergency surgeons from asia and the middle east, so that results may be biased. despite these limitations, the findings reflect the leadership and level of involvement of surgical teams during the pandemic. it identifies the urgent need for more training and better endowment of ppe among emergency surgical teams worldwide. the addressing of these issues will allow better preparation for future similar scenarios and guarantee a better response in case of a second wave of the pandemic to be registered in the coming months. respondents exercised leadership through the development of surgical protocols and safety measures. social media and video conferences resulted in capital importance for accessing reliable clinical management guidelines and for team communication while maintaining social distancing. urgent measures to assure sufficient availability of ppe shortage, particularly n95/fpp2/3 respirators must be addressed by healthcare administrators and governments. even though operative room preparation was adequate, very few had a specific covid-19 airway trolley at their institution; improvements in airway management equipment are 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patients infection prevention and control during health care when novel coronavirus (ncov) infection is suspected. interim guidance effective strategies to prevent coronavirus disease-2019 (covid-19) outbreak in hospital the lancet covid-19. protecting health-care workers. lancet covid-19: the crisis of personal protective equipment in the us personal protective equipment and intensive care unit healthcare worker safety in the covid-19 era (ppe-safe): an international survey ppe guidance for covid-19: be honest about resource shortages preparing for a covid-19 pandemic: a review of operating room outbreak response measures in a large tertiary hospital in singapore. se préparer pour la pandémie de covid-19: revue des moyens déployés dans un bloc opératoire d'un grand hôpital tertiaire au singapour how to manage smoke evacuation and filter pneumoperitoneum during laparoscopy to minimize potential viral spread: different methods from some -a video vignette. colorectal dis covid-19 information for health care professionals canadian anesthesiologists' society. covid-19 recommendations during airway manipulation impact of personal protective equipment on surgical performance during the covid-19 pandemic operative team checklist for aerosol generating procedures to minimise exposure of healthcare workers to sars-cov-2 risk of virus contamination through surgical smoke during minimally invasive surgery: a systematic review of literature on a neglected issue revived in the covid-19 pandemic era we would like to acknowledge all the members of 1 general and gi surgery department, royo villanova hospital, salud, av. de san gregorio s/n. 50015, zaragoza, spain key: cord-311829-pkcugj56 authors: despard, mathieu r.; friedline, terri; martin-west, stacia title: why do households lack emergency savings? the role of financial capability date: 2020-05-19 journal: j fam econ issues doi: 10.1007/s10834-020-09679-8 sha: doc_id: 311829 cord_uid: pkcugj56 many u.s. households have insufficient savings to cope with income losses, expenditure shocks, and other financial emergencies, yet little research evidence explains why. guided by sherraden (2013) model of financial capability, we expand on prior research that examines the role of financial knowledge by incorporating additional factors and testing income interactions to explain a greater proportion of variance concerning whether or not households have money set aside for emergencies. we analyzed data from the 2009, 2012, 2015, and 2018 national financial capability surveys and found that subjective financial knowledge, financial confidence, and savings account ownership, but not objective financial knowledge, were significant and consistent predictors of having an emergency fund. savings account ownership was the strongest predictor, accounting for an increase in the probability of having an emergency fund of 25% to 29% across study years. adding homeownership and ability to cover expenses to the models increased the proportion of variance explained by an average of 29%. strategies to promote emergency savings should be multifaceted and include help from financial educators and counselors to create greater financial slack as well as programs and policies to increase access to short-term savings opportunities and incentives. several recent studies and media stories have highlighted the lack of preparedness of most u.s. households to cope with financial emergencies such as a costly car repair or loss of income from work (fottrell 2017; morduch and schneider 2017) . in march 2020, as this manuscript was being drafted, the coronavirus pandemic began threatening the livelihoods of many workers who lacked paid leave and/or could not work from home, throwing the need for having an emergency fund into sharp focus. financial counselors and planners have long recommended setting aside enough money to cover regular household expenses such as housing and food for at least three months in the absence of income, a standard that just over half of u.s. households could meet in 2018 (finra investor education foundation [finra] 2019). most u.s. households lacked enough liquid assets to replace even one month of income (pew charitable trusts 2015) . apart from the magnitude of the pandemic, a lack of money set aside for emergencies is a problem because financial shocks are so common. larrimore et al. (2016) found that over a third of u.s. households experienced a health emergency and/or job loss in the prior year and nearly half (46%) could not cover an unexpected $400 expense with cash on hand. adopting a broader definition of shocks to include major vehicle and home repairs, pew charitable trusts (2017) found that over half of u.s. households experienced a shock in the prior year. furthermore, shocks are not isolated events: 70% of households that experienced a shock in 2014 experienced at least another one in 2015. difficulty coping with financial shocks puts households at risk for hardship and other negative outcomes. households without money set aside for emergencies are more likely than those with these assets to experience material hardship-difficulty meeting basic needs such as housing and food (beverly 2001 )-following financial shocks like the loss of a job (mckernan et al. 2009 ). conversely, having money set aside for emergencies is associated with lessened risk for hardship gjertson 2016 ) and less financial strain (shobe and boyd 2005; rothwell and han 2010) . whether or not households have enough money set aside for emergencies is informed by various explanations for saving behavior and household savings. one line of inquiry identifies a link between financial knowledge and savings (babiarz and robb 2014; hilgert et al. 2003; lusardi 2008a; woodyard et al. 2017 ) as well as motivational and behavioral factors (carroll and samwick 1998; grinstein-weiss et al. 2017 . other evidence points to the importance of access to financial services and incentives (friedline et al. 2019; mullainathan and shafir 2009; nam et al. 2013; schreiner and sherraden 2007 ). yet, research concerning factors that specifically explain whether or not households have emergency savings is limited (chase et al. 2011) , as most prior research has focused on retirement savings. consequently, practitioners and policy makers have little information to inform strategies to help households build emergency savings to better cope with financial uncertainty. the purpose of this study is to examine different factors that may explain whether or not households have money set aside for emergencies. we extended analyses from prior studies that used nfcs data to examine preparedness for financial emergencies (babiarz and robb 2014; woodyard et al. 2017 ) to contribute to the literature in four ways. first, we systematically introduced additional variables using hierarchical regression to test sherraden's (2013) conceptual model of financial capability. we examined the degree to which objective and subjective financial knowledge, financial confidence, and savings account ownership explained the probability of having an emergency fund. second, we tested a series of interactions to determine whether income moderated the relationship between constructs in sherraden's model and having an emergency fund. third, we added economic constraint and homeownership as additional controls found to be associated with household financial assets. fourth, we assessed the stability of our findings across four cross-sectional waves (2009, 2012, 2015, and 2018) of national financial capability studies (nfcs). we found that objective financial knowledge had a weaker association with having an emergency fund than identified in prior studies. subjective financial knowledge, financial confidence, and savings account ownership were stronger and more stable predictors. we also found that income moderated these relationships and that economic constraint accounted for a sizable proportion of the variance in having an emergency fund. collectively, these findings offer a more complete picture of the factors associated with preparedness for financial emergencies than previously captured (babiarz and robb 2014; woodyard et al. 2017) . we discuss the implications of these findings-principally that financial education may be a necessary but insufficient strategy to help u.s. households build resilience in the face of financial emergencies. this study is important because the lack of emergency savings among u.s. households has recently captured the attention of policy makers. in february 2019, the consumer financial protection bureau announced its "start small, save up" initiative to encourage consumers to establish and build emergency savings accounts. bills recently introduced in congress include proposals to encourage tax refund saving (refund to rainy day savings act, s.1018, h.r. 2112) and to make it easier for employers to offer short-term savings accounts with automatic contributions (strengthening financial security through short-term savings accounts act, s.3218). economic theory offers explanations for savings behavior and outcomes. the permanent income hypothesis (pih) holds that individuals seek to smooth consumption over time and thus will consume less if they expect their average long-term income to be less than current income (friedman 1957) . the life cycle hypothesis (lch) posits that individuals plan and adjust their consumption and saving over their life cycle to smooth consumption (modigliani 1966 ). yet browning and lusardi (1996) note that the pih and lch are theories of consumption, with saving being merely residual, not intentional. in contrast, the precautionary savings motive contends that individuals defer present consumption to insure against future income uncertainty (leland 1978) . similarly, the buffer-stock hypothesis suggests that individuals adjust their consumption based on a target for asset accumulation sufficient to smooth consumption given expected future income (carroll 1997; deaton 1991) . although the hypotheses outlined above were formed and have primarily been tested in relation to retirement saving and long-term asset accumulation, these hypotheses may also apply to emergency savings, i.e., short-term cycles of saving and dissaving to cope with financial shocks and smooth consumption (xiao and noring 1994) . individuals may adjust their consumption and engage in a form of nearterm precautionary saving, setting aside some portion of income or a windfall such as a tax return or work bonus that can be used to respond to unexpected income and expenditure shocks (collins 2015 ). yet a precautionary savings motive alone may not be sufficient for explaining savings behavior and outcomes. sherraden's (2013) conceptual model of financial capability posits that financial outcomes, such as having an emergency fund, occur when individuals have financial knowledge, skills, and access to financial products. for example, individuals with volatile incomes (morduch and schneider 2017) might recognize that an emergency fund will help them pay bills and cover unexpected expenses in months when income is less than their usual expenses. individuals may also need to know how to build emergency funds, such as by using irregular wind falls like tax refunds (grinstein-weiss et al. 2016 (fig. 1) . individuals also need the opportunity to apply their financial knowledge and skills by accessing and using safe and affordable financial products, such as checking and savings accounts (sherraden 2013) . for example, among young adults, financial inclusion (owning a savings and/or money market account or certificate of deposit) and financial capability (financial inclusion and having received formal financial education) were associated with having emergency savings, whereas financial education alone was not west and friedline 2016) . grinstein-weiss et al. (2015) found that average monthly savings were higher among participants in a matched savings program who received financial education compared to those who did not receive financial education, suggesting financial education and inclusion together may affect savings outcomes to a greater degree than financial inclusion alone. in sherraden's (2013) model, use of financial products and services is influenced by financial knowledge and skills, yet use is also conditioned by access to financial services, which vary across households based on geographic factors friedline et al. 2019 ). sherraden's model thus represents a departure from economic theory that discounts the role of the environment in conditioning tastes by assuming that financial service markets are perfect. concerning having an emergency fund, sherraden's (2013) model might posit that individuals need to understand the importance of saving for emergencies (financial knowledge), have budgeting and financial planning skills to ensure income can exceed expenses at least periodically to enable deposits (financial skills), and easy access to affordable savings accounts to enable asset accumulation. guided by this model, we reviewed evidence concerning the roles of financial knowledge, financial skills, and access to financial services in influencing saving. individuals who lack financial knowledge may discount the importance of saving (angrisani et al. 2016) , particularly why it is important to control spending and set aside money for unexpected dips in income or expenditures (lusardi 1998) . numerous prior studies draw a link between financial knowledge and financial behaviors and outcomes in the us (e.g., bernheim and garrett 2003; borden et al. 2008; hilgert et al. 2003; lusardi and mitchell 2007; servon and kaestner 2008) . hilgert et al. (2003) found a strong positive correlation between savings knowledge and saving behavior among respondents to the u.s.-based survey of consumers. individuals exposed to financial education while in high school were more likely to save as adults compared to those who did not receive financial education (bernheim et al. 2001 ). lusardi and mitchell (2011; found that individuals scoring higher on financial knowledge survey items were more likely to engage in retirement planning, compared to those with lower financial knowledge. recent research has examined the association between financial knowledge and emergency savings. babiarz and robb (2014) and woodyard et al (2017) analyzed data from the 2009 and 2012 nfcs, respectively, to examine relationships between objective and subjective financial knowledge, and having an emergency fund. concerning this link, babiarz and robb (2014) stated, "in theory, households should accumulate a reserve of wealth to protect themselves against unexpected or uninsurable risks (deaton 1991) . this behavior, however, was more likely to characterize households who accurately recognized the probability and severity of potential financial emergencies" (p. 41). using the 2009 nfcs data, the authors found that an additional correct financial knowledge answer was associated with 2.4% greater probability of having an emergency fund, while an additional point of subjective financial knowledge (on a seven-point likert scale) was associated with an 8% greater probability. woodyard et al.'s (2017) replicated study using 2012 nfcs data reported approximately 16% greater probability of having an emergency fund for each additional point of objective financial knowledge, as well as for one additional point of subjective financial knowledge. however, other studies analyzing nfcs data with a wider range of controls failed to find a link between financial knowledge and emergency savings west and friedline 2016) . huston (2010) drew an important distinction between financial knowledge and financial literacy. whereas the former refers to knowledge of basic financial concepts (chase et al. 2011; lusardi 2008b) , the latter refers to having the ability and confidence to apply this knowledge. this combination of knowledge and skill is reflected in sherraden's (2013) model of financial capability. for example, rothwell et al. (2016) found that the relationship between financial knowledge and emergency savings was mediated by financial self-efficacy and that knowledge alone did not predict savings outcomes. consistent with huston's (2010) definitions, sherraden (2013) described financial literacy as having the ability to act based on having both financial knowledge and skills. when combined with financial inclusion-the opportunity to act by accessing safe and affordable financial services-financial literacy leads to improved financial behavior. whether or not a household has a savings account may affect the likelihood of having an emergency fund. savings deposits tend to remain in accounts (sikkel and van meer 2015) , as funds set aside in savings accounts are less tempting than funds held in other ways (e.g., checking accounts, hidden cash) that are considered "saved" via mental accounting (thaler 1999) . the accounts themselves may act as commitment devices that make it easier for individuals to followthrough on intentions to save and guard assets from nonemergency consumption (ashraf et al. 2006; benhabib and bisin 2005) . account ownership is strongly associated with savings, as is intuitively expected. sixty-two percent of households with bank accounts set aside money for emergencies, compared to only 17% of households without bank accounts (federal deposit insurance corporation [fdic] 2018). participants who had a checking or savings account prior to starting a matched savings program had greater savings outcomes compared to participants without prior bank account use (grinstein et al. 2010) . fitzpatrick (2015) found an increase in asset accumulation among families with children who transitioned into bank account ownership following an electronic public benefit transfer mandate. income from public benefits remained stable, suggesting that the increase in assets could be attributed to account ownership. studies of various savings programs have demonstrated that savings increase with use of accounts and other financial products (adams and west 2015; collins 2015; manturuk et al. 2015; nam et al. 2013; schreiner and sherraden 2007; sherraden et al. 2003) . individuals who owned savings accounts as teenagers were more likely to own savings accounts, certificates of deposit, and stocks as young adults compared to those who did not own savings accounts as teenagers . account ownership and use is affected both by individual tastes and access to financial services. financial service preferences are affected by financial literacy (servon and kaestner 2008) , comfort, familiarity, and trust, and resources to afford bank accounts (rengert and rhine 2016; servon 2017). for example, the top reasons why individuals chose not to have a bank account were not having enough money to maintain accounts (53%) and a lack of trust in banks (30%) (fdic 2018) . concerning access, goodstein and rhine (2017) found that bank account ownership was affected by proximity of bank branches, while friedline et al. (2019) found an association between the availability of financial services in communities and households' savings account ownership. conversely, prior studies have found the proximity of alternative financial services such as check cashing to be associated with use of these services (bhutta et al. 2015; friedline and kepple 2017) . proximity to and availability of financial services varies by geography. despard et al. (2017) found that bank and credit union density was greater in the midwest and northeast than in the south and west. even if individuals had easy access to financial services, they may not have qualified for owning accounts due to past overdraft activity (campbell et al. 2012) . savings accounts are an important means of accumulating and protecting liquid assets, yet households use other methods for setting aside money for emergencies including checking accounts, keeping money at home, and asking family members to hold cash (christen and mas 2009; fdic 2018) . via mental accounting, a certain amount or proportion of one's checking account balance or cash held at home may be considered set aside or reserved for future use (thaler 1999; xiao and olson 1993) . nearly a quarter of households used checking accounts to set aside emergency funds, while 11% set aside funds at home or safeguarded by family or friends (fdic 2018) . tax refunds are a good opportunity for households to build an emergency fund. two-thirds of lower-income tax filers saved their refunds in a savings account, yet a third used a checking account to save their refund. some tax filers used multiple methods, including saving some of their refund as cash and through prepaid debit card . thompson et al. (2020) studied tax refund savings behaviors among lower-income filers, finding that 40% of filers in volunteer income tax assistance (vita) sites, 15% of filers using a free online tax filing program, and 33% of filers using a matched savings program, respectively, "saved" their refunds in checking accounts. savings accounts have structural features that make it more likely that deposited funds will remain and thus are an important means of building an emergency fund. still, not all households use savings accounts for this purpose, due to preferences or a lack of trust, proximal access, affordability, and/or account denial. consistent with sherraden's (2013) conceptual model of financial capability, the evidence reviewed above suggests that financial knowledge, skills, and confidence as well as savings account ownership may affect whether or not households have an emergency fund. accordingly, we offered the following hypotheses: h1: greater levels of objective and subjective financial knowledge increase the probability of having an emergency fund. h2: greater levels of financial confidence increase the probability of having an emergency fund. h3: owning a savings account increases the probability of having an emergency fund. we also examined whether these hypothesized relationships varied based on household income, i.e. whether income moderated these relationships. for example, the link between financial confidence and having an emergency fund may be stronger among households with greater income. higher income households may have greater financial slack that enables them to maintain consumption while simultaneously addressing other financial goals such as reducing debt, building an emergency fund, and saving for retirement. we expanded on prior studies using nfcs data that examined the role of financial knowledge (babiarz and robb 2014; woodyard et al. 2017 ) by testing additional factors informed by sherraden's (2013) financial capability framework -financial confidence and savings account ownership-that may more comprehensively explain whether or not a household has an emergency fund. by including financial confidence in our analyses, we assessed how financial literacy, the confidence and ability to use financial knowledge rather than financial knowledge alone (huston 2010) was associated with having an emergency fund. by including savings account ownership, we assessed the role of access to financial services. our study captured a more complete range of factors conditioned both by individual and environmental factors than was reflected in prior studies using nfcs data (babiarz and robb 2014; woodyard et al. 2017) to examine whether or not a household was prepared to weather a financial emergency. we also considered the role of income as a moderator with respect to explaining these relationships. in addition, we assessed these factors across four study years (2009, 2012, 2015, 2018) reflecting the immediate aftermath of the great recession and a recovery marked by steady economic growth which allowed us to assess the stability of predictors corresponding to sherraden's (2013) model. our findings can help guide financial educators and counselors and policy makers in considering how factors in addition to financial knowledge ought to inform efforts to help individuals and households build emergency funds. data for this study came from the 2009, 2012, 2015, and 2018 national financial capability study (nfcs) surveys commissioned by the finra investor education foundation. nfcs surveys asked questions concerning a range of financial circumstances, behaviors, attitudes, and knowledge, such as having a budget, self-assessed credit record, use of various financial products and services, and retirement plan participation. demographic questions captured characteristics such as age, gender, and race/ethnicity. the full survey questionnaire is available on the nfcs website. 1 the dependent variable was having an emergency fund, which was coded as a dummy variable. a value of 1 was assigned if the respondent replied yes to the following question, and a value of 0 if the answer was no: "have you set aside emergency or rainy day funds that would cover your expenses for 3 months, in case of sickness, job loss, economic downturn, or other emergencies?". independent variables of predictive interest used in hierarchical regression models included objective and subjective financial knowledge, financial confidence, and savings account ownership. these variables were chosen as indicators of constructs in sherraden's (2013) conceptual model of financial capability that are hypothesized as associated with an increased probability of having an emergency fund. objective financial knowledge was measured using correct responses to five questions assessing knowledge concerning interest, inflation, interest rates and bond prices, mortgage interest, and investment risk (see babiarz and robb 2014 for a detailed description of items). dummy variables indicating a correct answer were coded as '1â�² and an incorrect answer, don't know, or prefer not to say response coded as '0â�². correct responses were summed to create an index variable. this coding scheme and index creation is consistent with prior research using the same items (babiarz and robb 2014; knoll and houts 2012; woodyard et al. 2017 ). in addition, these objective financial knowledge items have been used in several prior studies (e.g., lusardi 2008b; lusardi and mitchell 2011) and validated by knoll and houts (2012) as part of a 20-item financial knowledge scale. values ranged from zero to five and scale reliability for correct responses across these five objective financial knowledge variables was î± = 0.63. subjective financial knowledge was measured using responses to the following question: "on a scale from 1 to 7, where 1 means very low and 7 means very high, how would you assess your overall financial knowledge?". financial confidence was included as a proxy for financial skills in sherraden's (2013) model of financial capability and a reflection of huston's (2010) definition of financial literacy. respondents were asked, 'how strongly do you agree or disagree with the following statements? -i am good at dealing with day-to-day financial matters, such as checking accounts, credit and debit cards, and tracking expenses'. responses were recorded using a sevenpoint likert scale where 1 indicated 'strongly disagree', 4 indicated 'neither agree nor disagree', and 7 indicated 'strongly agree'. with respect to financial skills in sherraden's (2013) model, responses to this question operate as self-appraisals of these skills. a dummy variable was created for savings account ownership with a value of '1â�² assigned if the respondent answered yes, if the household had a 'savings account, money market account, or cds', and '0â�² if the answer was no. this variable was included as a predictor because having a bank account is not a necessary precondition of setting aside money for emergencies (fdic 2018; grinstein-weiss et al. 2015; thompson et al. 2020; ) . furthermore, the dependent variable was measured by responses to a question about setting aside funds for emergencies, not conditional on doing so using a savings account. if owning a savings account and having an emergency fund were measuring the same phenomenon, we would expect the correlation between these two variables to be very high. however, savings account ownership was only moderately correlated with having an emergency fund (r = 0.30 to 36 across study years) while objective and subjective financial knowledge and financial confidence were similarly correlated with having an emergency fund (r = 0.21 to 0.33 across study years). in addition, the proportion of households that had an emergency fund but not a savings account ranged from 11 to 20% across study years which is similar to other survey estimates (fdic 2018) . these findings suggested that responses in the nfcs regarding savings account ownership and having an emergency fund were sufficiently independent and measured different phenomena. the following set of variables were used as covariates in multivariate models: age, gender, race/ethnicity, income, education, number of children, marital, employment, health insurance status, income shock, risk tolerance, and state of residence (see babiarz and robb 2014; woodyard et al. 2017 ). except where otherwise noted, responses of 'don't know' or 'prefer not to say' were coded as missing values. prior research indicates that ability to cover expenses morduch and schneider 2017; pew charitable trusts 2016) is associated with savings. ability to cover expenses also partially reflects cost of living and thus is an important variable to include in addition to income in models predicting having an emergency fund. for example, households living in urban areas with high housing costs may have greater difficulty setting aside money for emergencies, all other things being equal (e.g., income). furthermore, homeownership is correlated with savings (di et al. 2007; friedline et al. 2014; krumm and kelly 1989; friedline and freeman 2016) , including having an emergency fund (west and mottola 2016) . thus, ability to cover expenses and homeownership were added as covariates to models for sensitivity tests. a dummy variable was created for homeownership to indicate whether the respondent owned their home. lastly, ability to cover expenses was measured based on responses to the following question: 'in a typical month, how difficult is it for you to cover your expenses and pay all your bills?'. a dummy variable was coded as '1â�² if the respondent said, 'not at all difficult' and '0â�² if the respondent replied 'somewhat' or 'very' difficult. samples used in this study were from the 2009 (n = 28,146), 2012 (n = 25,509), 2015 (n = 27,564), and 2018 (n = 27,091) nfcs state-by-state surveys. nfcs samples were drawn using non-probability quota sampling from online survey panels. in each survey year, at least 400 responses were drawn from each state as well as the district of columbia and national sampling weights were calculated. four states in 2015 and two large states in 2018 were oversampled. additional information concerning sampling methods and results is available from the nfcs website. 2 proportions of missing data for model variables ranged from 0% to 3.72% in 2009, 0% to 3.97% in 2012, 0% to 4.1% in 2015, and 0% to 4.55% in 2018. building on babiarz and robb's (2014) probit regression models with objective and subjective financial knowledge as predictors of having an emergency fund, a hierarchical regression modeling approach was used to determine whether each additional variable of interest -financial confidence and savings account ownership -explained a greater amount of variance in having an emergency fund. a final model added homeownership and ability to cover expenses as additional controls. each of these variables was retained only if the result of a wald test was statistically significant, indicating that the variable accounted for better model fit than the preceding model without this variable. interaction terms were tested for income and each of the four predictors using a three-level ordered categorical indicator for income: under $50,000, $50,000 to $99,999, and $100,000 and above to roughly correspond to low-and moderate-income (lmi), middle income, and upper income, respectively. these interactions were tested to assess the degree to which the relationship between predictor variables (e.g., objective financial knowledge) and having an emergency fund vary by income. in addition to including significant income interaction terms in models for sensitivity tests, we also run separate probit regression models for each of the three income categories to conduct sub-sample analyses. sampling weights available from the nfcs datasets were added to all models to make findings nationally representative based on age, gender, ethnicity, and education, using data from the american community survey. marginal effects were calculated for each model, holding other variables constant at their respective means. in addition, model-predicted outcomes were calculated using the margins command in stata version 15 to indicate the proportion of respondents estimated to have an emergency fund based on each predictor variable. to convert financial literacy variables to binary indicators for the purpose of calculating predicted probabilities, values of '1â�² and '0â�² were assigned to above and at-or-below median scores, respectively. for example, the median score for subjective financial knowledge, which was measured on a seven-point scale, was five. thus values of '1â�² were assigned for scores of six and seven and values of '0â�² for scores of five and below. tjur's r-squared was used to identify the proportion of variance explained by probit models (tjur 2009 ). the 2009, 2012, 2015, and 2018 samples are described in table 1 . the proportion of respondents who said they had money set aside for emergencies rose each survey year: 39%, 44%, 51%, and 52% in 2009, 2012, 2015, and 2018, respectively. a nearly identical set of results was found for respondents who said they could cover their usual monthly expenses. the average number of correct responses to questions assessing financial knowledge held steady at around three out of five, declining slightly each year. concerning financial confidence, respondents generally felt they were good at handling financial matters. most respondents said they had a savings account, money market account, or certificate of deposit, and nearly two-thirds of respondents said they owned their homes. concerning demographic characteristics, most respondents in each year were white, female, and married. ages were well dispersed, as the sample in each year had a mix of young, middle aged, and older adults. by income, roughly equal thirds of respondents in each year had annual income under $35,000, $35,000 to $75,000, and $75,000 and above. slightly more than a third of respondents had a college degree or higher in each year, and most respondents indicated they were working. there was a general trend of improved economic circumstances across sample years, as households perhaps regained economic footing coming out of the great recession. the proportion of respondents who said they experienced income shocks decreased, while financial confidence and tolerance for taking financial risks increased, though declined in 2018. the proportion of respondents who said they had results from hierarchical probit regressions for each study year are displayed in table 2 . wald tests were statistically significant (p < 0.001) for all predictor variables in all sample years. that is, each addition of a predictor variable to a probit model explained a statistically significant greater proportion of variance. in the full model with all four predictor variables, marginal effects were statistically significant for all predictors except objective financial knowledge, which had a statistically significant association with having an emergency fund in the 2015 and 2018, but not 2009 and 2012 study years. during and soon after an economic downturn, financial knowledge may have a negligible relationship with setting aside money for emergencies. the largest marginal effects were found for savings account ownership, which was associated with 25% to 29% greater probability of having an emergency fund (p < 0.001), all other things being equal. adding savings account ownership increased the proportion of variance explained in having an emergency fund by two to three percentage points. the second and third largest marginal effects were found for subjective financial knowledge and financial confidence. one unit increases in these financial literacy indicators were associated with 5% to 6% and 2% to 5% greater probabilities of having an emergency fund (p < 0.001), respectively, all other things being equal. table 3 displays model predictions for the proportion of respondents with an emergency fund from probit regression models with the four predictor variables. like marginal effect results in table 2 , across all study years, model-predicted outcomes were greatest for savings account ownership. for example, in 2018, 58% of respondents with a savings account had an emergency fund, compared to 35% of those without a savings account, all other things such as age and income being equal. differences in model-predicted prevalence of having an emergency fund based on high versus low subjective financial knowledge and confidence was 7 to 11 percentage points across study years. in all four study years, household income was moderately correlated to having an emergency fund (r = 0.31 to 0.37). the prevalence of having an emergency fund rose with income. for example, in 2018, the prevalence rate among low-and moderate-income (< $50,000), middle-income ($50,000 to $99,999) and high-income ($100,000 and higher) was 35%, 61%, and 76%, respectively. income moderated the relationship between most predictor variables and having an emergency fund. for the 2009 sample, interactions between income and subjective financial knowledge (p < 0.001), financial confidence (p < 0.01), and savings account ownership (p < 0.05) were statistically significant for having an emergency fund. for all other study years, significant income interaction terms were found for objective and subjective financial knowledge, and financial confidence. to help better understand the moderating influence of income on the relationship between predictor variables and having an emergency fund, sub-sample analyses were conducted for each income group. results of sub-sample analyses are displayed in table 4 . marginal effects were statistically significant for all income groups and all predictor variables, except for objective financial knowledge, which had a significant association with having an emergency fund only among low-and moderate-income households in 2015 and 2018. that is, three out of four indicators of financial capability were consistent and statistically significant predictors of having an emergency fund across all income groups and in all study years. however, the magnitude of marginal effects differed by income. without exception, marginal effects were highest among middle-income ($50,000 to $99,999) households across all study years. to assess the stability of findings, a model adding statistically significant interaction terms (model v) and a model adding ability to cover expense and homeownership as additional controls (model vi) were run. as seen table 5 , the main results reported in table 2 were largely unchanged, with two exceptions. first, objective financial knowledge was no longer a significant predictor of having an emergency fund in 2018. second, the magnitude of the four predictors all declined after adding ability to cover expenses and homeownership, while the proportion of variance explained (tjur's r 2 ) rose substantially-by an average of 29% across study years. in this study, we examine constructs from sherraden's (2013) conceptual model of financial capability to explain variation in having money set aside for emergencies, an important indicator of household financial well-being. we use four cross-sectional panels of the national financial capability study (nfcs) state-by-state survey from 2009 to 2018 and produce remarkably stable results. three of the four financial capability constructs-subjective financial knowledge, financial confidence, and savings account ownership-are stable and statistically significant predictors of having an emergency fund across all four study years and for all income levels. these findings are consistent with our hypotheses and prior research. however, one difference is regarding objective financial knowledge, which has a statistically significant association with having an emergency fund only in certain study years and for certain income groups. the role of objective financial knowledge in explaining emergency savings may be over-estimated in prior studies using nfcs data (babiarz and robb 2014; woodyard et al. 2017) due to the omission of other predictors. a fuller picture of emergency savings emerges by including additional constructs -financial confidence and savings account ownership that comprise sherraden's (2013) model of financial capability, as well as incorporating additional controls such as ability to cover expenses and homeownership. the key implication of this conclusion is that it may take more than financial education-the typical remedy for a lack of financial knowledge -to influence households' preparedness for financial emergencies. it may take other types of interventions such as financial counseling and savings programs to influence this outcome. of the four constructs tested, savings account ownership was the strongest predictor of having an emergency fund. households with savings accounts or other savings vehicles may find it easier to set aside money for emergencies as these financial products may act as commitment devices (benhabib and bisin 2005) . this idea is consistent with prior findings concerning the "stickiness" of savings deposits (sikkel and van meer 2015) and the association between tax-time savings account deposits and reduced risk of material hardship among low-and moderate-income (lmi) households (grinstein-weiss et al. 2016) . having a savings account also enables households to take advantage of split direct deposit of paychecks, tax-time savings interventions (grinstein-weiss et al. 2017) , impulse savings programs (manturuk et al. 2015) , and other incentive programs that require a savings account or similar product to participate. yet nearly a quarter of us households lack a savings account (fdic 2018) , and some households may close their savings account when experiencing an income shortfall (rhine et al. 2016) . financial confidence and subjective financial knowledge also had statistically significant associations with having an emergency fund, while objective financial knowledge had the weakest association. this finding underscores the important distinction between financial knowledge and literacy, whereas the latter refers to the ability to understand and use financial information (huston 2010) . individuals lacking financial confidence may need support and guidance through financial counseling and coaching to take steps to build an emergency fund, not just to have information about the need to do so. that objective financial knowledge had less of an association than other factors with having money set aside for emergencies may be related to how it was assessed in the nfcs survey. the objective financial knowledge items assess knowledge concerning compound interest, inflation, bond pricing, mortgage payments, and portfolio diversification. despite the popularity of using these items in research on consumer finance, these items may be poor indicators of financial knowledge for individuals who have limited or no experience with credit cards, owning a home, and/or retirement accounts. this relates to what sherraden (2013) observes as the interaction between financial knowledge and skills and financial inclusion. for example, there are over 45 million consumers who are "credit invisible" meaning they lack a credit history with the three credit reporting agencies or have "thin" credit histories that cannot be scored. as a result, these consumers lack access to credit (brevoort et al. 2016) , which means they may be unfamiliar with credit-related financial concepts such as loan interest. similarly, over a third of the nfcs 2018 sample do not own homes and a majority have no investments, which means they are probably unfamiliar with mortgage and investment concepts, respectively. thus, given that higher-income consumers are more likely to enjoy access to credit and own homes and investments, these items may have a distinct socioeconomic status bias, while not directly measuring knowledge concerning precautionary saving. there are many other ways to measure financial knowledge (fernandes et al. 2014) , including an understanding of concepts that are more closely related to emergency savings, such as budgeting, cash flow, comparison shopping, automatic saving options, and use of financial services. measured differently, objective financial knowledge may have a stronger association with having money for emergencies than we discovered. our finding concerning subjective financial knowledge corroborates this point. the lower respondents assessed their financial knowledge, the less likely they reported having an emergency fund. this suggests that financial education efforts should be tailored to address specific financial health concerns such as the need to build emergency savings. this idea is consistent with the "just in time" hypothesis of financial education based on the recognition that outcomes of general financial education are limited and decay over time (fernandes et al. 2014) . we also find evidence that income moderates the relationship between predictor variables and having an emergency fund. factors such as subjective financial knowledge and financial confidence play a larger role in predicting whether middle-income households have an emergency fund compared to other income groups. it may be that middle-income households, in experiencing or striving to achieve upward mobility are accessing a more complex set of personal finance decisions (e.g., managing credit card debt while repaying student loans) amidst less of an income buffer compared to high-income households. whatever the case, financial educators and counselors might anticipate different types of challenges in building emergency savings among participants with different income levels (anderson et al. 2004 ). our study has important limitations to note. first, we did not directly observe having money set aside for emergencies. also, survey respondents might not have had an accurate idea of the amount of money equal to three months of their household's expenses. in addition, households may have had emergency savings, albeit in amounts less than three months of expenses. this circumstance was not observed through the nfcs surveys. second, as we note above, a broader and more relevant set of indicators of financial knowledge may have had a different association with money set aside for emergencies. third, our findings are correlational. readers should not infer from our findings that having greater financial knowledge or confidence or owning a savings account will result in households having emergency funds. also, unobserved factors may explain both the independent and dependent variables in our study. the same set of motivations, propensities, or tastes might explain whether individuals have savings accounts or high financial confidence and why they have enough money set aside for emergencies. this study examines predictors of households having money set aside to help cope with financial emergencies, guided by sherraden's (2013) conceptual model of financial capability. we find that subjective financial knowledge, financial confidence, and savings account ownership are steady predictors of having money for emergencies while objective financial knowledge is not. efforts to increase objective financial knowledge alone may be insufficient; financial counseling and coaching interventions can help households build financial skills and confidence and access savings accounts that meet their needs to prepare for emergencies. changes in public policies concerning access to safe and affordable financial products and services and targeted savings programs are also needed. an overall implication of our findings is that interventions to improve financial knowledge alone may not help households build an emergency fund. interventions such as financial counseling and coaching are needed to help individuals gain new skills and confidence to save. yet, we also find that ability to cover expenses alone explains seven to nine percent of variation in having an emergency fund. a household is unlikely to set aside money for emergencies if income does not at least occasionally exceed usual expenses to create the financial slack necessary to build assets (barr 2012; mullainathan and shafir 2009) . thus, financial counselors and coaches could help households identify ways to create financial slack, not just through reducing expenses-the usual focus of these services, but by maximizing use of existing public resources (e.g. tax credits, housing, food, child care, and health care subsidies) and increasing income (e.g., job training, additional education, microenterprise, small business development) (anderson et al. 2004 ). another strategy is to integrate financial education and counseling in services and systems aimed at increasing household income, such as workforce development. practitioners could also integrate financial counseling and coaching with access to and use of financial services, as is frequently done in both matched savings and "second chance" bank account programs. in a program designed to assist households that had been reported to chex systems for account mismanagement, targeted financial education and the opportunity to open both a checking and savings account showed positive outcomes. most who had opened a checking or savings account still had the account one to three years later, most repaid debts owed to financial institutions, and 75% routinely kept up with their account transactions (haynes-bordas et al. 2008) . the integration of financial education and counseling with access to financial services reflects sherraden's (2013) financial capability model and is consistent with prior research indicating better financial outcomes associated with owning bank accounts in addition to receiving financial education compared to financial education alone west and friedline 2016) . our findings affirm the importance of public policies to promote financial inclusion. nearly a third of households surveyed said products offered by financial institutions do not meet their needs for saving (pew charitable trusts 2016). only 9% of over 1600 bank branches surveyed indicated that they have entry-level accounts that meet national product standards for safety and affordability ). however, evidence from the fdic's pilot study of model safe accounts suggests that simple, low-cost savings accounts can be offered to a wider range of customers without introducing risk to banks (fdic 2012). the "borrow and save" program provides installment loans to credit union members as an alternative to expensive payday loans with a feature in which a portion of loan repayments are allocated to a savings account (national federation of community development credit unions and filene 2015). thus, to help households build an emergency fund, financial institutions need to consider products and services that meet the needs of a wider range of customers. in addition, households can benefit from various programs to encourage and incentivize saving. of note, a matched emergency savings program administered by a community development financial institution demonstrated that very low-income participants, some without earned income, could successfully save $500 over a 2 year period to ultimately receive a 2:1 match (adams and west 2015) . matched tax-time savings models including $avenyc have demonstrated moderate effects related to increased savings amounts among lower-income households (key et al. 2015) . to bring tax time savings to scale for lower-income workers, edin et al. (2015) proposed the rainy day earned income tax credit (eitc), a matched savings vehicle that allows eitc recipients to hold back 20% of their refund for a 50% match available to them 6 months after their first refund check. other programs that do not offer a savings match have also been shown effective. manturuk et al. (2015) found that encouragement and opportunity to direct small amounts toward a savings account linked to prepaid debt cards via text messages helped individuals build an emergency fund. messages encouraging lower-income online tax filers to save their refunds have shown success concerning savings deposits (grinstein-weiss et al. 2017 ). tax-time savings deposits have also been found to lessen risk for material hardship (grinstein-weiss et al. 2016) , suggesting saved refunds are being used as emergency resources. in tandem with policies to create slack in household budgets, initiatives to increase access to responsive financial products and services, these targeted savings programs offer promising and scalable solutions to households' persistent lack of emergency savings. the workplace is another promising channel for promoting emergency savings. employers can offer split direct deposit and match employees' deposits, as is done by the red tab foundation for employees of levi strauss and company in partnership with the nonprofit earn, which offers the digital platform to facilitate employee savings (red tab foundation, 2019). rhino foods' income advance program automatically rolls over employees' payroll-deducted small-dollar installment loan payments to savings deposits once the loan has been repaid (finra and filene research institute 2017). most (71%) employees indicated they would somewhat or very likely enroll in a "rainy day" savings program with payroll deduction if offered by their employer (harvey et al. 2018 ). funding no funding was received to support this study. data availability this article uses data from datasets made publicly available by the finra investor education foundation that contain de-identified survey data. conflict of interest mathieu despard, terri friedline and stacia martin-west declares that they have no conflict of interest. this article does not contain any studies with human participants performed by any of the authors. asset 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consumer perceived saving motives and hierarchical financial needs mental accounting and saving behavior key: cord-033328-ny011lj3 authors: vese, donato title: managing the pandemic: the italian strategy for fighting covid-19 and the challenge of sharing administrative powers date: 2020-09-03 journal: nan doi: 10.1017/err.2020.82 sha: doc_id: 33328 cord_uid: ny011lj3 this article analyses the administrative measures and, more specifically, the administrative strategy implemented in the immediacy of the emergency by the italian government in order to determine whether it was effective in managing the covid-19 pandemic throughout the country. in analysing the administrative strategy, the article emphasises the role that the current system of constitutional separation of powers plays in emergency management and how this system can impact health risk assessment. an explanation of the risk management system in italian and european union (eu) law is provided and the following key legal issues are addressed: (1) the notion and features of emergency risk regulation from a pandemic perspective, distinguishing between risk and emergency; (2) the potential and limits of the precautionary principle in eu law; and (3) the italian constitutional scenario with respect to the main provisions regulating central government, regional and local powers. specifically, this article argues that the administrative strategy for effectively implementing emergency risk regulation based on an adequate and correct risk assessment requires “power sharing” across the different levels of government with the participation of all of the institutional actors involved in the decision-making process: government, regions and local authorities. “and the flames of the tripods expired. and darkness and decay and the red death held illimitable dominion over all”. edgar allan poe, the mask of the red death, complete tales and poems (new york, vintage books 1975) p 273 international concern" (pheic). 2 in the light of its later levels of spread and severity worldwide, the who then assessed covid-19 as a "pandemic". 3 the pandemic has spread rapidly in several european union (eu) member states. italy, however, is a special case: here, the covid-19 outbreak spiralled upwards earlier and more severely than elsewhere in europe, reaching a high mortality rate and creating the conditions for the public healthcare system's collapse. in this scenario, the italian government (from now on the government) declared a nationwide state of emergency, 4 followed by increasingly restrictive measures aimed at slowing and containing the spread of the virus and mitigating the pandemic's effects under the by now well-known "flatten the curve" imperative. the last of these measures 5 established the national lockdown, extending the emergency rules to the entire country for six months 6 and, more generally, providing what has been called the "italian model to fight covid-19", namely "diminish viral contagions through quarantine; increase the capacity of medical facilities; and adopt social and financial recovery packages to address the pandemic-induced economic crisis". 7 in this article, starting from the main regulatory acts and considering recent scientific knowledge and epidemiological data on covid-19, we will examine the administrative measures the government has taken and the strategy it has implemented to deal with the pandemic in the immediacy of the emergency. after this initial analysis, we might legitimately wonder whether those measures and that strategy have proven effective in containing the pandemic. more generally, by analysing the administrative strategy, the article emphasises the role that the current system of constitutional separation of powers plays in emergency management and how this system can impact health risk assessment. an explanation of the risk-management system in italian and eu law will be provided and the following key legal issues will be analysed: (1) the notion and features of emergency risk regulation from a pandemic perspective, distinguishing between risk and emergency; (2) the potential and limits of the precautionary principle in eu law; 2 who, "statement on the second meeting of the international health regulations (2005) emergency committee regarding the outbreak of novel coronavirus (2019-ncov)", geneva, switzerland, 30 january 2020 <https://www. who.int/news-room/detail/30-01-2020-statement-on-the-second-meeting-of-the-international-health-regulations-(2005)emergency-committee-regarding-the-outbreak-of-novel-coronavirus-(2019-ncov)>. pheic has been defined in the international health regulations (ihr) of 2005 as an extraordinary event which can: (1) constitute a public health risk to other states through the international spread of disease; and (2) potentially require a coordinated international response. furthermore, this definition implies a situation that is: (1) serious, unusual or unexpected; (2) carries implications for public health beyond the affected state's national borders; and (3) and may require immediate international action. 3 who, "director-general's opening remarks at the media briefing on covid-19", 11 march 2020 <https://www. who.int/dg/speeches/detail/who-director-general-s-opening-remarks-at-the-media-briefing-on-covid-19-11-march-2020>. 4 resolution of the council of ministers of 31 january 2020, adopted pursuant to legislative decree 1/2018 (civil protection code) <https://www.gazzettaufficiale.it/eli/id/2020/02/01/20a00737/sg>. on the declaration of emergency rule, see european commission for democracy through law (venice commission) <https://www.venice.coe.int/ webforms/documents/default.aspx?pdffile=cdl-std(1995)012-e>. 5 dpcm of 9 march 2020 <www.gazzettaufficiale.it/eli/gu/2020/03/09/62/sg/pdf>. 6 for the general framework of all measures adopted by the italian state during the covid-19 emergency, see <https://www.camera.it/temiap/documentazione/temi/pdf/1203754.pdf?_1588279335853>. 7 fg nicola, "exporting the italian model to fight covid-19" (the regulatory review, 23 april 2020) <https:// www.theregreview.org/2020/04/23/nicola-exporting-italian-model-fight-covid-19/>. and (3) the italian constitutional scenario with respect to the main provisions regulating central government, regional and local powers. specifically, the article argues that the administrative strategy for effectively implementing emergency risk regulation based on an adequate and correct risk assessment requires "power sharing" across the different levels of government with the participation of all of the institutional actors involved in the decision-making process: government, regions and local authorities. following the declaration of the state of emergency, the government approved decree-law no. 6 of 23 february 2020 vesting the president of the council of ministers with wide ordinance powers to handle the emergency by issuing his own administrative decrees. 8 in particular, decree-law 6/2020 gave the prime minister the power to issue typical emergency administrative measures in order to ensure social distancing, impose lockdown areas, close offices and public services and suspend economic activities. in addition, it allowed him to adopt atypical administrative powers whereby "further containment and emergency management measures" could be established. 9 in a matter of days, the government approved three important regulatory acts based on the implementation of decree-law 6/2020: 10 first with the decree of the president of the council of ministers (dpcm) of 8 march 2020, 11 second with the dpcm of 9 march 2020 12 and third with the dpcm of 11 march, 13 the government established stringent emergency administrative measures to curb the pandemic's spread throughout the country. 14 in the first instance, these measures were gradual and concerned specific municipalities, provinces or regionsespecially in northern italythat were hardest hit by the virus and therefore classified as "red zones" subject to government-imposed local lockdowns. later on, the government established the national lockdown, and emergency measures were extended to the entire country for six months. in particular, pursuant to article 1(1) of the dpcm of 8 march 2020, the government imposed a lockdown in lombardy and another fourteen provinces of northern italy. in doing so, the government introduced several legal prohibitions, such as the ban on people travelling to and from places in the red zones. with the subsequent national lockdown, the government imposed a travel ban in the entire country according to article 1(1), dpcm of 9 march 2020, and prevented all forms of social gathering in public places or places open to the public across the country, according to article 1(2), dpcm of 9 march 2020. furthermore, pursuant to articles 1(1), 1(2) and 1(3), dpcm of 11 march 2020, retail businesses and personal services were suspended. 15 as a consequence of the national lockdown, the ministry of health's order of 20 march 2020 provided several stringent measures that prohibited many activities, such as the ban on accessing all public places, on exercising in public places and on going to holiday homes. 16 in addition, with its order of 28 march 2020, the ministry of health, in agreement with the ministry of transport, established that people entering italy by plane, boat, rail or road must declare their reason for travel, the address where they plan to self-isolate, how they intend to travel there and their phone number so that authorities can contact them throughout an obligatory fourteen-day quarantine. 17 moreover, several administrative sanctions were gradually established in the various regulatory acts. the last of these acts introduced rigorous sanctions for people who leave home without valid reasons and for undertakings that do not comply with the order to close. 18 in the meantime, the regions and local authorities also adopted several ordinances establishing emergency administrative measures for the pandemic in their area. 19 lastly, the government issued decree-law no. 19 of 25 march 2020, with the aim of rationalising and coordinating emergency powers among the different levels of government. 20 *** in the following pages, emphasising the role that the current structure of constitutional separation of powers plays in risk assessment, i will argue that the main problems of the italian administrative strategy for the covid-19 pandemic are due to the lack of effective "sharing of powers", and more specifically to the failure to share administrative 15 20 in particular, art 2(3) of decree-law 19/2020 did not affect the effects produced and acts adopted on the basis of decrees and ordinances issued pursuant to decree-law 6/2020 or art 32 of law 833/1978, and established that the measures previously adopted by the dpcms of 8 march 2020, 9 march 2020, 11 march 2020 and 22 march 2020 as still in force on the date of entry into force of the said decree-law shall continue to apply within the original terms. regulatory powers among the different levels of government with the participation and cooperation of all institutional actors involved in the emergency decision-making process: the government, regions and local authorities. 21 from this point of view, as i will attempt to explain, the failure to share administrative regulatory powers can have a decisive impact on risk assessment at the national level in terms of the effectiveness/ineffectiveness of the strategies adopted by the various institutional actors called upon to manage the emergency in their own areas. here, by "sharing powers", i mean the idea that the institutional actors involved in the decision-making process cooperate in the exercise of their powers by adopting consistent measures in the public interest; that is to say, with the aim of maximising the rights of individuals as required by the italian constitution. 22 power sharing does not mean homologation. indeed, adopting different administrative strategies at different levels of government might increase the effectiveness of the response to a pandemic, but these measures must be shared among all of the actors involved in emergency management. sharing powers, measures and local strategies will be useful for an effective policy for containing the virus's nationwide spread based on an overall risk assessment. hence, the idea of shared powers emphasises the role of cooperation in specific institutional contexts, such as italy's, where competences are allocated across the different levels of government. the sense, more generally, is that sharing powers in multi-level systems enables states to perform better in terms of democracy, as powers are balanced between state and local levels. 23 as we will see, however, the absence of effective power sharing at all levels of government in a pandemic can produce serious problems in correctly assessing risk and consequently in the emergency management strategy. in particular, i will discuss the problem of the lack of effective power sharing in italian policies from two key points of view: the government's administrative strategy in addressing the virus's spread by means of an "incremental approach" (section iv.1.a); and the government's administrative strategy in implementing a national pandemic health plan (section iv.1.b). before doing so, i will outline some key legal issues for the topics examined in this article. in particular, to put the administrative strategy devised by the government in the covid-19 emergency into context, i will analyse: (1) the notion and features of emergency risk regulation from a pandemic perspective, distinguishing between risk and emergency; (2) the potential and limits of the precautionary principle in eu law; and (3) the italian constitutional scenario with respect to the main provisions governing government's, regions' and local authorities' powers. 21 this preliminary analysis of key legal issues is useful for understanding why the administrative strategy has proven ineffective in managing the pandemic (sections iv.1.a and iv.1.b). placing the notion and its main features in the context of a pandemic, we could define emergency risk regulation as the action undertaken in the immediacy of a pandemic in order to mitigate its impact. 24 from this perspective, we should bear in mind the distinction between risk and emergency. generally speaking, the traditional approach of administrative law refers to the notion of emergency and not also to the notion of risk, which legal doctrine touches on only marginally. 25 with regards to the emergency, as a safeguard clause to deal flexibly with pandemic risks, 26 governments and other public authorities may invoke the use of extraordinary powers to restore the normal course of legal relations. 27 what is more, regulators have used emergency tools to act in the expectation of a risk for many years, although there is no denying that a risk is a potential danger, whereas an emergency is an actual danger. indeed, it should be sufficiently clear that emergency power is ineffective when applied in a situation that is only potentially dangerous. in this connection, it has been argued 28 that the methods of exercising administrative powers can be better regulated by putting the administrative regulation in the category of risk rather than that of emergency. we might observe that if the notion of "risk" characterises a peculiar, intermediate state between security and destruction, 29 in "emergency risk" the balance between these two clearly tilts towards the latter. 30 in fact, as it is triggered by a pandemic, emergency risk regulation presupposes the existence, or the mere threat, of a pandemic. the pandemic, as 24 a alemanno (ed.), governing disasters: the challenges of emergency risk regulation (cheltenham, edward elgar 2011) p xix. 25 however, the notion of risk in italian administrative law is analysed by m simoncini, la regolazione del rischio e il sistema degli standard. elementi per una teoria dell'azione amministrativa attraverso i casi del terrorismo e dell'ambiente [risk regulation and the standards system. elements for a theory of administrative action through the cases of terrorism and the environment] (napoli, editoriale scientifica 2010) chs 2 and 4, where the author postulating the notion of risk argues and suggests, in an innovative approach, the transition from the "emergency" perspective to the "risk regulation" perspective. 26 . beck is responsible for analysing the sociopolitical dimension of risk management and in particular the problem of the relationship between science and society through the criticism of the monopoly that scientific rationality currently holds. 30 alemanno, supra, note 24, xxii. a possible cause of disaster for humans, is an event of substantial extent causing significant physical damage or destruction, loss of life or drastic change to the natural environment. 31 typically, one speaks of a pandemic when a threat to people's health is perceived that calls for urgent remedial action under conditions of uncertainty. 32 fundamentally, emergency risk regulation in a pandemic event, as in other disasters, finds its natural regulatory space in two stages: mitigation and emergency response. 33 in principle, mitigation efforts attempt to reduce the potential impact of a pandemic before it strikes, while a pandemic response tends to do so after the event. however, the distinction between emergency mitigation and emergency response is not always very sharp. when called upon to act under the menace of a pandemic, governments must both mitigate and respond to the threat in a situation characterised by suddenness (emergency) and significance. 34 in a pandemic, emergency risk regulation is clearly called on to operate in the initial phase of the disease's spread, when the mere threat overshadows the regulatory context by virtue of its status as an emergency. accordingly, the most cost-effective strategies for increasing pandemic preparedness with administrative regulation, especially in resource-constrained settings, may consist of: (1) investing to reinforce the main public health infrastructure; (2) increasing situational awareness; and (3) quickly containing further outbreaks that could extend the pandemic. in addition, especially once the pandemic has begun, a coordinated response should be implemented where the public regulator focuses on: (4) maintaining situational awareness; (5) public health messaging; (6) reducing disease transmission; and (7) care and treatment of the ill. successful contingency planning and an administrative strategy using the emergency risk regulation approach call for surge capacity, or in other words the ability to scale up the delivery of health interventions in proportion to the severity of the event, the pathogen and the population at risk. 35 the pandemic may produce significant impact on the regulatory context by justifying the partial or total suspension of the ordinary decision-making process. 36 departures from the rule of law, or simply from established procedures, are generally perceived as necessary if the event has met the significance threshold. however, the use of emergency administrative measures, such as temporary and exceptional measures, should be considered legitimate only for the period in which the pandemic 31 ibid, xxii-xxiii. see also dd caron, "addressing catastrophes: conflicting images of solidarity and self interest" in dd caron and ch leben (eds), lasts. 37 by contrast, prolonging exceptional order beyond the time of the pandemic means that any powers and measures designed to be temporary will be made permanent, intensifying the controlling authority's capacity, even though this might limit the enjoyment of individual rights. 38 in addition, if the general need to prevent a pandemic cannot be ignored, it should be well thought out as an opportunity for risk regulation to prevent not only the sudden impact of a pandemic situation, but also any distorting effects or mishandling of the necessary recourse to emergency powers. consequently, it might now be inferred that emergency risk regulation in the context of a pandemic is a relevant regulatory methodology that combines the risk approach with the possibility of resorting to extraordinary measures in case a pandemic occurs. this methodology is essential for an effective administrative strategy for dealing with a pandemic because it permits constant monitoring and management of risks that can have serious consequences for society. by assessing the risks and taking proportionate measures, the negative effects of the emergency can be reduced and the use of emergency powers can be limited. indeed, it should be pointed out that the principle of reasonableness, which is generally invoked in the exercise of emergency powers against immediate danger, does not operate in emergency risk regulation. instead, as i will claim later, it will be the precautionary principle that matters (section iii.2). furthermore, it must be said that emergency risk regulation entails an accurate assessment of the factual situation based on scientific evidence. 39 to apply this methodology correctly, a variety of factors must be consideredincluding the real level of the threat as well as how people perceive itin a step-by-step analysis based on the available scientific knowledge. in particular, as i will claim in analysing the italian policies (sections iv.1.a and iv.1.b), the administrative strategy for effectively implementing emergency risk regulation in a pandemic requires power sharing across the different levels of government with the participation of all of the institutional actors involved in the decision-making process in order to adopt consistent measures based on the constant monitoring and updating of the nationwide epidemiological risk assessment. hence, effective sharing of administrative powersand more specifically the administrative regulatory powers for emergenciesbetween the government, regions and local authorities would optimise the adoption of proportionate measures for controlling and containing the virus throughout the country, avoiding or at least delaying the application of stringent measures such as the lockdown of municipalities, provinces, regions or entire states. 37 g martinico and m simoncini, "emergency and risk in comparative public law" (verfassungsblog, 9 may 2020) <https://verfassungsblog.de/emergency-and-risk-in-comparative-public-law/>. according the authors, it is the facts and not the law that indicate the conclusion of an emergency. thus, the risks posed by the use of extraordinary administrative measures should be considered, especially at the end of the emergency when the government's powers should be subject to legal control in order to avoid departures from original objectives. in the same sense, see also simoncini, supra, note 27, 39. 38 on the state of exception, see c schmitt, die diktatur: von den anfängen des modernen souveränitätsgedankens bis zum proletarischen klassenkampf (berlin, duncker & humblot 1989). schmitt's jurisprudential thinking placed the state of exception at the very centre of analysis, beginning with his work on the roman dictatorship. 39 martinico and simoncini, supra, note 37. in managing the pandemic, the government's administrative strategy should take the emergency risk regulation methodology we have just outlined into account. in the eu legal system, the precautionary principle 40 is described in article 191(2) tfeu on environmental policy. 41 the jurisprudence of the european court of justice (ecj) played a prominent role in elevating the precautionary principle to the status of a general principle of eu law. some ecj judgments in health matters are seminal in this regard. 42 according to the ecj's jurisprudence, the precautionary principle requires that competent authorities adopt appropriate administrative measures to prevent specific potential health risks. the ecj's approach maintains that an appropriate application of the precautionary principle presupposes the identification of hypothetically harmful effects for health flowing from the contested administrative measure, combined with comprehensive assessment of the risks to health based on the most reliable scientific data available. 43 in like manner, the european commission (ec) has contributed significantly to outlining the features of the precautionary principle in the eu legal system. in the communication of 2000, the ec sought to establish a common understanding of the factors leading to recourse to the precautionary principle and its place in decisionmaking. 44 according to the ec communication, the principle covers those circumstances where scientific evidence is insufficient, inconclusive or uncertain, but where preliminary scientific evaluation provides reasonable grounds for concern that the potentially dangerous effects on human health might be inconsistent with the chosen level of protection. 45 various factors can trigger the adoption of precautionary measures. these factors inform the decision on whether to act or not, this being an eminently political decision, a function of the risk level that is "acceptable" to the society on which the risk is imposed. 46 the ec has also established guidelines for those situations where action based on the precautionary principle is deemed necessary in order to manage risk. in these situations, a cost-benefit analysis to compare the likely positive and negative effects of the envisaged action and of inaction is recommended, and it should also include non-economic considerations. 47 however, risk management in accordance with the precautionary principle should be proportionate, meaning that administrative measures should be proportional to the desired level of protection. in some cases, an administrative response that imposes a total ban may not be proportional to a potential risk; in others, it may be the only possible response. in any case, such measures should be reassessed in the light of recent scientific data and changed if necessary. in eu law, therefore, the precautionary principle has been widely recognised as a defining principle of risk regulation alongside the regulatory aim of a high level of protection. nevertheless, this principle might prove ineffective or even harmful if applied in a "strong" form. the strong form of the principle has been authoritatively criticised 48 on the grounds that it suggests that regulation is required whenever there is a potential risk to health, even if the supporting evidence is conjectural and the economic costs of administrative regulation are high. in particular, if governments adopt the strong form of the principle, it would always require regulating activitiesconsequently imposing a burden of proof each timeeven if it cannot be demonstrated that those activities are likely to cause harms. 49 in addition, as the need for selectivity of precautions is not simply an empirical fact but is a conceptual inevitability, no society can be highly precautionary with respect to all risks. 50 44 hence, in this strong form, the precautionary principle proves ineffective and even harmful by requiring stringent administrative measures that can be paralysing, in that they prohibit regulation and all courses of action, including inaction. thus conceived, this principle may not lead in any direction or provide precise guidance for governments and regulators. recently, the limits of the precautionary principle have been analysed in the field of administrative and constitutional law. an interesting recent work proposes that precautionary and optimising constitutionalism are a dichotomy. 51 in summary, the theory advances two distinct propositions. the first is that constitutions should be viewed as devices for regulating political risks. those political risks are referred to as "second-order risks", as opposed to "first-order risks" such as wars, diseases and other social ills. 52 many of these risks are described as "fat-tail risks" that are exceedingly unlikely to materialise, but more likely than in a normal distribution, and are exceedingly damaging if they do materialise, as in the case of a pandemic. 53 under "maximin constitutional" approaches, it is suggested that precautionary rules can overcompensate for these low-likelihood risks and even cause the very dangers that they seek to prevent. 54 hence, precautionary constitutionalism is myopic in focusing on certain risks, and the notion of unappreciated or unaccommodated risks is central. on the basis of this hypothesis, the best way to regulate risk is thus to avoid obsessive views on risk avoidance or precautions and instead to allow greater flexibility in addressing the full array of risks inherent in government. 55 what vermeule calls "optimising constitutionalism" is an answer to those who frame their understanding of the constitution along more rigid precautionary principles. 56 vermeule's approach has been criticised. 57 following these criticisms, i believe that this approach also reveals some critical points about the notion of risk. unless one adopts a more fungible notion of risk, i do not believe that "precautionary constitutionalism" is suboptimal for risk. it depends on how one weighs the risks involved in governing, even if one accepts risk analysis as the best measure for the success of a constitutional system. i claim, more generally, that correctly applying the precautionary principle, although it works better in a context of risk rather than one of emergency, is nonetheless important in managing a pandemic because it makes it possible to delay the implementation of stringent emergency measures. we have emphasised that administrative precautionary measures, unlike emergency ones, do not suspend the rule of law, since they activate soft government regulation that does not jeopardise fundamental rights concurrent with those threatened by imminent danger. hence, in my opinion, precautionary measures, where they are effectively shared across the different levels of government through appropriate risk assessment, would serve to avoid or at least delay governments' activation of a state of emergency. activating a state of emergency, consequently, would trigger hard government regulation through emergency measures that suspend the rule of law and therefore jeopardise fundamental rights. in a particular context such as the covid-19 pandemic, the precautionary principle could also be invokedand the implementation of precautionary administrative measures would be usefulin the presence of an emergency declaration issued by governments. in this sense, i argue that the declaration of a state of emergency for a pandemic is based on a technical risk assessment (ie technical discretion 58 ) by the administration (eg government). in a pandemic, then, the emergency relates essentially to the capacity of administrations (eg governments, health authorities) to manage cases requiring healthcare (eg intensive care for respiratory support, hospitalisations for advanced pharmacological treatments and so on). thus, the subject of the technical assessment of the fact (the pandemic) is be provided by the evaluation relating to the administration's capacity to fulfil the tasks established by the legal system to protect the right to health enshrined in article 32 of the italian constitution (section iv.2). furthermore, to be effective in emergencies such as a pandemic, the notion of the principle to which i refer should not entail the activation of precautionary measures typical of its strong version (which is exemplified in the well-known phrase "better safe than sorry"). in its strong version, in fact, the precautionary principle would be both paralysing and uneconomical, since it requires that any and all risks be prevented, even those that are least likely to occur or have been created artificially for 58 italian legal doctrine distinguishes between "administrative discretion" and "technical discretion" under the influence of ms giannini, il potere discrezionale della pubblica amministrazione political reasons (i am thinking here of george w. bush's preventative war doctrine) in order to justify stringent administrative measures issued by governments for purposes not necessarily related to the alleged risk. by contrast, balancing costs against benefits might provide the basis of a principled approach for making decisions in complex contexts, such as the italian legal system, where the current constitutional separation of powers can lead to an inadequate and incorrect assessment of risks and therefore to ineffective emergency management by the different levels of government. in any case, scientific evidence is an essential prerequisite for better regulation by acting on the precautionary principle. to be cost effective, governments should take precautionary administrative measures based on scientific knowledge and thus carefully assess the risks they intend to manage. taking the potential and limits of the precautionary principle from the perspective we have outlined above into account might have an impact on governments' ability to deal effectively with pandemic emergencies. this matters in the case of italy, where the current structure of the constitutional separation of powers between the government, regions and autonomous local authorities plays a crucial role in effectively managing the pandemic emergency. analysing the italian constitutional scenario can provide substantial guidance for understanding the legal structure of powers and competences of government, regions and local authorities and explain why assessing pandemic risk can be impacted by a given separation of powers. such an analysis can shed light on the administrative strategy implemented by the government in the pandemic and enable us to evaluate its effectiveness in managing covid-19 across the country. first of all, we should bear in mind that the italian constitution (from now on the constitution) does not explicitly refer to emergency power, except for a state of war (article 78). however, this power has traditionally been included in the typical powers that the constitution assigns to the government. in the constitutional system, the main rules governing the government's powers are established by articles 76 and 77. indeed, parliament does not have a monopoly on legislative power, and the government may also issue laws by two legal instruments that should be understood as extraordinary: legislative decree and decree-law. in particular, article 76 allows parliament to delegate its legislative power to the government, which in turn is given the power to issue legislative decrees. hence, the legislative decree is a form of delegated law-making power, where parliament may pass an enabling act entrusting the government to adopt one or more acts that have legal force. generally, the legislative decree is a legislative tool that is often deployed in all matters where a strong technical content is present. the second extraordinary instrument, the decree-law, is provided for by article 77. this is a form of law-making through emergency powers that the government may exercise in "exceptional cases of necessity and urgency" and under "its own responsibility". 59 the government can thus issuewithout an enabling act from parliament as required by the provisions of article 76administrative measures that have the force of ordinary laws. however, such administrative measures will lose their effects as of the date of issue if parliament does not transpose them into an ordinary law within sixty days of their publication. 60 with the major reform on "administrative federalism" enacted by law no. 3 of 18 october 2001, which amended title v of the constitution, italy rapidly devolved legislative and regulatory powers to the regions. 61 fundamentally, the constitutional amendment provided a new framework for the distribution of powers and competences between the national and local levels. 62 it established a new institutional structure by dividing legislative and administrative competences and powers across the different levels of government. 63 the amended articles of the constitution are the basis for the fundamental reform of administrative federalism. article 114 recognises local authorities (municipalities, provinces, metropolitan cities) and regions as autonomous entities of the state with their own statutes, powers and functions in accordance with the principles laid down in the constitution. article 117 establishes the role and legislative powers of the state and regions, indicating those matters for which the state has exclusive legislative power and those for which concurrent legislation of both the state and the regions is possible. the regions have exclusive power in all matters not expressly covered by state law. municipalities, provinces and metropolitan cities also have regulatory powers for the organisation and implementation of the functions attributed to them. specifically, article 117(3) establishes that the state and regions have concurrent power, and the regions have regulatory powers, in matters of public health. 64 in this connection, at the national level, parliament and government are called upon to: (1) adopt fundamental health principles by means of framework laws and guidelines; and (2) establish essential levels of healthcare. at the regional level, the regions implement: (1) general legislative and administrative activity; (2) the organisation of health facilities and services; and (3) the provision of healthcare based on specific local needs. article 118 provides for the subsidiarity principle, according to which all functions are exerted by municipalities, while the possibility remains to confer them to higher levels of government in order to guarantee the uniform implementation of spending functions across the country. article 120 guarantees national unity and the unitary nature of the constitutional system by providing for the government's substitution power. 65 according to article 120(2), the government can act for the regions and other local authorities if: (1) the latter fail to comply with international rules and treaties or eu legislation; (2) in the case of grave danger for public safety and security; or (3) whenever such action is necessary to preserve legal or economic unity and in particular to guarantee the basic level of benefits relating to civil and social entitlements, regardless of the geographical borders of local authorities. to this end, the law shall lay down the procedures to ensure that (4) subsidiary powers (ie the government's substitution power) are exercised in compliance with the principles of "subsidiarity" and "loyal cooperation". lastly, with regards to powers and competences in emergencies, it should be noted that in the italian legal system several authorities can introduce specific regulatory acts establishing administrative measures needed to deal with emergencies in accordance with the constitution. the power of ordinance has a particular role in managing emergencies, as it can be exercised in situations of necessity and urgency. in particular, the legal system provides for: (1) 66 as we will see, the structure of power just described highlights the problem of risk assessment among the institutional actors involved in the administrative decisionmaking process. though the current system of allocation of powers and competences to the regions and other local authorities might be an advantage in terms of correctly assessing and managing risk in their areas, at the national level, this system requires an effective sharing of powers and strategies between the centre and the periphery, where the measures of the regions and local authorities must be adopted in accordance with the measures advanced by the government, and vice versa. since correct risk assessment by an authority must take the characteristics of its area into accountdata on the epidemiological situation, for example, or on the average age of 65 the legal nature of the "state's substitution power" in italian legal doctrine has been extensively discussed. in particular, some scholars argue that art 120 provides a form of "administrative" substitution of the state over the regions, and that art 117(5) concerns "legislative" substitution. other scholars agree on the idea that art 120 provides the genus of substitution powers, whereas art 117(5) refers to one species of the genus, being a mere specification of art 120. however, the constitution seems clear on this point. as we have seen, the provisions of art 120 speak of the "government", while the provisions of art 117(5) speak of the "state". the population, and the capacity of the health system with regards especially to the availability of intensive care bedsit might be assumed that in the italian legal system's effective risk assessment could be facilitated by the specific competences established by the constitution for the regions and other local authorities in health matters. however, as i will argue, this is a theoretical advantage that works only if power is effectively shared between the different levels of government. in fact, in order to provide an adequate and correct risk assessment at the national level and take effective measures to contain and manage the pandemic, the current system needs powers and strategies to be shared between local authorities, regions and the government. sharing administrative powers at all levels of government is an important part of the task of states. 67 indeed, enhancing multi-level regulatory governance has become a priority in many eu states. for this reason, the eu supports sharing of administrative regulatory powers by encouraging better regulation at all levels of government, calling on the member states to improve coordination and avoid overlapping responsibilities among regulatory authorities. 68 in italy, until the adoption of constitutional law 3/2001, regulatory reform had been promoted, designed and implemented mainly at the national level. with the reform, as we have seen (section iii.3), such a centralised approach lost legal and political ground. at the same time, responsibilities for developing and implementing administrative regulation policies have not been explicitly allocated to either the state, the regions or the local authorities. hence, the responsibility for administrative regulation and regulatory reform lies with each of the levels of government in the matters where they exert legislative powers. in like manner, there is no overall competence at the central level to monitor and control regulatory reform programmes at the local level. accordingly, the new constitutional structure calls for effective sharing of administrative powers across the different levels of government. on the basis of the analysis carried out so far, i will now argue that the main problems of the italian administrative strategy for the covid-19 pandemic are due to the lack of effective sharing of administrative powers and, more specifically, to the failure to share regulatory powers across the different levels of government with the participation and cooperation of all institutional actors involved in the emergency decision-making process: the government, regions and local authorities. in particular, this problem 67 oecd, "the territorial impact of covid-19: managing the crisis across levels of government" (last updated 16 june 2020) <https://read.oecd-ilibrary.org/view/?ref=128_128287-5agkkojaaa&title=the-territorial-impact-of-covid-19managing-the-crisis-across-levels-of-government>. 68 the european committee of the regions (cor), "division of powers between the european union, the member states and regional and local authorities" (december 2012) <https://cor.europa.eu/en/engage/studies/documents/ study-division-powers/study-division-powers-en.pdf>. see also, oecd-puma, "managing across levels of government" (1997) <http://www.oecd.org/governance/budgeting/1902308.pdf>. has impacted the risk assessment of the various authorities called upon to manage the health emergency. as a result, the problem has impacted nationwide risk assessment and, consequently, the management of the emergency at the national level, leading to the adoption of inconsistent measures by the various institutional actors involved in the administrative decision-making process. in particular, i discuss this problem in italian policies from two key points of view: the government's administrative strategy for managing the virus's spread by means of the "incremental approach" (section iv.1.a) and the government's administrative strategy for implementing the nationwide pandemic health plan (section iv.1.b). in doing so, i shall take into account the considerations presented above concerning emergency risk regulation (section iii.1), the precautionary principle (section iii.2) and the rules governing powers in the constitutional scenario (section iii.3). one of italy's main problems in relation to the ineffective sharing of administrative powers for managing the pandemic is clearly displayed in what i will call the "incremental approach". 69 this approach is essentially based on the "progressive" application of emergency measures by the government in order to manage the "exponential" spread of the virus. the italian administrative strategy for the pandemic is fundamentally founded on such an approach. in fact, as we have seen (section ii), the government addressed the pandemic by enacting several decrees (dpcms) that "progressively increased" restrictions in lockdown areas (red zones), which were then extended from time to time until they finally applied to the entire country in the national lockdown. in my opinion, although the incremental approach may be a correct application of the principle of proportionality, given the government's proportionate use of emergency powers in dealing with the pandemic, it is the result of an ineffective sharing of administrative regulatory powers between the government, regions and local authorities. indeed, the progressive enforcement of lockdown areas, which from time to time increased the extent and severity of the emergency measures, demonstrates the difficulty of governing the spread of the virus in the red zones rather than the effective implementation of a proportionate administrative strategy. and this is mainly due to the lack of effective cooperation between the government and the regions in exercising their respective emergency powers. from a general point of view, the incremental approach reveals the limited effectiveness of the national and local measures and strategies for managing and containing the pandemic when those measures and strategies are not shared. i argue that even the stringent national lockdown 70 is essentially the result of the ineffective sharing and planning of administrative measures and strategies for managing the pandemic across the different levels of government and especially, in 69 on this approach, see g pisano, r sadum and m zanini, "lessons from italy's response to coronavirus" (harvard business law review, 27 march 2020) <https://hbr.org/2020/03/lessons-from-italys-response-to-coronavirus#comment-section>. 70 dpcm of 9 march 2020 <www.gazzettaufficiale.it/eli/gu/2020/03/09/62/sg/pdf>. this case, between the government and the regions. one can legitimately wonder whether the government can adopt an effective administrative strategy for managing the emergency without sharing and planning their measures with those of the regions. from this perspective, we can say that the government's incremental approach has proven ineffective in coping with the pandemic. i will now explain why in the following points. (1) regarding risk assessment for pandemics, the science 71 shows that the spread of covid-19 is rapid and exponential. consequently, the incremental approach does not work if it is not properly implemented with the effective participation of all institutional actors involved in managing the pandemic. scientific data 72 and statistics 73 on the spread of the virus were not predictive of what the situation would have been in the short and medium term. hence, a correct risk assessment of the virus's nationwide spread would have suggested that the administrative measures and, more generally, the strategies should have been shared among all players involved in the main strategy. very often, however, the government's strategy has not been in line with those of the regions, revealing an inadequate assessment of the risk that the virus would spread throughout the country, and thus the ineffective sharing of emergency powers. in fact, some important emergency measures implemented by the regions clearly contradict the government's main strategy. to take a few examples, 74 marche region ordinance no. 1 of 25 february 2020, issued pursuant to decree-law no. 6 of 2020, established measures that were more stringent than the government's, disregarding the latter's strategy. for this reason, the government contested the order before the court. 75 although a judgment in favour of the government was handed down and the challenged ordinance was suspended, the marche region legitimately adopted a new ordinance establishing emergency measures based on the same decree-law no. 6/2020, once again disregarding the government's strategy. another paradigmatic case is provided by a series of ordinances by the campania region aimed at imposing a more stringent lockdown at the local level than the lockdown established by the government at the national level. unlike the marche case, the ordinances of the campania region, although contested before the administrative judge, were not suspended, thus making the government's strategy ineffective. 76 consequently, in the absence of effective sharing and planning of the main strategy with the regions, the government had to 'increase' the emergency measures from time to time until finally imposing the stringent national lockdown. (2) in the absence of power sharing and strategies based on correct risk assessment at the national level, the government's incremental approach seems to have played a considerable role in people's behaviour, inducing them to make "bad choices". as the data show, 77 the government's incremental lockdown of municipalities, provinces and regions in northern italy induced masses of people to move towards the southern regions, spreading the virus to parts of italy that had not yet been affected. an emblematic case of this kind took place immediately after the dpcm of 8 march 2020 (see section ii) locked down lombardy and another fourteen provinces in northern italy, spurring thousands of people to flee to the south. such potential negative externalities, as well as other negative spill-overs or distortions, should have suggested that the government share its regulatory acts with those of the "target" regions (ie the northern regions), as well as with the other regions that could be indirectly jeopardised by the lockdown measures (ie the southern regions). alternatively, the government should have undertaken to coordinate the strategies of the regions and local authorities in order to enhance the adoption of effective control measures for people exiting the red zones and entering less affected regions. 78 more generally, in applying lockdown measures, the government should have shared and planned its strategy with the regions on the basis of a common risk assessment that took into account not only the regional territories, but the entire country. accordingly, the government should have established effective countermeasures together with all of the regions potentially involved in lockdown decisions to prevent the virus from spreading from high-risk to low-risk areas. an effective emergency response must be coordinated as a consistent system of actions taken simultaneously by the different actors involved in the decision-making process. (3) the government's incremental approach also revealed the problem of effectively sharing and planning precautionary measures (see section iii.2) across the different levels of government. the critical situation that arose because of the epidemic's severity called for effective testing of symptomatic and asymptomatic cases, as well as proactive tracing of potential positives across the country. on this point, these precautionary measures were supported by scientific data on the transmission of covid-19 by asymptomatic people. 79 the absence of a shared strategy for the adoption and implementation of precautionary measures proved particularly harmful in regions where the epidemic risk is higher. indeed, it is no coincidence that the outbreak spread so quickly in northern italy and especially in lombardy. in this region, the efficient public rail transport network 77 connecting urban areas, large numbers of commuters 80 and high levels of air pollution 81 are thought to have increased the incidence of infection. from this point of view, it is clear that risk assessment has been inadequate, and strategies have thus been ineffectively shared between lombardy and the government. the government should have promoted an effective precautionary strategy for health checks by sharing it with the strategies of the regions and ensuring efficient nationwide implementation on the basis of a global risk assessment. conversely, data on infections and deaths reveal that strategies were not shared effectively with the hardest-hit regions. (4) the incremental approach shows that most of the problems of administrative strategy are also motivated by political issues between parties governing regions and belonging to the coalition now governing the country. from the time when the virus began to spread, the multi-level management of the emergency has triggered competition and institutional division between the government and regions 82 due to policymakers' political differences. the management of the pandemic, in fact, has thrown light on the deep political division between the government, led by the coalition of left-wing parties such as the democratic party and the five star movement, and the hardest-hit regions -lombardy and venetoled by traditionally right-wing populist parties such as the league and brothers of italy. in particular, many of the administrative measures taken by the regions were in contrast with the government's strategy, largely for political reasons. from this standpoint, it can be seen that there has been an "institutional clash" between the regional governments and the national government on the political and administrative actions to be taken to effectively manage the emergency. it is no coincidence that the government's minister of health is a member of one of the opposition parties in lombardy and veneto, and that the governors of lombardy and veneto belong to the coalition opposing the government. to give a few specific examples, a bitter dispute has occurred between prime minister giuseppe conte and attilio fontana, governor of lombardy and member of the rightwing populist party league, with regards to the ineffective management of the emergency in the region most affected by the virus. similarly, as we have seen, luca ceriscioli, governor of the marche region and member of the centre-left party in the majority coalition, opposed the government's decision to declare a state of emergency only in the northern regions. 83 in essence, these strong political divisions have impacted effective power sharing among the different levels of government, causing problems for the government's incremental administrative strategy. (5) the incremental approach also shows the important role that scientific competence plays in emergency management. 84 in this regard, one of the main goals of scientific expertise is to inform and legitimise governments' decisions, especially in high-uncertainty situations relating to public health. during the covid-19 outbreak, scientific and technical experts have assisted central and regional governments by contributing to the content of decisions and, more generally, of administrative emergency management strategies. as scientific evidence is the basis for sound political choices, scientific and technical experts have become part of the rationale of governments' decisions and have been useful in reassuring the public with concrete solutions. 85 indeed, in the immediacy of a pandemic, as is logical to assume, the demand for scientific expertise increases as governments search for certainty in understanding problems and choosing effective measures for managing the emergency. especially in the most delicate phases of an emergency, scientific expertise is useful in informing, legitimising and justifying government evaluations and responses to problems, even as political and administrative considerations continue to govern such choices. the result is an increased reliance on scientific expertise and politicisation of scientific and technical information. 86 by invoking scientific expertise, policymakers create the need for what is perceived as evidence-based policymaking, which suggests to the public that political and administrative decisions are based on reasoned and informed judgments 87 aimed at ensuring the public interest and guaranteeing individual rights. however, a major problem is that scientific expertise might obscure the accountability of decisions. as scientific and technical experts serve to inform and legitimise political and administrative decisions, they may also obscure responsibility for policy responses and outcomes. 88 scientific expertise helps to establish the severity of a pandemic in a population, to understand the epidemiological trend over time and to evaluate the effects of political and administrative measures, from mitigation to suppression. nonetheless, undertaking policy actions is the responsibility of government leaders. as scientific expertise becomes more prominent in the policy process, who is accountable for policymaking becomes more obscure. 89 to work better in emergencies, scientific expertise also requires effective sharing of administrative powers based on accurate risk assessment, as i will now explain. in italy, since the beginning of the virus's spread, the various institutional actors, especially the government and the regions, have established their own scientific task forces to support administrative measures and strategies in managing the pandemic. the main problem is that, by doing so, risk assessment at the national level is fragmented. conflicts can also arise between institutional actors involved in the 84 decision-making process. in this scenario, indeed, the government and the regions have adopted administrative decisions and strategies based on the risk assessments provided by their own central and regional task forces. it should be noted that this situation, like others discussed here, derives from the current constitutional architecture of separation of powers where the decision-making process is assigned to the different levels of government. however, managing a pandemic requires a comprehensive risk assessment. italian policies matter, as they show how, at the beginning of the pandemic, some regions' task forces underestimated covid-19, while other regions gave it a certain importance. this behaviour on the part of policymakers was not led by the government, which, on the contrary, criticised the regional governments' solutions. the outcome, as i claimed for the incremental approach, is that the government's measures and strategies are not shared with those of the regions and vice versa, and policymakers' accountability is obscured by invoking scientific expertise for pandemic management decisions. b. implementing the national pandemic health plan there is no doubt that a pandemic affects the whole of society. no single organisation can effectively prepare for a pandemic in isolation, and uncoordinated preparedness of interdependent public organizations will reduce the ability of the health sector to respond. 90 a comprehensive, shared, coordinated, whole-of-government approach to pandemic preparedness is required. 91 the government's strategy, as we have seen in the incremental approach to dealing with the emergency, proved particularly ineffective due to the failure to share administrative powers with the other institutional actors involved in the pandemic decision-making process, particularly the regions. but this, as we shall see now, was not the only weak point. i will argue here that another of the major problems was the lack of effective implementation of the national pandemic health plan. in particular, we will see how and why the ineffective implementation of the plan by the government, regions and local authorities posed serious problems for containing the spread of the virus and, more specifically, for avoiding the collapse of the public healthcare system. on this point, one of the main problems for public health posed by the novel coronavirus is its ability to spread with exceptional ease and speed, 92 threatening to overwhelm the healthcare system. in particular, what should be especially clear from the data is the critical situation of the intensive care system in italy, 93 which has been severely weakened by the pandemic. 94 intensive care system at the national level, cooperating with the regions and local authorities to ensure that critical care bed availability is efficiently managed. in this case, effective actions shared among all institutional actors and based on an adequate and accurate risk assessment at the national level would avoid saturating the intensive care system in the medium and long term, while the government should be able to increase capacity in the short term. yet, the data on the intensive care system show that the situation was inefficiently managed in the regions hardest hit by covid-19, especially in lombardy, which paid a high price at the local level for the ineffective implementation of the pandemic health plan at the national level. more generally, it should be emphasised that this point also demonstrates the importance of sharing administrative powers between government, regions and local authorities to implement the pandemic management plan effectively throughout the country. in this connection, many elements based on scientific and epidemiological data demonstrate that the covid-19 pandemic called for effective cooperation and coordination across all levels of government. in addition, it must be borne in mind that fighting a pandemic hinges on many factors, most of which are time consuming or in any case cannot be accomplished quickly. preparing a candidate vaccine, for example, takes a long time in terms of both preclinical and clinical development. likewise, developing and testing an effective drug involves complex multi-stage clinical trials. such considerations might be sufficient on their own to justify taking effective actions to mitigate the pandemic emergency's impact on the public healthcare system. in this phase, as we have seen, emergency risk regulation requires that regulatory action be taken in the immediacy of an emergency in order to mitigate its impact (section iii.1). to avoid the collapse of the public health system, the government should thus have contained the spread of the virus by effectively implementing the nationwide pandemic management plan with the participation of all institutional actors. the who has recognised the importance of sharing administrative powers through the participation and cooperation of the various institutional actors involved in the strategy against pandemics. in this regard, the who has drawn up specific guidelines 95 for implementing a pandemic influenza preparedness plan 96 that states should apply in order to manage the spread of the virus throughout their territories. in particular, the who's guidelines encourage states to develop efficient plans, based on national risk assessments, with the effective participation of institutional actors at all levels of government. in italy, the most serious problem is that the government, although it had already developed its own national plan, 97 foster its effective adoption by the regions and local authorities, disregarding a crucial point of the who's guidelines. consequently, the failure to implement the national pandemic plan, as we have seen, created the conditions for the collapse of the public health system, with the overcrowding of intensive care units and the consequent loss of life. *** in conclusion, the italian policies regarding the covid-19 outbreak can demonstrate the importance of: (1) rethinking the incremental approach; and (2) implementing a national health plan for pandemics by sharing powers, and more specifically administrative regulatory powers for emergencies based on an adequate and accurate risk assessment at the national level, among the different levels of government with the participation, cooperation and coordination of all institutional actors involved in the pandemic decision-making process. as we have seen, sharing administrative powers at the different levels of government plays a particularly important role in managing emergencies in the constitutional scenario, where competences are distributed between government, regions and local authorities, and several institutional actors are allowed to adopt regulatory acts (see section iii.3). the major changes that the constitutional amendments have brought to policymaking in the italian legal system require that constant support be provided to the regions and local authorities, especially in emergencies. despite significant decentralisation, the government still has a fundamental role to play in sharing and coordinating administrative powers at the different levels of government and in ensuring loyal cooperation among all of the institutional actors involved in emergency decisionmaking processes. indeed, the government is tasked with promoting and coordinating "action with the regions" (article 5 of law 400/1988), as well as with advancing cooperation "between the state, regions and local authorities" (article 4 of legislative decree 303/1999). 99 similarly, the government must promote "the necessary actions for the development of relations between the state, regions and local authorities" and ensure the "consistent and coordinated exercise of the powers and remedies provided for cases of inaction and negligence" (article 4 of legislative decree 303/1999). looking at the constitutional perspective, some possible solutions might be proposed. (1) in the italian constitutional scenario, although concurrent power to legislate on matters of public health is vested in the state (ie the government) and the regions pursuant to article 117(3), the state (ie the government and the regions together), on the basis of the principle established by article 32(1), "safeguards health as a fundamental right of the individual and as a collective interest". i argue, more specifically, that safeguarding health is a task of the state based on the fundamental principle of the constitution referred to in article 3 (2) , where the duty of the state is to "remove those obstacles of an economic or social nature" that, by constraining 99 legislative decree 303/1999 <http://www.parlamento.it/parlam/leggi/deleghe/99303dl.htm>. the "freedom and equality of citizens", impede the "full development of the human person and the effective participation of all workers in the political, economic, and social organisation of the country". thus, i believe that under the joint interpretation of article 3 (2) and article 32 of the constitution, as well as the principle of loyal cooperation, the government and the regions must act by sharing administrative powers (and strategies) among them in order to protect the fundamental right to health. in so doing, the government can play an essential role in promoting institutional balance and cooperation between the national and local levels, maximising loyal cooperation and implementing vertical and horizontal subsidiarity. (2) sharing administrative powers for emergencies can also be encouraged and enhanced through the effective implementation of constitutional tools, such as the system of conferences based on the principle of loyal cooperation. (a) the conference on the relationships between government, the regions and the self-governing provinces is the key legal tool for multi-level political negotiation and collaboration. it serves in an advisory, normative and planning capacity and acts as a platform facilitating power sharing. (b) the conference on the relationships between government and the municipalities coordinates relations between the government and local authorities through studies, information and discussion of issues affecting local authorities. (c) the permanent conference on the relationships between government, the regions and the municipalities deals with areas of shared competence. 100 (3) in order to "safeguard health as a fundamental right of the individual and as a collective interest", article 120(2) of the constitution could be applied whenever it is necessary to guarantee "the national unity and the unitary nature of the constitutional system". i claim that this provision, which establishes the government's administrative substitution power, provides for the centralisation of administrative powers in specific cases contemplated by the constitution. in this sense, article 120(2) lays down that the government can act for the regions and/or local authorities in cases of "grave danger for public safety and security". in the light of this definition, the government's substitution for the regions and/or local authorities might be invoked as a result of the "grave danger for public safety", as well as in order to preserve "economic unity" and guarantee the "basic level of benefits relating to civil and social entitlements". in my view, however, the government should exercise its power of substitution as an extrema ratio whenever effective sharing among all of the institutional actors has not been implemented. article 120(2) is clear in this regard, requiring that the substitution power be exercised in compliance with the principles of "subsidiarity" and "loyal cooperation". 100 italy's national pandemic plan was adopted through the permanent conference on the relationships between central government, the regions, municipalities and other local authorities <http://www.regioni.it/sanita/2006/02/ 14/accordo-stato-regioni-9-2-06-su-pandemia-influenzale-97179/>. administrative powers"and more specifically the administrative regulatory powers for emergenciesbased on an adequate and accurate risk assessment, across the different levels of government with the participation, cooperation and coordination of all institutional actors involved in the emergency decision-making process: the government, regions and local authorities. fundamentally, i emphasised that the italian case reveals the importance of sharing administrative powers from two main points of view. first, i argued that the "incremental approach" to dealing with the emergency, although based on the proportionate use of powers, is largely ineffective or even harmful in the absence of cooperation among all actorsthe regions and local authoritiesinvolved in the main strategy implemented by the government (section iv.1.a) . second, i discussed the importance of cooperation between the government, regions and local authorities for the effective and efficient implementation of a nationwide pandemic health plan (section iv.1.b). i suggested that these points be viewed from a constitutional perspective in order to propose some possible solutions. from this perspective, the problems of effective sharing of administrative powers across the different levels of government could be resolved by systematically interpreting the constitution and implementing specific constitutional tools provided by the legal system (section iv.2). in conclusion, more generally, i argue thatand this is the main thrust of the articleadministrative powers should be shared across the different levels of government based on an adequate and accurate risk assessment with the participation and cooperation of all of the institutional actors involved in the emergency decision-making process in order to safeguard the fundamental rights enshrined in the constitution as well as in eu and international law. in pandemics, this aim must be achieved not only to guarantee the right to health, but also to safeguard all of the rights that might be jeopardised by the exercise of administrative powers and, more specifically, the exercise of emergency powers in dealing with the pandemic. the strong measure of "lockdown", for example, should be the extrema ratio of administrative powers because it suspends the rule of law and jeopardises rights. indeed, as i have claimed in analysing the italian policies, sharing powers with effective cooperation between government, regions and local authorities in managing the pandemic would optimise the adoption of nationwide virus containment measures, avoiding or at least delaying the application of stringent emergency measures such as the lockdown of municipalities, provinces, regions or even the entire country. taking into consideration the correct application of emergency risk regulation (section iii.1) and the precautionary principle (section iii.2), although lockdowns aim to contain specific areas that are most affected by the virus, they must be proportional to the risk that they intend to curtail. when such measures are adopted to protect the right to health, as is the case in a pandemic, this right must be balanced with other rights. yet, if administrative powers are not shared effectively across the different levels of government, the balancing principle might be disregarded by jeopardising one or more rights without legitimate justification (eg the right to freedom of movement enshrined in article 16 of the constitution). this is the problem that the italian policies bring to light: a problem that i believe that the government must take into account in the near future as it strives to manage covid-19 and other similar pandemics. perspectives on the precautionary principle les avatars du principe de precaution en droit public le principe de précaution en droit communautaire: stratégie de gestion des risques ou risque d'atteinte au marché intérieur? the legal origins of the precautionary principle are to be found in the vorsorgeprinzip established by german environmental legislation in the mid-1970s; see there is a close relationship between the two principles that has led some to argue that they may be used "interchangeably". however, other authors contend that the prevention principle applies in situations where the relevant risk is "quantifiable" or "known" and there is a certainty that damage will occur. in this sense, see, respectively, wt douma principio di prevenzione e novità normative in materia di rifiuti dal pericolo al rischio: l'anticipazione dell'intervento pubblico" [from danger to risk: the anticipation of public intervention] (2010) 2 diritto amministravio 355. 42 ecj case t-13/99 pfizer animal health sa v council in the same sense, see also case c-157/96 national farmers' union case c-180/96 united kingdom v. commission [1998], ecr i-2729 case c-236/01 monsanto agricoltura italia art 77 of the italian constitution <https italian constitutional justice in global context il sistema amministrativo dopo la riforma del titolo v della costituzione amministrazione e costituzione sussidiarietà e diritto alla salute substantial undocumented infection facilitates the rapid dissemination of novel coronavirus (sars-cov2) a novel coronavirus emerging in china, key questions for impact assessment mathematical biosciences and engineering 3062-87. for daily reports around the world, cf. who of the marche regional administrative court suspended the marche region ordinance issued on 25 the campania regional administrative court in particular, i maintain that this power would have been useful as a remedy for inaction or delay on the part of the regions and local authorities in implementing the national pandemic health plan or adopting emergency measures. in such cases, substitution powers may be granted to the central level of government (the appropriate ministry or the council of ministers), which intervenes instead of the local level (the regions and/or local authorities).the same considerations on the government's administrative substitution power can be applied to the following solutions as "ex post remedies" for the failure to share administrative powers effectively across the different levels of government.(4) the government has extraordinary administrative power to annul illegitimate measures (eg ordinances) issued by local authorities in order to "safeguard the unity of the national legal system" (article 138 of law 267/2000 101 and article 2 of law 400/1988). 102 the power, generally applied to measures issued by the municipalities, can be extended to regional measures on the basis of article 120(2) of the constitution. 103 (5) the government has the right of action to challenge illegitimate measures issued by the regions and other local authorities before the court, in accordance with the constitutional provisions governing judicial review in the italian administrative justice system (articles 24, 101, 103, 111, 113 and 125 of the constitution). in this article, starting from the main regulatory acts and considering scientific knowledge and epidemiological data on covid-19, i have analysed the administrative measures and strategies for fighting the pandemic implemented by the government in the immediacy of the emergency.specifically, i carried out this analysis to verify this strategy's effectiveness at managing the pandemic throughout the country.in analysing the administrative strategy, i emphasised the role that italy's current system of constitutional separation of powers plays in emergency management and how this system can impact health risk assessment.to do so, i first illustrated the risk management system in italian and eu law and discussed some key legal issues that are useful for clarifying the main points of the matter and for understanding the weaknesses of the administrative strategy with a view to proposing solutions that the government might take into account in adopting its strategy.in particular, i briefly examined the notion and features of emergency risk regulation (section iii.1), the potential and limits of the precautionary principle (section iii.2) and the rules governing powers and competences in the italian constitutional scenario (section iii.3).to summarise the main points of this analysis, i stressed that the italian policies for managing the pandemic demonstrate the importance of effective "sharing of key: cord-006818-2lclcf1x authors: tibary, a.; rodriguez, j.; sandoval, s. title: reproductive emergencies in camelids date: 2008-06-02 journal: theriogenology doi: 10.1016/j.theriogenology.2008.04.024 sha: doc_id: 6818 cord_uid: 2lclcf1x emergencies in theriogenology practice go beyond just saving the life of the patient, but also preserving its reproductive abilities. camelid emergency medicine is a relatively new field. this paper discusses the most common reproductive emergencies, their diagnosis, treatment, and prognosis in male and female camelids. the conclusions drawn are based primarily on clinical observations by the authors over the last 25 years. special consideration is given to peculiarities of the species, particularly in the choice of obstetrical manipulations and therapies. in theriogenology practice, emergencies are defined not only in terms of concerns for the welfare of the patient, but also for its future reproductive life. the challenge often faced with reproductive emergencies is how to preserve the life of the patient and maximize the chance to maintain reproductive ability. in camelids, this is even more important, as assisted reproductive technologies have either not yet been perfected (semen preservation, in vitro embryo production, nuclear transfer) or are not allowed (embryo transfer) by some breed registries. in the case of pregnant females, which constitute the majority of reproductive emergencies, the life and welfare of the neonate must also be considered. the objective of the present paper is to review the most common reproductive emergencies in male, female, and neonatal camelids. this review draws primarily on the clinical experience of the authors, as there are very limited controlled studies regarding clinical reproduction and emergency care in camelids. although many disease processes that present as emergencies may have some severe repercussions on the reproductive process in the male, our review will be limited to diseases and accidents with sudden onset that are directly linked to the urogenital system. reproductive emergencies in the male camelid are primarily due to sudden onset of visible abnormalities in the external genitalia. these abnormalities can be summarized as acute scrotal or preputial swelling, preputial prolapse or paraphymosis, and post-surgical emergencies [1] [2] [3] . in camels, preputial swelling is also a primary clinical sign of acute trypanosomiasis, a disease with high morbidity and mortality in many countries where camel breeding is important [3] . www.theriojournal.com 2.1. general approach to examination of the male for reproductive emergency as with any other emergency, accurate body weight, body condition score, physical examination, degree of dehydration, baseline complete blood count (cbc), blood biochemistry, and urinalysis should be part of the initial evaluation. immediate placement of an intravenous catheter is indicated in severely compromised or recumbent animals. ultrasonography of the urogenital organs should also be conducted. testicular thermoregulation is very important for normal spermatogenesis in camelids. therefore, compromised testicular thermoregulation in these animals should considered serious, as the effect on spermatogenesis can be long lasting or permanent. acute scrotal swelling is generally due to heat stress, trauma, or a local or systemic infectious process. testicular torsion and scrotal hernia are commonly considered as differential diagnoses in other large animal species, but have never been encountered in camelids in our practice [2] . scrotal and preputial edema and development of severe hydrocele are features of heat stress in the male llama and alpaca [2] . this syndrome is relatively common in the usa. factors predisposing to heat stress include prolonged high ambient temperature and humidity, inadequate shade, long fleece, dark coat color, and obesity. the risk for heat stress is exacerbated by stresses such as transportation, exercise, fighting, and breeding [4, 5] . hyperthermia results from impaired evaporative cooling, particularly under hot and humid conditions [5] . scrotal edema may be the first clinical sign in the male. the exact pathophysiology of the scrotal and ventral abdominal edema is not well understood. contributing factors may include inability of the pampiniform plexus and testicular artery to cope with the fluid turnover, or vascular thermal injury resulting in impaired wall permeability and extravasation of intravascular proteins, electrolytes, and fluid into the interstitium. many cases may resolve spontaneously, but leave the male infertile for various intervals, usually lasting from 2 months to years [2] . spermatogenesis (sperm production and semen quality) was severely impaired in llamas housed at an ambient temperature of 29 8c for 4 weeks [6] . these temperatures, relatively common in summer months in many countries outside the native range of south american camelids, can result in infertility due to decreased sperm numbers, decreased motility, and increased abnormalities. the heat index (ambient temperature â humidity) would cause even more severe changes in hot and humid summers [6] . in advanced cases, other clinical signs appear and include hyperthermia, increased salivation, anorexia, depression, ataxia, muscular weakness, dehydration, ketosis/hepatic lipidosis, and dyspnea/hyperpnea [4, 5] . these animals generally display an inflammatory or stress leukogram. anemia may be secondary to hemolysis. serum biochemical abnormalities may include hypophosphatemia, hypocalcaemia, hypomagnesaemia, hyponatremia, hypochloridemia, hypo-or hyperkalemia, hyperglycemia, and elevated serum ast and cpk concentrations. serum glucose concentration >300 mg/dl has been associated with a poor prognosis. severe electrolyte imbalances and damage to the thermoregulatory center in the hypothalamus will be the end point of the disease progress in nontreated animals, leading to multi-organ damage or failure and increased mortality [4, 5] . stabilization of the heat-stressed animal should include urgent cooling of the core body temperature to the normal range (shearing, spraying the ventral abdomen with cold water, fan), and fluid therapy to rehydrate the animal and correct metabolic abnormalities. intravenous isotonic sodium bicarbonate solution may be required to treat metabolic acidosis. maintenance fluid rates are 30-40 and 80-120 ml/kg/day in adults and crias, respectively. pulmonary edema is a serious risk if fluids are administered too fast (>20 ml/ kg/h). palliative therapies against other complications should include nasal oxygen insufflation in hypoxemic patients, nonsteroidal anti-inflammatory drugs (nsaids; e.g. flunixin meglumine), antioxidants (vitamin e and selenium), and broad-spectrum antibiotics. steroids such as dexamethasone may be indicated in advanced cases, but should not be used in females in the second half of pregnancy. therapeutic diuresis with furosemide is indicated in animals with respiratory distress due to pulmonary edema. heat stress is best prevented by timely shearing, adequate hydration (clean, cool water) and providing shade and cooling mechanisms such as sprinklers, a pond, or wading pool. prevention of obesity and reduction of stresses of long transportation, handling and breeding during the hottest part of the day also reduce the risk for heat stress. the primary indicator of heat stress risk is not only the ambient temperature, but also the humidity. the heat stress index (hsi), expressed as the ambient temperature (8f) + humidity (%), is considered too high when it reaches or surpasses 160 (e.g. combination of 100 8f and 60% humidity). traumatic injuries to the scrotal area are relatively common in the male camelid and are usually inflicted by other males; they occur when new, mature males are added to a paddock, particularly when competing for breeding. severe traumatic fighting injuries are more common in camels during the rutting season [7, 8] . scrotal traumatic injuries are relatively rare in wild camelids, probably because of their strict social organization. traumatic injuries are often due to bites and can range from a superficial scrotal laceration to severe testicular rupture and hemorrhage. testicular hemorrhage may occur without external lacerations, but requires ultrasonographic evaluation of scrotal contents [7] . treatment protocols should focus on reducing local swelling, preventing infectious complications, and providing a tetanus toxoid booster. unilateral castration is the treatment method of choice for severe unilateral testicular trauma involving the tunica vaginalis and testis [8] . testicular and epididymal inflammation may present as an emergency in the male camelid. the most common complaint is a sudden onset of lameness or reluctance to breed and visible swelling of the scrotum. various infectious agents have been reported in cases of orchitis that are spread by hematogenous routes, such as brucella abortus, brucella meletensis and streptococcus equi zooepidemicus, or the agent may ascend from scrotal wounds [9, 10] . treatment with systemic antimicrobials is often unrewarding. therefore, for unilateral orchitis, unilateral orchidectomy is the best option for the welfare of the male and salvage of reproductive ability [8, 9] . 2.6. acute penile/preputial swelling acute penile or preputial swelling may be due to complications from urolithiasis or traumatic injuries. the etiology of urinary calculi in the camelid is not well understood, but is suggested to be similar to that in other domestic ruminants [11] [12] [13] [14] [15] [16] [17] . early clinical signs of urethral obstruction often go undetected. some males may show increased straining to defecate, odontoprisis, inappetence and ileus, followed by anorexia, frequent unsuccessful attempts at micturition or dribbling blood tinged urine, and signs of abdominal discomfort [13] [14] [15] [16] . complications of urethral obstruction include urethral or urinary bladder rupture. this may happen within 2 days of the first clinical signs. in emergency cases, the animal presents with anorexia, inability to pass urine, and signs of depression. physical examination often reveals tachycardia, tachypnea, and elevated rectal temperature. complete blood count may reveal an elevated white cell count and neutrophilia with a left shift, increases in fibrinogen, increased creatinine kinase and aspartate aminotransferase activity, hyperglycemia, hypercreatininemia and increased urea nitrogen. serum electrolyte abnormalities included hyponatraemia, hypochloraemia, and hyperkalaemia. fluid obtained by abdominocentesis or from the preputial swelling has increased creatinine concentration [12] [13] [14] [15] [16] . increased serum urea nitrogen and creatinine concentrations suggest uroperitoneum [16] . transcutaneous ultrasonography of the ventral abdomen may enable visualization of subcutaneous free fluid and tissue edema in the case of urethral rupture and a large volume of free fluid in the abdominal cavity in the case of urinary bladder rupture. with the latter, it may not be possible to visualize the urinary bladder. transrectal ultrasonography may reveal dilation of the pelvic urethra if the bladder is intact. the prognosis is grave if there is hydroureter and hydronephrosis [16] . uroliths are often located in the distal penile urethra, approximately 7-12 cm from the penile orifice, but are occasionally immediately proximal to the sigmoid flexure. camelids, like domestic ruminants, have a urethral recess at the ischial arch, making catheterization of the urinary bladder exceedingly difficult. management techniques for obstructive urolithiais is similar to those reported in ruminants and include repair of the ruptured urinary bladder and relief of the obstruction via retrograde flushing and urethrotomy. however, these techniques do not salvage the reproductive career of the animal. flushing, followed by tube cystotomy, may be the only option to try to salvage the reproductive life of the animal [16] . postsurgical management should include multiple therapies, including antimicrobial (procaine penicillin, 30,000 iu/kg im, twice daily; and gentamicin sulphate, 6.6 mg/kg iv, once daily), anti-inflammatory (flunixin meglumine, 1 mg/kg iv, twice daily) and intravenous fluids. prognosis for life is fair, but prognosis for return to breeding is usually guarded [16] . preputial lacerations are relatively common in breeding males. they are usually a consequence of masturbation (breeding the ground or objects) or complications from foreign objects within the prepuce. hair-ring lacerations of the penis are common in llamas and suri alpacas. males may present because the owner has observed an abnormal protrusion of the prepuce, or discomfort during urination or mating. however, bloody or purulent discharge may be the only clinical sign. preputial and penile lacerations can quickly become complicated and jeopardize the reproductive life of the male due to development of severe inflammation and adhesions. injured males may continue to attempt breeding, further exacerbating the lesions [7] . evaluation of penile and preputial injuries is best performed under heavy sedation or general anesthesia. the penis should be completely exteriorized and inspected for lesions. early management of preputial and penile injuries should center on providing adequate protection of the traumatized tissue and prevention of infection and complication with urine scalding. the initial treatment is to replace viable prolapsed preputial mucosa and maintain it in place with a purse string suture. daily cleaning of the sheath with saline, and application of local anti-inflammatory and antimicrobial ointment (petercillin) for 3-5 days will reduce the chance of further complications. sutures may be removed after 7-10 days. excessive preputial prolapse with slight necrosis requires circumferential resection and anastomosis of the prepuce. prognosis for return to normal breeding activity is poor if adhesions or abscesses develop at the base of the prepuce [2, 18] . the most common post-surgical complication in the male camelid is post-castration hemorrhage, often secondary to inadequate time to insure hemostasis of the testicular cord. management of these conditions is not different from other species and includes placing the male in a calm environment and packing the bursa for 6-24 h. several commercial hemostatic agents are available and may be helpful [19] . exteriorization of the soft palate (dulla) is a characteristic rutting behavior in the dromedary camel [7] . furthermore, permanent exteriorization of the soft palate during the rut season is a common in the dromedary. this usually starts with an impaction of the diverticulum with food or a foreign body [20, 21] . part of the impacted soft palate becomes trapped under the molars and is traumatized during mastication. traumatic lesions of the soft palate range in severity from superficial cuts and bruises to severe lacerations accompanied by hemorrhage; these lesions are rapidly complicated by infection and development of severe inflammation and edema. formation of large abscesses is not uncommon. in most cases, the inflamed organ is permanently hanging from the side of the mouth and becomes progressively necrotic [22] [23] [24] . in a few cases, the soft palate is swollen, but not exteriorized, and blocks air exchange, which may lead to asphyxiation. if the condition is not treated, the animals become emaciated due to dysphagia and impairment of mastication and deglutition. management of these cases requires surgical ablation of the soft palate [20] . surgical excision of the soft palate can be performed under heavy sedation and a local block. large vessels are ligated with resorbable suture material. laser ablation is the best approach. postsurgical management includes administration of nsaids, antimicrobials, and tetanus prophylaxis. animals should be on soft feed for at least 3-4 days after surgery. urethral rupture and subcutaneous infiltration of urine is relatively common in draught camels and is due to a tight strap. advanced stages are managed surgically by complete urethrostomy. animals present with varying degrees of ventral swelling and prolapse of mucocutaneous junction of the penis and prepuce. tissue necrosis is common, and may include the penis due to pressure ischemia. surgical debridement [25] , phalectomy, or both, may be required [26] . reproductive emergencies in female camelidae can be divided into emergencies occurring in the nonpregnant female, severe pregnancy complications, obstetrical emergencies, and postpartum emergencies. emergencies requiring intervention during parturition and the immediate postpartum phase must concurrently take into account emergencies pertaining to the neonate. the most common reproductive emergencies in nonpregnant females are traumatic injuries during breeding or iatrogenic injuries during reproductive examinations. although rare, breeding trauma may occur during an unsupervised paddock mating. in camels, traumatic injuries are not always restricted to the reproductive tract, and include bite wounds and fractures of the pelvis and/or dislocations. these traumatic injuries are seen in multiple-sire breeding systems. in south american camelids, breeding trauma may occur by heavy llama males trying to breed alpacas. discussion of these types of traumatic injuries are beyond the scope of this paper, but should be considered in downer syndrome in females with a history of recent (<24 h) mating. iatrogenic traumatic injuries are by far the most common emergency in camelid practice; they include perforation of the rectum, colon, vagina, or uterus. anal sphincter bleeding due to excessive stretching and rectal prolapse can occur secondary to transrectal palpation, particularly when there is already a predisposing factor for excessive straining (e.g. pelvic mass, urinary bladder disease). however, these are not life threatening and can be managed successfully with sedation, a caudal epidural, and protection of the prolapsed tissue. rectal and colonic injuries have been reported in llamas and alpacas, and are a common reason for malpractice suits. rectal or colonic injuries may happen during breeding, but they more commonly are due to excessive manipulation during transrectal palpation or ultrasonography [27, 28] . the examiner will usually recognize that an injury has occurred when palpating llamas and camels. however, in alpacas, when the ultrasound transducer is mounted on an extension for reproductive examination, the practitioner may not detect evidence of perforation until it is too late. the amount of blood retrieved with the palpating hand is variable; it is the sensation of rupture or tear that is most indicative of the seriousness of the injury. since the distance between the anus and the peritoneal reflection is very short (2-3 cm in alpacas, 4 cm in llamas, and 6-10 cm in camel), complete rectal tears in camelids are rapidly complicated by peritonitis. often the only clinical sign is reluctance to stand, lethargy and progressive dehydration a few hours after a reproductive examination. severe toxic shock and death follows within 8-24 h if no medical action is taken. all suspected rectal or colonic injuries should be immediately referred to a surgical facility. the animal should be sedated and started on intravenous antimicrobial and anti-inflammatory therapy for transport. further evaluation at the referral facility includes cbc, blood chemistry, transabdominal ultrasonography, and abdominocentesis. animals with evidence of peritonitis should be immediately prepared for surgical correction by celiotomy or celiotomy and pubic symphysiotomy to allow peritoneal lavage. stable patients without alarming changes in their blood and peritoneal fluid characteristics may be further evaluated under epidural anesthesia to decide if a transanal repair is possible. evaluation of the injury can be performed under general anesthesia. the anal sphincter is dilated using stay sutures on the mucocutaneous junction. gentle evacuation of the rectal cavity may be attempted by low-power vacuum aspiration until the lesions can be visualized. use of a flexible videoendoscope can facilitate this evaluation. in llamas and camels, lacerations due to transrectal palpation are usually located in the ventral aspect of the rectum, 5-20 cm anterior to the anus. however, in alpacas, particularly when the perforation has occurred with a transducer mounted on an extension, the lesion can be dorsal. also, in these cases, the presence of more than one perforation is possible, perhaps due to faulty alignment between the extremity of the transducer and the extension rod. transanal repair is successful if the laceration is not deep [28] . celiotomy with pubic symphysiotomy is the only option for caudal injuries and in particular for alpacas. successful repair of rectal and colonic injuries by celiotomy or celiotomy/pubic symphysiotomy has been reported in a few llamas [28] . preventive measures for colonic rectal injuries include use of caution when choosing the candidate for transrectal palpation, ample lubrication, and cautious use of an extension rod, particularly in maiden or agitated females. sedation of the female or relaxation of the rectum and rectal sphincter may be obtained by epidural anesthesia or instillation of 2% lidocaine into the rectal cavity before examination. most cases of uterine perforations seen in our practice are iatrogenic, due to aggressive placement of foley catheters, infusion pipettes, and biopsy forceps. these are more common in alpacas than in llamas and camels. they become an emergency if a major blood vessel is damaged, or if an irritating substance (e.g. iodine) is infused into the abdominal cavity. females with these injuries may present with colicky signs consistent with peritonitis or hemoperitoneum. anemia is a feature if there is sufficient blood loss; for example, one animal had a pcv of 10% following an endometrial biopsy. suspicion is based on a history of recent gynecological examination and the feel of a ''pop'' during manipulation. the patient should be worked up as for any case of colic of abdominal origin [12] . supportive therapy includes nsaid's and antimicrobials. blood transfusion and surgical intervention may be indicated if the pcv is <8%. vaginal perforation with severe bleeding may be controlled by vaginal compression packs. any clinical syndrome occurring during pregnancy may have a serious effect on the fetus. therefore, monitoring fetal well-being should be part of any protocol for medical management of the pregnant female and particularly in the case of emergencies. camelids rely exclusively on the cl for progesterone secretion and maintenance of pregnancy. therefore, severe illness associated with an inflammatory or extreme stress response may rapidly lead to luteolysis and abortion (with all its complications). pregnant females may present with a variety of emergency clinical syndromes, ranging from severe colic, downer (lateral or sternal continuous recumbency), anorexia, diarrhea, depression, neurologic conditions, excessive straining, vaginal discharge, premature lactation, vulvar dilation, or vaginal prolapse. some of these presentations may have a genital origin. the cardinal rules in handling emergencies in the pregnant females are a thorough physical evaluation of the dam, evaluation of the fetus, and ruling in or out the genital origin of the presenting complaint after stabilization of the dam. the main emergencies of genital origin in the pregnant female are uterine torsion, vaginal prolapse, impending abortion, and uterine rupture. the main complication of any emergency in late pregnant females is hepatic lipidosis. pregnancy can also exacerbate clinical diseases. for example, in a recent outbreak of respiratory diseases in alpacas and llamas in north america, morbidity and mortality was highest in females in their last trimester of pregnancy. an important principle in our practice is that any suspicion by an owner that ''something is wrong'' with a pregnant female is taken seriously. behavioral assessment may be conducted while taking history, unless the female is obviously depressed or painful. a detailed history should be obtained and include breeding dates, time and methods used for pregnancy diagnosis, history of previous illness of reproductive disorders, onset and duration of the clinical problem, and recent treatments. if the female is obviously in severe distress, blood samples should be taken immediately and the female stabilized before further examination. oxygen therapy may be indicated for severely compromised females. a jugular catheter should be placed immediately to allow fluid therapy and emergency anesthesia if needed. sedation may be needed for some females in order to complete evaluation. choices of drugs and dosage for sedation should take into account their effect on the fetus. butorphanol tartrate (0.05-0.1 mg/kg) provides good sedation and has minimal effect on the cardiovascular system. however, there is a mild decrease in systemic vascular resistance that can be relevant if uterine blood flow is already compromised [29] . transabdominal ultrasonography should be used to determine fetal well-being, and the integrity of the uterus and placenta. in addition to the reproductive organs, abdominal viscera and the peritoneal cavity should be assessed [30] . in advanced pregnancy, imaging of abdominal viscera becomes very difficult in the absence of severe displacement. for complete imaging of abdominal contents, the lower abdomen should be clipped and cleaned with alcohol from the xyphoid region to the base of the mammary gland. the area to be examined may need to be extended dorsally to the flank in order to visualize the dorsal aspect of the abdomen and the kidneys. cranially, the projection area of the liver may also need to be prepared for examination. for transabdominal ultrasonography, a 5 mhz linear-array transducer may be sufficient for mid-pregnancy and in small patients, whereas in the last trimester, the use of a 2.5-3.5 mhz sector transducer provides better penetration and imaging of the abdomen. transabdomimal ultrasonography may also be used to locate distinct pockets of free peritoneal fluid and to perform abdominocentesis. other imaging techniques such as radiography, mri or ct scanning may be indicated in the case of downer females, but they are not routine procedures and are only a possibility in referral centers. following transabdominal ultrasonography, transrectal palpation and ultrasonography should be performed, albeit, cautiously, as this may cause additional stress. administration of an epidural and infusion of a mixture of lidocaine and lubricant in the rectal cavity may reduce straining, provide some relaxation, and facilitate the examination in llamas and alpacas. the primary objective of transrectal palpation is to determine the location and direction of the broad ligaments and evaluate the caudal abdomen for any masses or abnormalities of the pelvic area, kidneys, and urinary bladder. transrectal palpation in the female sitting in a sternal position may offer some challenges for the inexperienced practitioner. the quantity and quality of fecal material in the rectal cavity should be evaluated. severely stressed camelids often have profuse diarrhea, whereas an absence of fecal material and/or the presence of scant mucoid feces may be due to intestinal transit disorders or tenesmus. vaginal examination should be performed with a speculum after thoroughly cleaning the perineal area. the speculum should be advanced slowly, while concurrently examining the vagina for any abnormalities. the cervix is evaluated for the degree of relaxation and opening. the cervix of the llama and alpaca is often difficult to visualize during late pregnancy, but it should be obvious if it is patent. manual examination of the vagina and cervix may be indicated in some cases, but this procedure is often limited by the size of the examiner's hands. assessment of fetal well-being is an important component in the evaluation of medical crises. unfortunately, there is a paucity of information regarding fetal biophysical characteristics in camelids. however, based on clinical experience in the authors' laboratory, the two main indicators for fetal distress are fetal heart rate and rhythm. normal fetal heart rate in mid-to late-pregnancy range from 1.6 to 1.8 times that of the dam. in that regard, fetal heart rate is usually 80-115 bpm in the last trimester of pregnancy, but decreases to 80 bpm a few days before parturition. fetal heart rates that are consistently >130 or <50 bpm suggest fetal distress. the fetal heart rhythm should be regular and respond to phase of activity by a 10-20% increase in rate. fetal activity is maximal in the first half of pregnancy, but substantially reduced in the last 2 months. the entire fetus should be examined to determine fetal position and number. normal fetal positioning for parturition appears to occur a few hours before parturition. it is not uncommon to image the fetus low in the abdomen with the dorsum against the diaphragm and all limbs pointing to the pelvic area. transverse position of the fetus in the abdomen does not mean a transverse position inside the horn, but rather reflects the position of the entire pregnant horn. that the fetus is entirely in the left horn and the special arrangement of the pregnant horn vis-à-vis the abdominal viscera may contribute to signs of discomfort in some females in late pregnancy. late in pregnancy, the presence of twins is best confirmed by abdominal radiography [31] . fetal biometrics may provide data regarding fetal growth and stage of pregnancy, but in our experience, most measurements are not very accurate and cannot be used for physical bioprofiling [32, 33] . fetal fluids are difficult to assess, due to the low volume of amniotic and allantoic fluid in camelids. uteroplacental thickness should be evaluated in the horn containing the fetus (left horn) only, as the placenta may appear thicker in the nonpregnant horn. the combined uteroplacental thickness should be <8 mm in the last trimester. excessive edema of the uterine horn or premature placental detachment are relatively easy to detect and require immediate intervention if the female is at term. a minimum baseline evaluation of a severely depressed or colicky pregnant female should include complete blood count (cbc), blood chemistry, and fibrinogen. evaluation of peritoneal fluid (abdominocentesis), fecal evaluation, and urinalysis should be considered in select cases. although a stress leukogram is often present in many females, neutrophil count, immature neutrophil count, neutrophil morphology, packed cell volume, and fibrinogen concentration are very valuable in evaluating inflammatory and toxic states. anemia may be due to blood loss, or the onset of other problems such as mycoplasma hemolamae. blood chemistry will determine electrolyte imbalances and risk for hepatic lipidosis, a major concern in anorectic, stressed pregnant females. hypoprotenemia is often present in old pregnant females and may predispose to metabolic complications. in some cases, the serum may be grossly hyperlipemic (white). however, lipemia and ketonemia are not always present in hepatic lipidosis. elevated concentrations of nonesterified fatty acid (nefa; >400 mmol/l) and b-hydroxybutyrate (bhb) are important indicators of stress and liver compromise. liver compromise is also indicated by elevated bile acids, gamma-glutamyl transferase, aspartate transaminase, and sorbitol dehydrogenase [17, 34] . furthermore, arginal calcium and magnesium concentrations or hypocalcemia may be present in late-pregnant females and require correction and monitoring. progesterone is the major hormone evaluated routinely during pregnancy [35, 36] . determining baseline progesterone concentration is a good practice if an assay is readily available. the cl is the primary source of progesterone throughout pregnancy in camelids; pregnancy cannot be maintained if blood progesterone concentrations are <1 ng/ml [37] . progesterone concentrations may be substantially altered by level of hydration and weight and body condition score of the female. progesterone supplementation is still a subject of debate. estrone sulfate concentrations in plasma increase after 80 days of pregnancy, reaching a peak immediately before parturition. determination of relaxin concentration may be helpful in the evaluation of placental function, but this assay is not widely used [35] . there are no studies on the effect of a compromised liver (typically due to hepatic lipidosis) on steroid metabolism and blood steroid concentrations. supportive therapy in pregnant females depends on the symptoms and degree of compromise. it may include oxygen therapy, fluid therapy, antimicrobials, and nsaid's. compromised pregnant females should be placed immediately on broad spectrum systemic antimicrobials. our primary choices of antimicrobials have been ceftiofur in alpacas and llamas and longacting tetracycline in camels. uterine torsion remains the main genital cause of colic or depression in pregnant new world camelids. there are no detailed studies regarding the epidemiology of this disorder. it is noteworthy that uterine torsion is not common in camels (a. tibary, unpublished observations), nor is it common in llamas and alpacas in south america (j. sumar, personal communication). perhaps this apparent difference is due to nutrition or body size. in our experience, there are two common stages of pregnancy at presentation: 8-10 months and at parturition. clinical signs of uterine torsion are quite variable, ranging from mild discomfort to severe colic, diarrhea, and anorexia. we have had cases present simply as ''quieter than usual'' and ''decreased appetite'' or ''just a little off her normal routine'' [31] . the female may display signs of pain, circling, kicking at the belly, lateral recumbency, and excessive vocalization. tachypnea and tachycardia are very common. the cbc and blood chemistry are consistent with a stress leukogram, with various metabolic changes (hepatic lipidosis) depending on the duration and severity of the problem [38] . diagnosis is based on transrectal palpation of the broad ligaments, as described in other large animal species [31, 38] . clockwise torsion is indicated if the left broad ligament is stretched across midline to the right and over the uterus, whereas the right ligament is shorter and pulled ventrally and medially under the uterus. palpation of the broad ligament may elicit a severe painful reaction. difficulties encountered in transrectal evaluation for uterine torsion include physical limitations, particularly in alpacas (tight anal sphincter, narrow pelvis and size of the examiner's hand and arm), as well as a lack of experience palpating late-pregnant camelids in a sternal position. although diagnosis by vaginal palpation has been reported by practitioners, in our experience, it is not reliable unless the torsion includes the cervix. with a severe colic, a definitive diagnosis may not be possible until exploratory laparotomy. alternatively, the female could be palpated under general anesthesia, which provides greater relaxation of the anal sphincter and perineal area [39] . transrectal ultrasonography may sometimes reveal increased dilation of the blood vessels. although it was reported that the majority (>90%) of camelid uterine torsions are clockwise [38] , this has not been our experience; therefore, direction of the torsion needs to be ascertained before attempting nonsurgical correction. correction of uterine torsion can be accomplished nonsurgically by rolling or surgically after coeliotomy. both techniques are very efficient. rolling should be considered only if the uterus and its vasculature are not compromised. rolling may be performed done under general anesthesia, sedation, or without sedation. the female is placed on lateral recumbency on the side of the direction of the torsion and rolled while the fetus is maintained in position with a small plank or with the fists [31, 38] . the pain usually disappears immediately after correction of the torsion and females may return to normal activity immediately. however, if they have been anorexic, correction of metabolic disorders should included in post-surgical management. surgical correction may be performed following flank or midline laparotomy. midline laparotomy is the preferred method in late pregnancy [39] [40] [41] [42] . the success rate of both rolling and surgical correction is very high, as is survival of the fetus. no special management is needed if the torsion has been diagnosed and corrected early. however, anorexia and pain may cause hepatic lipidosis, in which case the patient should be placed on broad spectrum antimicrobial therapy [39] . monitoring blood progesterone is useful, particularly if an assay is readily available. the need for progesterone supplementation after correction of a torsion remains controversial. complications of uterine torsion include abortion, uterine rupture/hemorrhage, endotoxemia, and death of the dam [38, 40] . splenic torsion concurrent with uterine torsion has been described in one case, with persistent pain following correction of the uterine torsion [39] . uterine rupture is often secondary to severe or inadequate clinical management of a uterine torsion. females usually present in an advanced stage of shock, in lateral recumbency. abdominocentesis may reveal large amount of serosanguinous or bloody fluid. severe pain with presence of serosanguinous peritoneal fluid may also be due to splenic torsion [39] . the only option is surgical intervention to remove the fetus and salvage the uterus. complete hysterectomy should be considered if the uterus is severely compromised. vaginal prolapse has been described during the first half of pregnancy, but the condition is more common during the last 2 months of pregnancy [31, [43] [44] [45] . it is likely due to softening of tissues due to increased estrogen concentration during the last part of pregnancy. predisposing factors include age (older females), parity, and body condition (obese and very thin females) [31, 45] . the prolapse tissue may be limited to 3-5 cm, and visible only in the recumbent female. however, with increased inflammation and edema of the tissues, the degree of prolapse increases and becomes permanently exteriorized. prolapse of the entire vagina and exteriorisation of the cervix is rare, but possible. prolonged periods of prolapse increase inflammation and can cause severe necrosis of the vaginal mucosa, potentially resulting in ascending infectious placentitis. increased tenesmus with risk of abortion and/or rectal prolapse occurs in chronic cases. furthermore, rectal and vaginal prolapse may be the only indications of dystocia or abortion [45] . the prognosis for the life of the fetus and dam is relatively good if the condition is treated early. in camels, the vaginal tissue is maintained in place with a bühner suture around the vulva. in the alpaca and llama, a shoelace suture pattern is sufficient. more advanced cases of prolapsed vagina with increased tenesmus may require epidural anesthesia [44] . the animal should be monitored regularly and the suture removed if signs of impending parturition are observed [41] . other complications of pregnancy in camelids include ventral abdomen herniation, prepartum downer syndrome, metabolic diseases, and premature lactation/ placentitis. hydrops of fetal fluid is extremely rare in camelids. ventral herniation during pregnancy is often a complication of previous abdominal surgeries, including cesarean section. in addition to determining the primary cause of these disorders and assessing the chances for survival of the female, determination of fetal well-being and the possibility of induction of abortion or parturition should be contemplated. abortion can be induced with the prostaglandin f 2a analogue, cloprostenol (250 mg in llamas and alpacas, and 500 mg in camels). the same dose is sufficient for induction of parturition, with good neonatal survival at >330 days of pregnancy and sufficient mammary gland development and colostrum production. abortion or parturition occurs approximately 18-22 h after prostaglandin treatment. in a few situations, a second treatment with a prostaglandin f 2a analogue is necessary [45] [46] [47] . giving llamas or alpacas >5 mg of pgf 2a (dinoprost thrometamine) has been associated with severe respiratory distress. most neonatal deaths occur during birth or shortly thereafter. adequate obstetrical management and monitoring for early signs of distress are closely linked with the chances of survival of the cria and the reproductive future of the dam. proper procedures, immediate neonatal care, and close of observation of the newborn, are the best means of reducing neonatal losses. normal parturition and proper obstetrical techniques have been reviewed in detail elsewhere and are not very different from the approach used in other large animal species (especially horses) [31] . it is estimated that approximately 5% of all camelid births will require some assistance and $2% will require advanced obstetrical expertise. obstetrical problems are an emergency in camelids, due to the relatively explosive and short duration of stages of parturition (similar to the mare). all normal births are in an anterior longitudinal presentation. dystocia of maternal origin include uterine inertia, uterine rupture, and failure of appropriate dilation of the cervix or vestibulum [31, 45, 48] . uterine torsion and failure of cervical dilation require delivery by cesarean section. however, it is important to confirm that the dam is at term and to first rule-out uterine torsion [31, 49] . dystocia of fetal origin occur most commonly as a result of malpositioning or malposture, and to a lesser degree, presence of malformations, twins, and large fetuses. the most common fetal causes of dystocia are carpal or shoulder flexure or head deviations (lateral and ventral). breech and transverse presentations are possible and are common reasons for cesarean section [31, 50] . fetal abnormalities causing dystocia include schistosoma reflexus, contracted tendons, and ankylosis of the hind limbs or neck [7] . other anomalies that may complicate delivery include fetal anasarca and an emphysematous fetus resulting from fetal death and gas production during decomposition [31] . although twining is rare in camelids, a few twin births have been reported. delivery of twins may be complicated by both fetuses in the birth canal at the same time. in our experience, all dystocias due to twins required a cesarean section to preserve the integrity of the female reproductive tract [31] . regarding obstetrical procedures, there are three major differences between camelids and ruminants: (1) the pelvic inlet is narrower; (2) the cervix and vaginal are more prone to laceration and severe inflammation (often leading to adhesions); (3) risks for neonatal hypoxia and death are increased by the forceful uterine and abdominal contractions and the rapid detachment of the microcotyledonary placenta. consequently, (1) early recognition of dystocia is paramount, (2) obstetrical decisions and manipulations should be rapid, and (3) supportive care should be provided to the dam and fetus (if alive) before and during manipulation. dystocia is recognized by prolongation of the first or second stage of labor. assessment of the health of the female and viability of the fetus is the first step in managing obstetrical cases. providing analgesia (epidural and administration of butorphanol) may facilitate examination of the parturient alpaca. prolongation of the first stage of parturition is primarily due to failure of cervical relaxation and uterine torsion [50] . examination of the parturient female is continued by vaginal palpation to judge cervical dilation, determine the presentation, posture and position of the fetus and its viability, and to formulate a course of action based on the findings. abdominal radiography may be helpful in determining position, posture and number of fetuses in alpacas [31, 50] . fetal manipulations are similar to other species, but need to be restricted to a maximum of 15-20 min. a different approach should be attempted if fetal position, presentation, and posture suggest that manipulation is not possible, or if manipulations are not fruitful after 15 min. we consider that fetotomy is not an option in alpacas and most llamas and camels. surgical relief of dystocia (cesarean section) remains the best approach if controlled vaginal delivery cannot be achieved in <20 min. techniques for cesarean delivery in camelids are well described [41, 51] . we recommend a flank approach in camels and any severely compromised dam. this technique does not require deep general anesthesia and can be performed under sedation and a regional block, which is a good choice under field conditions. a midline celiotomy approach is ideal if the uterus is compromised or needs to be completely exteriorized [41, 51] . regardless of the type of obstetrical intervention, adequate oxygen delivery to the uterus is essential for a healthy neonate. reducing uterine blood flow or oxygen-carrying capacity of the blood is liable to harm the fetus and may increase fetal or neonatal mortality. in most species, uterine blood flow is reduced when the dam is exposed to pain or stressful conditions. sedatives, analgesics, and anesthetics may all supress cardiac output and therefore decrease blood flow to the fetus. in addition, certain drugs or drug combinations may further decrease uteroplacental perfusion, due to their tonic effect on the myometrium. unfortunately, there are no studies on the effects of anesthetics on the uterus and fetus in camelid. xylazine, a drug of choice for sedation of camelids in the field, markedly reduced blood flow (by as much as 59%) and availability of oxygen to the uterus. furthermore, 5 min after xylazine treatment, uterine artery resistance increased by 165%. xylazine has also been associated with increased myometrial contraction in ruminants and could cause increase fetal morbidity and mortality, at least in these species [52, 53] . this effect was not significant in mares. there are no studies on the effect of xylazine on uterine perfusion in camelids. in sheep, the fetus responds to hypoxia, hypotension and hypovolumia with increased concentrations of acth, vasopressin and cortisol, via activation of the hypothalamic-pituitary axis, mediated by changes in afferent neural activity of arterial baroreceptors and chemoreceptors; it has been suggested that the fetal response is primarily mediated through chemoreceptors [54] . ketamine, a dissociative anesthetic and known noncompetitive inhibitor of glutamatergic n-methyl-daspartate (nmda) receptors, blocks the fetal reflex bradycardic response to maternal ventilatory hypoxia and may not be a good choice for anesthesia. this corroborates our observations in camelids where use of ketamine as a preanesthesic has been associated with severely depressed neonates. propofol (2,6-di-isopylphenol compound) is a small molecule that is rapidly metabolized; its advantages are rapid onset and offset of action and redistribution from the central nervous system. even with continuous propofol anesthesia, maternal and fetal heart rate and blood pressure were not affected in pregnant ewes [55] . this makes the drug ideal for induction of anesthesia for cesarean section or for surgical management of uterine torsion. propofol decreased myometrial activity in the gravid ovine uterus in vivo [56] and in uterine muscle from gravid humans in vitro [57] . in vivo, there is no effect on placental perfusion. it can induce a transient tachycardia and decrease in po2 and ph in the dam, but these effects have minimal repercussions on fetal heart rate and blood pressure. because propofol is primarily metabolized by the liver, it should be used with caution in females with hepatic lipidosis. maintenance of general anesthesia with isoflurane or sevoflurane are ideal, because these inhalation anesthetics are rapidly eliminated [56] . the combination propofol/isoflurane has been used successfully by our group in emergency cesarean section in camelids; a similar combination was also very good for cesarean section in the bitch [60, 61] . it is noteworthy that the effects of these anesthetics may be exacerbated by pre-existing conditions in the fetus (e.g. hypoxia) [56, 58, 59] . postpartum emergencies are often due to complications of obstetrical situations. however, females may present for emergency critical care with a history of what appears to have been an uncomplicated parturition. in addition to the primary genital problems that may alarm the owner (i.e. traumatic injuries, bleeding, uterine prolapse, and retained placenta) some of these cases present with ataxia, prolonged recumbency, and varying degrees of anorexia or depression as primary complaint. evaluation of the postpartum female should include a complete history and a detailed account of the obstetrical situation, including delivery of the placenta. the female should be assessed by complete physical examination, cbc, blood chemistry, transabdominal and transrectal ultrasonography, and vaginal examination. excessive fluid in the abdomen would warrant abdominocentesis. due to their small perineal body and powerful expulsive efforts, rectal-vaginal tear is common following overt obstetrical manipulations in camelids. a common cause of these tears is rapid vaginal delivery of the fetus without sufficient preparation of the vulva and vestibular area. episiotomy should be considered in females with insufficient dilation of the vulva, particularly maidens. cases seen in our practice are often a complication of fetotomy. rectal-vaginal tears may be repaired immediately, or a few weeks later, after second-intention healing [41] . postpartum uterine tears are not as dramatic as in the mare, unless there is involvement of a large vessel or severe contamination of the uterus and peritonitis. uterine bruising is often seen following excessive obstetrical manipulation (particularly fetotomy). uterine involution is very rapid in the camelid and small, dorsal uterine tears may heal spontaneously; the only sequela may be infertility due to peri-uterine adhesions. complications from uterine tears are often due to severe contamination, either during obstetrical manipulation or following partial or total retention of the placenta [62] . these females may initially appear comfortable, then slowly develop a fulminating peritonitis. clinical signs of toxemia may appear within the first 24 h, but it may take as long as 3-4 days for the clinical picture to become recognizable. it is important that these cases be stabilized, with antimicrobial and anti-inflammatory therapy initiated at the first sign of compromise. uterine lavage should be considered only after verification of the integrity of the uterine wall and should be monitored by transabdominal ultrasonography to visualize remnants of the placenta. a case of complete passage of the placenta into the abdominal cavity was described in a llama with progressive deterioration of health, which eventually succumbed to peritonitis 11 days after dystocia [62] . it is not clear how uterine tears occur in camelids; although most are associated with obstetrical manipulation, we have seen cases following spontaneous and apparently uneventful parturition. therefore, every female should be monitored to ensure delivery of the placenta, followed by inspection of the placenta to ensure that it is complete. the camelid placenta is epitheliochorial, mircocotytledonary and is rarely retained more than 36 h, even after dystocia. if a uterine tear is detected in the early postpartum period by direct vaginal palpation, an attempt could be made to induce uterine prolapse after treatment with epinephrine and epidural anesthesia. alternately, the uterine tear can be repaired after celiotomy. if the placenta is still present, it should be pealed from the endometrium around the tear before suturing. in cases of unexplained fever, abdominal pain or anorexia in the postpartum female, exploratory celiotomy or laparoscopy should be considered. adjunctive therapy for peritonitis is indicated and should include abdominal lavage and systemic broad-spectrum antimicrobial and anti-inflammatory therapy, along with intravenous fluid therapy for cardiovascular support. postpartum hemorrhage from the uterine arteries is less common in camelids than mares. most of the postpartum hemorrhage cases diagnosed by our group consist of rupture or laceration of the vaginal uterine artery. this artery is easily recognized by palpation per vaginum during obstetrical manipulation and is peculiarly large in camelids. excessive manipulation, and in particular fetotomy, may cause erosion of the mucosa and laceration of the artery. unfortunately, many of these hemorrhages are missed, as no outward signs are apparent until it is too late. typically, blood accumulates within the uterus for a few hours, followed by cardiovascular collapse. in one case, the female was found dead in her stall 2 h after delivery. ruptured vaginal arteries may be sutured and blood transfusion should be considered in females with a pcv <10%. packing of the vaginal with compresses, i.e. a device similar to the ''umbrella pack'' used in humans, may be helpful. partial or total uterine prolapse occur secondary to dystocia, manual removal of a retained placenta, and excessive use of oxytocin (dose and frequency). uterine prolapse is far more common in camels than in llamas and alpacas, and is often associated with hypocalcemia, selenium deficiencies, and retained placenta [49, 50] . dairy camels seem to be more prone to uterine prolapse [63] [64] [65] [66] [67] [68] [69] . uterine prolapse occurs generally immediately (first 30 min) after parturition or abortion [50] . techniques for replacement are similar to those reported in cattle and small ruminants, and are usually done under sedation and epidural analgesia. the placenta is often easily peeled off and should be removed if possible before replacement of the uterus. the female is positioned in sternal recumbency, with the hind quarters slightly elevated. the uterus should be inspected for any lacerations or hemorrhage. the area of major risk for hemorrhage is located near the cervix where the uterine artery may be exposed. the uterus is cleaned with warm dilute povidone iodine solution before replacement. a bühner suture is used in camels and a shoelace pattern can be used around the vulvar lips in alpacas and llamas. uterine prolapse tends to reoccur if the uterine horns are not fully extended. hysterectomy should be considered if the uterine tissue has sustained severe damage [8, 31, 70] . rectal prolapse has been reported in llamas and camels. pregnant females with tenesmus and diarrhea are predisposed. rectal prolapse can be intermittent. in a case of a dromedary female near term, rectal prolapse was noticed intermittently, without vaginal prolapse. treatment of the underlying cause and surgical repair have been successful [3, 71] . emergency postpartum complications in camelids include a vast array of conditions which often manifest themselves as lethargy, depression and progress towards a downer female syndrome. the approach to diagnosis of the causes of downer syndrome is similar to that used in cattle [72] . predisposing factors include septic metritis, necrotic vaginitis, retained placenta, hypocalcemia, dystocia, pelvic injuries, hemorrhage, and presence of compressive lesions. a milk fever syndrome (hypocalcemia), similar to the condition in dairy cattle, is also observed in dairy camels. toxic mastitis has been described in dairy camels, but not in south american camelids [73] . in addition to physical evaluation, cbc and blood biochemistry, the evaluation of the downer postpartum camelid should include transrectal and transabdominal ultrasonography and potentially collection and evaluation of cerebrospinal fluid. more advanced imaging techniques may be required in some cases in order to detect neoplastic masses. although, retained placenta is not usually an emergency in camelids, failure of delivery of the placenta following a cesarean section may lead to severe complications. severe swelling of the vulva and vagina are painful conditions associated with overt obstetrical manipulation. females experiencing these complications may have persistent straining and abandon their neonate. untreated vaginal and cervical inflammation may lead to adhesions and development of pyometra. females with severe inflammation of the birth canal should be treated with systemic and local anti-inflammatory drugs. daily application of cold compresses and treatment with ointments with anti-inflammatory and antimicrobial properties may reduce inflammation and adhesions. in an epidemiological study in the united kingdom, 4-11% of deaths amongst llamas and 17-33% of deaths in alpacas occur during the first 6 months of life. a high proportion of these deaths occur within the first week of life [31, 74] . in camels, neonatal mortality can reach 50% of the calf crop in the first 10 days of life [45] . newborn morbidity and mortality is very high in the immediate neonatal (<1 week old) period following obstetrical manipulations, cesarean section, prematurity, or dysmaturity [75] . these losses are often due to complications from hypoxia, failure of passive transfer, and intrapartum infection. the clinical signs are often nonspecific and vague, resulting in an individual that is slow to adapt to extrauterine life, or that dies suddenly within the first few days of life. infections may be acquired in utero or intrapartum, and should be suspected if the newborn has elevated plasma fibrinogen concentrations in the first 12-24 h of life, the placenta appears abnormal, or the dam exhibited uterine discharge peripartum [75] . therefore, immediate identification and care of the newborn camelid at high risk for sepsis is an important part of reproductive emergencies. the newborn should be evaluated within the first hours of life to detect any abnormalities of development or maladjustment to extra-uterine life. physical and behavioral parameters of the normal newborn are shown ( table 1 ). assessment of the newborn cria should include evaluation of the epidermal membrane and placenta, respiration, cardiac function, and the presence of obvious congenital abnormalities. the epidermal membrane, which is normally translucent, may become yellow or brownish due to meconium staining in case of fetal stress due to dystocia. many congenital abnormalities have been described in camelids, some of which can be lethal. amongst the most important are: cleft palate, choanal atresia, atresia ani, and heart defects. the initial examination of the cria should establish if any of these abnormalities are present (table 2) , so they can be corrected early or a decision made to humanely euthanize the cria. neonatal cases are presented with a wide variety of nonspecific complaints based on deviations from the normal appearance and behavior presented above. the minimum database used to evaluate the cria include: evaluation of maternal transfer of immunogobulins, cbc (including differential count and determination of plasma fibrinogen concentration), arterial blood gas analysis, serum chemistry, and aerobic and anaerobic blood cultures. contrast radiographs of the nasopharyngeal area may be indicated if choanal atresia is suspected as a cause of dyspnea [76] . any cria delivered before day 315 of pregnancy should be considered premature. premature birth may be a consequence of a stressful illness during pregnancy or due to a decision to induce parturition because of severe compromise to the dam. recently, the authors have seen a high rate of premature births following an outbreak of respiratory diseases. premature birth may also be secondary to uterine pathology (i.e. placentitis or placental insufficiency) [77] . premature crias display specific phenotypic characteristics, including a birth weight significantly (>20%) lower that that the average for the farm, and a thick epidermal membrane firmly attached to the foot pads and the mucocutaenous junctions. a ''floppy'' syndrome, often seen in premature camelids, includes inability to rise, to hold the head up, or to maintain sternal recumbency and floppy ears (new world camelids), due to immaturity of the cartilage. the coat appears silky and the limbs are overextended at the carpus and fetlock, due to laxity of the tendon and poor muscle tone. the incisors are not erupted and the suckling reflex is absent or weak. premature neonates adapt to extrauterine life very slowly. due to the normal elevated fetal cortisol concentrations, they may appear healthy initially, but become comprised a few hours later due to developing metabolic problems. these problems are often due to hypoxemia, acidosis, hypoglycemia, and limited body reserves or poor thermogenic ability. premature neonates are exposed to a wide range of respiratory and intestinal compromise due to immaturity of these systems. respiratory distress may be notice by labored or even open-mouth breathing. this syndrome is likely due to lack of surfactants required for normal air sac expansions and inefficient oxygen absorption. mortality rate is very high is these crias if they do not receive immediate attention [31, 50] . intestinal immaturity in premature crias predisposes them to failure of passive transfer, even if colostrum is ingested orally in the first hours of life (failure of absorption). they also tend to be more at risk for bloating and meconium retention due to poor gut motility. dysmature or hypoxic neonates are often the result of induction of parturition, severe illness during pregnancy, or prolonged gestation. they usually present with similar biophysical characteristics as the premature neonates, except that they may have normal body development. mature compromised crias are usually the result of lengthy obstetrical manipulation or delivery via cesarean section. the degree of compromise depends on several factors. there is a complete lack of evidence-based medicine in emergency critical care of newborn camelids; most of the available information is anecdotal and based on clinical experience with other species. premature or stressed neonates require intensive care in the first few hours of life. they should be placed immediately in a warm environment. baseline cbc and blood biochemistry are indicated to determination status of hydration and electrolytes, blood glucose concentration, total protein and igg at 24-36 h. at-risk patients should receive an intravenous plasma transfusion. if the suckling reflex is absent, tube feeding is necessary and should be restricted to small volumes every 2-3 h, to reach 10-15% of body weight by 24 h of life. oxygen supplementation may be required if respiratory distress is pronounced. lung function should be monitored by blood gas analysis. aminophylline, an adenosine a (2a)-receptor antagonist like caffeine, has been given for 3 days to stimulate the central nervous system and regulate breathing and to stimulate the type ii pneumocytes to produce components for the surfactant production [78, 79] . intraoperational administration of aminophylline to the dam may be advantageous if a cesarean section is planned [79, 80] . doxapram is routinely used to stimulate the central nervous system and relieve neonatal apnea following dystocia or cesarean section [81, 82] . we general administer a small dose sublingual (5 mg in llama and alpaca crias and 50 mg in camels) initially after a cesarean section or dystocia. in neonates with severely depressed respiration, this dose, or up to twice this dose, should be given iv or iv. the neonate should be monitored closely for convulsions or hyperventilation. sepsis is a major concern in all compromised neonates. in one study, the median age at presentation of [75, 76, 83] . both gram + and gram à organisms have been isolated from neonates with septicemia. based on common isolates, the antibiotics of choice for camelids at high risk of sepsis include the following combinations (enrofloxacin and ppg, enrofloxacin and ceftiofur, ceftiofur and gentamicin) [75, 76, 83] . gentamicin should be used with care, as it can be extremely nephrotoxic to severely dehydrated newborn camelids, or if there is already evidence of renal dysfunction. blood cultures may be submitted, but broad-spectrum antimicrobial treatment should be started without delay. supportive treatment should include nsaids (ketoprofen 4 mg/kg sid) to control pain and toxemia and antiulcer medication (omeprazol, given orally, 2 mg/kg daily) to offset the effect of stress and nsaid. intravenous fluid therapy is indicated in all dehydrated, hypoglycemic newborns, however caution should be exercised regarding the rate of fluid replacement, as camelids are prone to pulmonary edema. severely dehydrated crias require fluid therapy. the type of fluid should be determined based on glucose, electrolyte and blood gas evaluation. generally, a balanced isotonic solution with 2% dextrose and bicarbonate to correct metabolic acidosis are sufficient. dextrose concentration may be increased to 5% in hypoglycemic crias. rate of administration should aim to correct half of the deficit over the first hour, and the other half over the next 2 h. total or partial parenteral nutrition should be considered in severely depressed crias that are unable to nurse [84] . prognosis for life and normal growth depends primarily on the interval between birth and providing emergency care. diseases in the first 24 h of life are usually associated with congenital abnormalities, digestive (meconium retention), urinary problems (urine retention), exposure or malnutrition. the most common lethal congenital abnormalities that affect the camelid neonate are: choanal atresia, atresia ani or coli, and heart defects. most commonly, affected animals will suffer from severe respiratory, circulatory or metabolic complications. heart defects can be very severe and lead to death of the cria within a few hours, but most will survive for a few days to months, with the only abnormality being failure to thrive. syncope or fainting were observed in crias with severe heart defects. choanal atresia is the lack of opening of the nasal air passages, resulting from the presence at the level of the choanae of a membranous or osseous separation between the nasal and pharyngeal cavities [85, 86] . diagnosis can be confirmed by mouth to nose artificial breathing or by contrast radiographs of the head after injection of a radio-opaque substance in the nasal cavity. maxillofacial agenesis or dysgenesis ''wry face'' is a head deformity characterized by varying degrees of deviation of the maxilla. this abnormality may be associated with choanal atresia. there is no treatment for this condition and the cria should be euthanized. respiratory distress associated with congenital goiter has been described in camels [45] . atresia ani and atresia coli are, respectively, the lack of opening of the anal sphincter and lack of connection between the colon and the rectal cavity. these abnormalities results in the blockage of the intestinal transit and accumulation of fluid in the gastrointestinal tract. the cria becomes progressively bloated and depressed. ultrasonographic and radiologic examination of the abdominal cavity allows confirmation of the diagnosis. atresia coli may be mistaken for meconium retention. in the female cria, these abnormalities may involve the genital tract. surgical correction of the atresia ani has described [87] . congenital blindness associated with different ocular defects has also been reported and will impact neonate behavior and wellness [88] [89] [90] . it is important that the practitioner established the diagnosis of congenital abnormalities with certainty, because some of these may be hereditary [91, 92] . meconium is the amniotic fluid ingested by the fetus during pregnancy. meconium is usually passed within 18-24 h after birth as dark pasty or stringy feces. clinical signs of meconium retention include straining, squatting, tail wagging, anorexia, and signs of abdominal discomfort. initial treatment consists of one or two warm soapy water enemas (20-40 ml). if after two enemas, the meconium has not passed, intravenous fluids may be indicated, as multiple soapy water enemas may irritate the rectal mucosa, resulting in severe straining and rectal prolapse [93] . crias that have retained meconium may have other abnormalities and should be examined closely. routine administration of enemas to every newborn cria should be discouraged. urine retention may be associated with congenital abnormalities of the urinary and genital tracts [94] . in males, urethral blockage (aplasia) results in bladder rupture. in females, vulvar agenesis or atresia vulvi present with an obvious bulging of the perineum and often symptoms of pain, due to the large quantity of urine in the uterus and abdominal distension [31, 71] . accidents to the umbilical stump are not uncommon. the simplest form is persistent bleeding, which can be treated with hemostasis provided by a hemostat or sutures. persistent urachus is not as common as in other species. umblical hernia and rupture of the abdominal wall with eventration has been seen by the author following dystocia due to uterine torsion and may be due to wrapping of the cord around the fetus. these are easily replaced surgically. failure of passive transfer is a major cause of neonatal mortality in camelids [95] . assessment of igg concentrations can be performed 18 h after birth [96] [97] [98] . serum total protein concentrations <5 mg/ dl are also very indicative of failure of passive transfer. in these cases, hyperimmune plasma should be given iv or ip (15-25 ml/kg). commercial products are now available (triple j farm, kent laboratories, 777 jorgensen place, bellingham, wa 98226, usa). this product is collected from llamas regularly immunized with clostridium perfringens type c, escherichia coli bacterin-toxoid, clostridium chauvoeisepticum, clostridium haemolyticum, clostridium novyi, clostridium tetani and clostridium perfringens types c and d bacterin-toxoid, killed equine herpes virus-1, bovine rota-coronavirus modified live virus, j-5 e. coli bacterin, imrad 3 killed rabies vaccine, and inactivated cultures of leptospira canicola, leptospira grippotyphosa, leptospira hardjo, leptospira ichterohaemorrhagiae and leptospira pomona. reproductive emergencies involve not only saving the health but also the reproductive future of the patient. emergencies in the pregnant female present an additional challenge, in that the fetus has to be considered regarding response to treatment and viability. at times, it is important to make a decision as to which of the two (dam or fetus) has more economic or sentimental value, or chances to survive. one of the main challenges in emergency care in camelids is the lack of evidence-based scientific data on treatment and outcome assessment. although extrapolation from other species has been possible, it is important to remember species peculiarities, especially with regard to fluid therapy. handling of obstetrical situations is particularly important, as many female camelids loose their ability to reproduce due to iatrogenic vaginal adhesions and cervical trauma from prolonged manipulation. in the male, hyperthermia (environmental or pathologic) is the leading cause of reproductive loss and client education regarding its prevention and early recognition is paramount for successful preservation of fertility. veterinarians involved in camelid practice, of which reproductive services (including reproductive emergencies and neonatology) represents over 70% of the complaints, should have a very good understanding regarding anatomical, physiological and medical peculiarities of camelids, and utilize their experience in other species. this makes an excellent point for the importance of comparative approach to training theriogenologists and large animal veterinarians. emergency drugs and protocols (table 3) should be in place to ensure timely delivery of critical care and improved outcomes. uro-genital defects, renal agenesis, atresia vulvi preputial prolapse in an alpaca reproductive physiology and infertility in male south american camelids: a review and clinical observations pathology and surgery of the reproductive tract and associated organs in the male camelidae heat stress in a llama (lama glama): a case report and review of the syndrome hyperthermia in llamas and alpacas changes in testicular histology and sperm quality in llamas (lama glama), following exposure to high ambient temperature theriogenology in camelidae: anatomy, physiology, 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[complete bilateral choanal atresia in a llama surgical correction of anorectal atresia and rectovaginal fistula in an alpaca cria congenital glaucoma in a llama (lama glama) congenital cataracts and persistent hyaloid vasculature in a llama (lama glama) congenital coloboma in a llama congenital abnormalties an overview of camelid congenital/genetic conditions perinatal and neonatal care of south-american camelids urinary obstruction in a hermaphroditic llama failure of passive immunoglobulin transfer: a major determinant of mortality in newborn alpacas (lama pacos) a note on colostral immunoglobulin g concentrations versus subsequent serum concentrations in naturally suckled llama (lama glama) and alpaca (lama pacos) crias evaluation of assays for determination of passive transfer status in neonatal llamas and alpacas passive transfer of colostral immunoglobulin g in neonatal llamas and alpacas congenital defects in the llama medicine and surgery of south american camelids: llama, alpaca, vicuna, guanaco renal agenesis in an alpaca cria anderson kl. bilateral renal agenesis in an alpaca cria atresia vulvi in camels (case reports) a case of atresia ani with rectovestibular fistulae in an alpaca (l. pacos) surgical repair of a cleft soft palate in an alpaca surgical repair of a bilateral choanal atresia in a llama surgical treatment of a congenital flexural deformity of the tarsal joint in a llama management of bilateral flexural deformity of the metacarpophalangeal joints in three alpaca crias surgical correction of carpal valgus deformity in three alpacas multiple non-lethal congenital anomalies in a llama diaphragmatic hernia in a llama key: cord-322541-yzum868k authors: moon, suerie; sridhar, devi; pate, muhammad a; jha, ashish k; clinton, chelsea; delaunay, sophie; edwin, valnora; fallah, mosoka; fidler, david p; garrett, laurie; goosby, eric; gostin, lawrence o; heymann, david l; lee, kelley; leung, gabriel m; morrison, j stephen; saavedra, jorge; tanner, marcel; leigh, jennifer a; hawkins, benjamin; woskie, liana r; piot, peter title: will ebola change the game? ten essential reforms before the next pandemic. the report of the harvard-lshtm independent panel on the global response to ebola date: 2015-11-23 journal: lancet doi: 10.1016/s0140-6736(15)00946-0 sha: doc_id: 322541 cord_uid: yzum868k nan the west african ebola epidemic that began in 2013 exposed deep inadequacies in the national and international institutions responsible for protecting the public from the far-reaching human, social, economic, and political consequences of infectious disease outbreaks. the ebola epidemic raised a crucial question: what reforms are needed to mend the fragile global system for outbreak prevention and response, rebuild confi dence, and prevent future disasters? to address this question, the harvard global health institute and the london school of hygiene & tropical medicine jointly launched the independent panel on the global response to ebola. panel members from academia, think tanks, and civil society have collectively reviewed the worldwide response to the ebola outbreak. after diffi cult and lengthy deliberation, we concluded that major reforms are both warranted and feasible. the panel's conclusions off er a roadmap of ten interrelated recommendations across four thematic areas: 1 preventing major disease outbreaks all countries need a minimum level of core capacity to detect, report, and respond rapidly to outbreaks. the shortage of such capacities in guinea, liberia, and sierra leone enabled ebola to develop into a national, and worldwide, crisis. • recommendation 1: the global community must agree on a clear strategy to ensure that governments invest domestically in building such capacities and mobilise adequate external support to supplement eff orts in poorer countries. this plan must be supported by a transparent central system for tracking and monitoring the results of these resource fl ows. additionally, all governments must agree to regular, independent, external assessment of their core capacities. • recommendation 2: who should promote early reporting of outbreaks by commending countries that rapidly and publicly share information, while publishing lists of countries that delay reporting. funders should create economic incentives for early reporting by committing to disburse emergency funds rapidly to assist countries when outbreaks strike and compensating for economic losses that might result. additionally, who must confront governments that implement trade and travel restrictions without scientifi c justifi cation, while developing industry-wide cooperation frameworks to ensure private fi rms such as airlines and shipping companies continue to provide crucial services during emergencies. when preventive measures do not succeed, outbreaks can cross borders and surpass national capacities. ebola exposed who as unable to meet its responsibility for responding to such situations and alerting the global community. • recommendation 3: a dedicated centre for outbreak response with strong technical capacity, a protected budget, and clear lines of accountability should be created at who, governed by a separate board. • recommendation 4: a transparent and politically protected who standing emergency committee should be delegated with the responsibility for declaring public health emergencies. • recommendation 5: an independent un accountability commission should be created to do systemwide assessments of worldwide responses to major disease outbreaks. rapid knowledge production and dissemination are essential for outbreak prevention and response, but reliable systems for sharing epidemiological, genomic, and clinical data were not established during the ebola outbreak. • recommendation 6: governments, the scientifi c research community, industry, and non-governmental organisations must begin to develop a framework of norms and rules operating both during and between outbreaks to enable and accelerate research, govern the conduct of research, and ensure access to the benefi ts of research. • recommendation 7: additionally, research funders should establish a worldwide research and development fi nancing facility for outbreak-relevant drugs, vaccines, diagnostics, and non-pharmaceutical supplies (such as personal protective equipment) when commercial incentives are not appropriate. we do not have the capacity to respond to this crisis on our own. if the international community does not stand up, we will be wiped out. we need your help. we need it now.n aimah jackson, team leader, médecins sans frontières ebola treatment center, monrovia. address to the un security council, sept 18, 2014 1 the west african ebola epidemic that began in 2013 was a human tragedy that exposed a global community altogether unprepared to help some of the world's poorest countries control a lethal outbreak of infectious disease. the outbreak engendered acts of outstanding courage and solidarity, but also immense human suff ering, fear, and chaos, largely unchecked by high-level political leadership or reliable and rapid institutional responses. the outbreak continues as of november, 2015. it has infected more than 28 000 people and claimed more than 11 000 lives, 2 brought national health systems to a halt, rolled back hard-won social and economic gains in a region recovering from civil wars, sparked worldwide panic, and cost several billion dollars in short-term control eff orts and economic losses. 3, 4 guinea, liberia, and sierra leone were most badly aff ected. the ebola outbreak is a stark reminder of the fragility of health security in an interdependent world, and of the importance of building a more robust global system to protect all people from such risks. 5 a more humane, competent, and timely response to future outbreaks needs greater willingness to assist aff ected populations, and systematic investments to enable the global community to perform four key functions: 1. strengthen core capacities within and between countries to prevent, detect, and respond to outbreaks when and where they occur. 2. mobilise faster and more eff ective external assistance when countries are unable to prevent an outbreak from turning into a crisis. 3. rapidly produce and widely share relevant know ledge, from community mobilisation strategies to protective measures for health workers, and from epidemiological information to rapid diagnostic tests. 4. provide stewardship over the whole system, entailing strong leadership, coordination, priority-setting, and robust accountability from all involved. 6 the ebola outbreak emphasised failures in performing all four of these functions. clarity about roles, responsibilities, and rules-and accountability for adherence to them-is essential in a complex system that must involve local, national, regional, and international actors spanning the public, private, and non-profi t sectors. yet, this clarity and accountability was fundamentally absent. without addressing these governance issues, we will remain wholly unprepared for the next epidemic, which might very well be more devastating, virulent, and transmissible than ebola or previous disease outbreaks. [7] [8] [9] the independent panel on the global response to ebola is a joint initiative of the harvard global health institute and the london school of hygiene & tropical medicine to review the global community's response to the ebola outbreak. the 19 members come from academia, think tanks and civil society around the world, with expertise in ebola, disease outbreaks, public and global health, international law, development and humanitarian assistance, and national and global governance. the panel took a global, system-wide view with a special focus on rules, roles, and responsibilities to identify changes necessary to prevent and prepare for future outbreaks. this panel report outlines the main weaknesses exposed during diff erent phases of the ebola outbreak, followed by ten concrete, interrelated recommendations across four thematic areas: preventing major disease outbreaks, responding to major disease outbreaks, research-production and sharing of data, knowledge, and technology, and governing the global system, with a focus on who. our primary goal is to convince high-level political leaders worldwide to make necessary and enduring changes to better prepare for future outbreaks while memories of the human costs of inaction remain vivid and fresh. the ebola outbreak witnessed many types of failures. for analytical purposes, we divide the epidemic roughly into four phases, underlining the most salient issues that arose. during the initial phase from december, 2013, to march, 2014, the fi rst infections occurred in a remote rural area of guinea where no outbreaks of ebola had previously been identifi ed. 10 the lack of capacity in guinea to detect the virus for several months was a key failure, allowing ebola eventually to spread to bordering liberia and sierra leone. this phase underscored the problem of inadequate investments in health infrastructure, despite national governments' formal commitments to do so under the international health regulations (2005), 11 and awareness among donors that many lower income countries would need substantial external support. it also underscored inadequate arrangements between governments and who to share, validate, and respond robustly to information on outbreaks. in march, 2014, a second phase began in which intergovernmental and non-governmental organisations began to respond, starting with médecins sans frontières, which already had teams on the ground. that month, both guinea and liberia confi rmed ebola outbreaks to who. by march 24, ebola was confi rmed in conakry, home to more than one in seven guineans. two months later ebola had spread to three capital cities with international airports. without any approved drugs, vaccines or rapid diagnostic tests, health workers struggled to diagnose patients and provide eff ective care. without suffi cient protective gear, and initially without widespread understanding of the virus, hundreds of health workers themselves became ill and died. despite médecins sans frontières' warnings about the unprecedented scope of the outbreak, 12 national authorities in guinea downplayed it for fear of creating panic and disrupting economic activity. 12, 13 internal documents 14 suggest similar concerns might have infl uenced who, which publicly characterised the outbreak in march as "relatively small still". 15 who's global alert and response network sent an expert team to support national eff orts, as did others such as the us centers for disease control and prevention. however, those teams withdrew from guinea and liberia in may when reported cases decreased, even as viral transmission continued. 16 in late may, sierra leone became the third country to declare an ebola outbreak to who. for the fi rst time in the known history of ebola, the virus had spawned sustained outbreaks in three countries. this should have raised substantial alarm, as coordination was weak between the national governments of liberia, guinea, and sierra leone, the borders extremely porous, and human movement and trade highly fl uid. in late june, médecins sans frontières labelled the situation as "out of control" and publicly called for more international attention and resources. 17 this second phase witnessed three interrelated failures. first, in a failure of political leadership, some national authorities did not call for greater international assistance despite the humanitarian crisis, and in some cases downplayed the outbreak. second, who's in-country technical capacity was weak, shown by its decision to withdraw its international team too soon and its poor responses in guinea and sierra leone to requests for technical guidance from ministries of health and health-care providers. 18, 19 third, who did not mobilise global assistance in countering the epidemic despite ample evidence the outbreak had overwhelmed national and non-governmental capacities-failures in both technical judgment and political leadership. the third phase began in july as cases, global attention, panic, and responses all grew. funding increased, with the world bank committing us$200 million in the fi rst major external fi nancing response. 20 media attention and public interest substantially increased after the evacuation of two infected us aid workers from liberia. 21 fear and hysteria in response to ebola infections in the usa later led to quarantines of returning aid workers and other measures counterproductive for controlling the epidemic. 22 dozens of countries, private companies, and universities began implementing travel restrictions, and many airlines ceased fl ying into the region. 23 on aug 7, who convened the international health regulations emergency committee, and the next day the director-general offi cially designated the ebola outbreak a public health emergency of international concern ("an extraordinary event which is determined...to constitute a public health risk to other states through the international spread of disease and to potentially require a coordinated international response." 11 ) detected cases grew expon entially. ebola treatment centres in all three countries were stretched beyond capacity and forced to turn away patients at their gates. 12 a growing lack of trust between population groups and government authorities hindered community mobilisation and public education. 24 in the ensuing weeks, the global community mobilised, with new commitments of fi nancing, health personnel, and logistical support from the african union, china, cuba, the european union, the uk, the usa, the world bank, the international monetary fund, and the un agencies. the un security council passed resolution 2177 declaring the outbreak a threat to international peace and security, the only time it has done so regarding an outbreak and only the second resolution ever (after hiv/aids in 2000) to focus on a disease. 25 the un secretary general created a new entity to coordinate the international response, the un mission for emergency ebola response. 26 additionally, trials for two candidate vaccines were launched in europe and the usa, and who convened an expert group to develop guidance for the ethics of using experimental therapies. 27 despite increased mobilisation of political attention and resources, this third phase witnessed several failures. first, public and private restrictions on trade and travel further harmed an already suff ering region and hindered control eff orts. 16, 28 second, the operational response commenced slowly, taking months for funding, personnel, and other resources to reach the region. [28] [29] [30] third, the creation of the un mission for emergency ebola response bypassed the pre-existing un body for emergency coordination, the offi ce for the coordination of humanitarian aff airs, further blurring the lines of responsibility for international coordination. fourth, fi eld staff often reinvented strategies for community mobilisation and contact tracing because relevant lessons from previous ebola outbreaks in uganda and the democratic republic of congo were not eff ectively transferred. 31 fifth, international staff with ebola sometimes received experimental therapies (albeit, the effi cacy and risks of which were unknown) and were evacuated while national staff largely were not, a demoralising and often deadly distinction for many health workers. 32, 33 sixth, there was poor understanding of how to take into account community beliefs, practices, and solutions, properly address rumours, and involve local leaders-with sometimes fatal consequences for health workers and communities. 34 a fourth phase began towards the end of 2014 as the epidemic turned a corner. the total number of cases began to decline in the hardest hit countries as community leaders and organisations joined control eff orts, even before large-scale global assistance arrived. ebola had been imported into nigeria, mali, and senegal in the second half of 2014. nevertheless, rapid information sharing, and mobilisation of health workers for contact tracing and patient care had limited the outbreak in senegal to one confi rmed infection. 35 in nigeria, the nigerian center for disease control, previous experience with polio eradication eff orts and a lead poisoning emergency were all cited as important factors in successful control of the outbreak in africa's most populous country. 36 by the end of january, 2015, more than $5 billion had been committed for the ebola response (although the proportion of these funds actually spent on ebola and in the aff ected countries remains unclear). 37 research and development eff orts were quickly operationalised despite uncertainty on processes for regulatory approval, with at least three vaccine candidates, three blood products, and fi ve drug candidates in clinical trials, with who playing a coordinating role. 38 during this phase, the binding constraints were no longer political attention, funding, or human resources, but operational coordination, accountability for eff ective use of funds, and maintaining momentum to prevent new infections. amidst the crisis, many acts of courage, solidarity, innovation, and leadership prevailed, often at a substantial personal cost. in west africa more than 800 local health workers contracted ebola caring for the sick; more than 500 of those caregivers died. 39 community members volunteered to trace contacts, local leaders educated communities, and religious authorities promoted new burial practices to prevent transmission. several non-governmental organisations vocally advocated for a stronger global response, treated patients, trained health workers, supported community mobilisation and longer-term recovery eff orts. additionally to massive funding from traditional donors, the african union, the economic community of west african states, cuba, and china made substantial contributions of personnel, funding, logistics, and technology (huang y, council on foreign relations, personal communication). 40 private foundations and companies contributed funds, with $245 million from the top fi ve contributors, along with meaningful in-kind assistance, such as air lifts. 3 the initiation and conduct of clinical trials were accelerated amidst the challenging conditions of an outbreak, enabled by the cooperative eff orts of industry, research funders, regulatory authorities in the usa, europe, and west africa, scientists, and directly aff ected communities. these positive steps notwithstanding, this panel's overarching conclusion is that the long-delayed and problematic international response to the outbreak resulted in needless suff ering and death, social and economic havoc, and a loss of confi dence in national and global institutions. failures of leadership, solidarity, and systems came to light in each of the four phases (panel 1). recognition of many of these has since spurred proposals for change. we focus on the areas that the panel identifi ed as needing priority attention and action. preventing small-scale outbreaks from becoming largescale emergencies needs a minimum level of core capacities in all countries to detect, report, and respond rapidly (panel 2). in the wake of the severe acute respiratory syndrome (sars) outbreak, governments committed to developing such core capacities by 2012 under the revised international health regulations (2005), with the 2012 deadline extended for some countries to 2014, then 2019 after ebola struck. according to self-assessments, as of 2014, two-thirds of countries had not met their core capacity requirements and 48 countries had not responded to who queries regarding their readiness. 41 the international health regulations did not include binding obligations for donors to provide support to poorer countries to meet these obligations, nor to fund who to fulfi l its mandate to provide technical assistance. 42 these shortcomings did not attract serious action or funding until the ebola outbreak. despite unprecedented international fi nancing during the past decade to combat particular diseases in developing countries, health systems in many resource-poor settings remain ill-prepared for outbreak response. 43 no alternate strategy has been developed to supplement these national-level weaknesses. if countries remain unable to detect outbreaks in a timely way, the rest of the chain of international health regulation-stipulated notifi cations and responses will fail once again. 44 additionally, according to the international health regulations, countries agreed to report potential health emergencies within 24 h to who for joint risk assessment, with the option of doing so confi dentially. who was also permitted to receive, analyse, and ask for verifi cation of outbreak information received from non-governmental sources. governments might hesitate to report outbreaks publicly for fear of political and economic repercussions, as occurred in china with sars in 2003. yet, history has shown that early reporting is essential to reduce both the health toll of an outbreak and its political and economic consequences. governments agreed in the international health regulations to prompt notifi cation, and in return, were reassured of the curtailment of unwarranted trade or travel restrictions and support from who technical assistance. during the ebola outbreak, however, 40 countries and many private fi rms implemented restrictions on travel or trade, despite who's recommendations against such measures and the security council's warnings about the resulting isolation of aff ected countries. 23, 25, [45] [46] [47] [48] we conclude that several concrete steps must be taken to prevent future outbreaks from becoming large-scale catastrophes. who should convene governments and other major stakeholders within 6 months to begin developing a clear global strategy to ensure that governments invest domestically in building core capacities and to mobilise adequate external support to supplement eff orts in poorer countries. there is growing momentum in the wake of ebola for such investments: the us government has committed $1 billion to build core capacities in at least 30 developing countries, including guinea, liberia, and sierra leone. 49 this work is being coordinated under the global health security agenda, a us-launched initiative that now consists of nearly 50 countries. 50 at its june, 2015, summit, the group of 7 (g7) announced support for 60 countries, although the g7 did not explicitly commit funds nor agree to a concrete plan. 51 financial commitments for recovery have also been made at various ebola conferences and summits. 52-54 other initiatives might also contribute to core capacity building. these include the gates foundation's child health and mortality prevention surveillance network, 55 the joint institut pasteur-china centers for disease control initiative to train west african scientists in outbreak response, 56 the merieux foundation's laboratory strengthening activities in west africa, 57 and the uk's £195 million fleming fund for antimicrobial resistance. 58 these welcome signals need to become sustained budget commitments to support national or regional plans, such as the mano river union post-ebola socioeconomic recovery programme, 59 and reviewed systematically beyond this initial phase at forums such as the g7, the g20, and the world health assembly. furthermore, dialogues about health security should not be isolated from broader discussions about development fi nancing, including of the sustainable development goals, as ebola exposed how substantially an epidemic could roll back hard-won development gains. a clear, coordinated plan, supported by a transparent central system for tracking and monitoring these resource fl ows, will be needed to minimise fragmentation and ensure that core capacities are systematically built and sustained. the proposed accountability commission for disease outbreak prevention and response (recommendation 5) should monitor investments and results for core capacity building. further analysis is needed to estimate the required level of additional funding. strategic investments for international health regulation core capacities can and should also strengthen broader health systems. 7,60 for example, health information systems can support surveillance and monitoring of outbreaks and routine health services; training and payment of community health workers and civil society service providers can help achieve universal health coverage, while providing an essential trained workforce during emergencies. additionally, regional and subregional actors should develop capacities to supplement gaps at the national level. for example, in africa, national governments, the african development bank, and other donors should invest in the infrastructural backbone for a network of laboratories, information systems, and training of african national emergency responders based in centres of excellence. the pan american health organization has shown the feasibility of a regional network of centres for disease control, and building such a network could be a central task of the proposed african centres for disease control and prevention. although the african centres for disease control and prevention might be perceived as a competitor to the who regional offi ce for africa, a clear delineation of responsibilities for outbreak response versus other health issues should enable close collaboration between the two. finally, governments must agree to regular, independent, external assessment of their core capacities. monitoring requirements should accompany external fi nancing. assessments will also be needed in self-fi nancing countries. some governments objected at the 2015 world health assembly to independent assessment. 61 nevertheless, a method for peer assessment piloted by fi ve countries through the global health security agenda could provide a basis for a monitoring process acceptable for all countries. political leaders, governments, and international organisations must strengthen the set of incentives and disincentives so that governments report disease outbreaks early. among these should be stronger disincentives for implementing trade and travel restrictions without a scientifi c or public health basis. who should promote transparency by publishing lists of countries that delay reporting disease outbreaks, while commending countries that rapidly share public information as mexico did in 2009 with h1n1. who publicly challenged china's government to be more transparent about sars, showing the organisation's potential political power. who should also publicly disclose lists of countries that implement trade and travel restrictions when who temporary recommendations advise against them and countries that do not provide a science or public health rationale for such measures (as required by the international health regulations). doing so will require a delicate balancing act between who's role as trusted interlocutor with governments on sensitive outbreak-related information, and its role as guardian of the international health regulations. although an individual government might object to such scrutiny in the short term, politically supporting who's prerogative to do so serves the long-term interests of global public health. 62 funding bodies such as the world bank, the asian infrastructure investment bank, the african development bank, and the new development bank (previously known as the brics development bank) should create economic incentives for early reporting by committing to disburse emergency funds rapidly to assist countries when outbreaks strike and compensating for economic losses that might result. the world bank's proposed pandemic emergency financing facility or the african union's african risk capacity agency 63 off er the possibility of insurance to mitigate the economic costs linked to outbreak reporting. the trigger for disbursement should be a risk assessment done under the aegis of who. because private fi rms such as airlines and shipping companies are not directly bound by public international law, alternate governance mechanisms are needed to prevent isolating countries when outbreaks strike. the 16 these could include designating a un focal point for the private sector during outbreaks, designing industry-wide cooperation frameworks, and developing codes of conduct. if preventive measures fail and an outbreak escalates into a major crisis, responsibility for taking action and alerting the broader global community must be clearly designated (fi gure 1). as noted, countries agreed as part of the international health regulations to notify who of any potential public health emergency of international concern within 24 h of assessment. who rapidly shares information with the global alert and response network, a loose network coordinated by who of academics, government scientists, non-governmental organisations, and health volunteers. the global alert and response network analyses and assesses reports, deploys investigators, conducts laboratory examination and identifi cation of the outbreak cause, and advises on further measures, including, as a fi nal resort, a potential public health emergency of international concern declaration. however, the global alert and response network's skeleton staff is too small to deploy in multiple suspected outbreaks, its budget has been severely cut, and it is not authorised by who to draw public attention to a crisis. responsibility for declaring a public health emergency of international concern belongs to the who director-general, who convenes an emergency committee of independent experts for a recommendation. however, the director-general did not use her international health regulation-granted authority to convene the emergency committee nor declare a public health emergency of international concern until 5 months after guinea and liberia had notifi ed who. 64 in view of the severity of ebola virus disease, rapid cross-border spread, weaknesses of the aff ected national health systems, the post-confl ict setting, 65 and repeated warnings from nongovernmental organisations in the region, 12 the director-general had ample reason to raise international attention by convening the emergency committee or declaring a public health emergency of international concern earlier. the committee responsible for reviewing who's performance during the ebola outbreak (the who ebola interim assessment panel) and leaked internal emails suggest several reasons for the delay including concerns about political opposition from west african leaders, economic ramifi cations, and a culture within who discouraging open debate about sensitive issues, such as emergency declarations. 14,64 who might also have hesitated because it was sharply criticised for creating panic by declaring a public health emergency of international concern during the relatively mild 2009 h1n1 pandemic. 9 whatever the root causes, the delay emphasised the risks inherent in vesting such consequential decision making power in a single individual. this risk is heightened when there is no institutional mechanism of accountability for leadership failures. after the public health emergency of international concern declaration, a substantial global response was mobilised. however, this response arrived late, was slow to deliver funds and health workers, was infl exible in adapting to rapidly changing conditions on the ground, was inadequately informed about cultural factors relevant to outbreak control, and was poorly coordinated. the result was, in essence, a $5 billion scramble. an excessive burden fell on national and international nongovernmental organisations and local communities to do the highest-risk work such as patient care and burials. the creation of the un mission for emergency ebola response as an ad hoc body operating outside established humanitarian response structures reportedly made coordination of the crisis response even more diffi cult. 64, 66 funding was low until the upsurge of commitments in september, 2014, and, even then, there were long lags between pledges and disbursement. by one account, national surveillance identifies event of concern assessment of public health risk (48 h) affected country reports to who (24 h) response at who headquarters response in country who director-general convenes emergency committee to assess for public health emergency of international concern; director-general consults affected state emergency committee advises director-general who issues temporary recommendation if national capacity is outstripped, international actors should supplement national efforts director-general withdraws public health emergency of international concern declaration in case of state failure, actors operate under un coordination public health emergency of international concern controlled emergency committee reviews public health emergency of international concern status and recommendation if disease crosses borders, affected governments coordinate responses with support from regional and global organisations nearly $3 billion had been pledged by the end of 2014 but only a third of this money was disbursed. 69 furthermore, transparency of fi nancial fl ows is crucial to minimise duplication, to ensure aid goes to areas of most need rather than those easiest to assist, and to ward against mismanagement. however, transparency was, and remains, wholly inadequate: on the donor side, multiple tracking systems exist but it remains impossible to construct a clear, comprehensive picture of monetary and in-kind pledges and disbursements across the many public and private donors. 37 on the recipient side, who received what funds to do which tasks also remains an opaque puzzle-and assessing the eff ect or effi cient use of those funds is more diffi cult still. we off er three further recommendations to tackle these issues. high-level political leaders must clearly designate who is responsible for responding when disease outbreaks outstrip national capacities, invest in the capacity to respond, and ensure accountability for fulfi lment of these responsibilities. although national governments and nongovernmental organisations working on the ground are the fi rst line of defence when outbreaks arise, who is crucial for the second line of defence when governments need international support or when an outbreak strikes more than one country. to strengthen who's capacity during outbreaks, we welcome the stocking panel's recommendation to create a who centre for emergency preparedness and response, and off er several additional recommendations regarding its key functions and attributes. the centre should merge the outbreak risk assessment and response capacities that reside in the global alert and response network with who's humanitarian teams, which presently respond to natural disasters, refugee crises, and other large catastrophes. its operational lines of authority from headquarters to regions and countries should be clearly designated. the centre should assess risks on the basis of the information that countries and others provide to who, and mobilise necessary laboratory, epidemiological, clinical, communications, and logistical responses. it should have powerful analytical, data processing, and advisory capacity to command respect in both policy and scientifi c communities. the centre should develop rapid response and strong coordinating capacity, and be able to assemble the world's best expertise to tackle disease threats. between crises, the centre should develop protocols, build relationships, and negotiate agreements with governments, multilateral organisations, non-governmental organisations, private fi rms, and other actors to mobilise rapidly during emergencies, including strengthening capacities in developing countries so that they might better respond nationally and participate internationally. in a multicountry outbreak, the centre should ensure government-to-government coordination by establishing channels of direct communication for rapid information sharing. it should be responsible for building a virtual global health workforce from both industrialised and developing countries by setting standards for certifying crisis responders, ranging from communications experts and logisticians to surgeons and managers. these responders would continue working for their home organisations, but provide surge capacity in a crisis. finally, the centre should provide technical assistance to countries to build and maintain international health regulation-mandated core capacities. the centre should have its own executive director who is accountable for performance jointly to a separate board of directors and to the director-general. the multistakeholder board should include broad repre sentation of governments from each who region, scientifi c expertise including about animal health, operational responders from all sectors, and funders. the executive director should inform the board immediately when the centre's risk analysis suggests that coordinated international action is needed and mobilise an appropriate response. similar governing structures have worked eff ectively for who-affi liated entities including the global polio eradication initiative, the international agency for research on cancer, unitaid, and the special programme for research and training in tropical diseases. the centre's budget should be protected and adequately resourced through a dedicated revolving fund. the fund should immediately disburse money for rapid scale-up when a crisis strikes, then be replenished from funds raised for that crisis to be ready for the next one. the centre and its board should work closely and routinely with the director-general so that the highest levels of leadership are constantly aware of evolving disease threats, and can marshal who's legal, political, and human resources at regional and country levels when needed. who should use its international health regulation-granted authority to expedite access to aff ected sites by technical teams and pressure any state that impedes international responses to, or obscures, disease threats in its territory. the centre must have access to sensitive outbreak information that countries are required to share with who; further analysis is needed as to whether this would require amendment to the international health regulations. a third line of defence will be needed if the initial response does not succeed and an outbreak becomes a humanitarian crisis (eg, a un level 3 emergency 68 ), threatening not only public health, but also political, economic, and social stability. international coordination of the large-scale eff ort needed in this case should be done by the offi ce for the coordination of humanitarian aff airs. however, because the offi ce for the coordination of humanitarian aff airs (and most other humanitarian actors) do not specialise in crises precipitated by disease outbreaks, they should develop in-house capacity and a broad coordination framework with the health sector for such emergencies. member states should amend the international health regulations to broaden responsibility for declaring a public health emergency of international concern. the director-general convenes, and is advised by, an ad hoc emergency committee constituted from a list of independent experts; however, authority and responsibility to declare a public health emergency of international concern rests exclusively with the director-general. we recommend the creation of a standing emergency committee that meets regularly, with the mandate to declare a public health emergency of international concern by a majority vote of its members. the emergency declaration should trigger other actions, such as fi nancial disbursements by development banks, emergency data-sharing and specimen-sharing rules, and emergency regulatory procedures for new drugs, vaccines, and diagnostics (recommendations 6 and 7). the director-general should chair, communicate, and explain the standing emergency committee's decisions. following an open call for nominations, the director-general would appoint the fi rst members; thereafter, the standing emergency committee itself would periodically vote in new members to preserve its independent character. minutes and votes of standing emergency committee members should be published immediately following each meeting for the sake of transparency, to build external confi dence, reduce political interference, and strengthen the committee's hand against resistant states. similarly to other institutions responsible for technically complex yet politically consequential decisions, such as central banks or drug regulatory authorities, the standing emergency committee must be protected from political pressure that might interfere with its judgment. the committee should possess high-level public health expertise and base its decisions on scientifi c principles and evidence, assessing risks for human health, disease spread, and international traffi c. the standing emergency committee should have adequate economic expertise to weigh the risks of disrupted trade and travel against those posed by the outbreak and advise on how to ameliorate economic harm. the standing emergency committee should also issue early warnings of major potential risks on the basis of continuing assessments done by the who centre. the committee should also consider replacing the present binary system, which calls for determining the presence or absence of a public health emergency of international concern, with a graded system of warnings. 64 finally, the standing emergency committee should publish an annual report detailing its activities to ensure public accountability and continued political attention to health threats. the committee should be fi nanced purely through assessed contributions to protect against undue donor infl uence. a committee does not by defi nition operate more eff ectively than an individual, and might succumb to risk aversion and dysfunction; nevertheless, the combination of measures described above should provide the standing emergency committee with the autonomy and capacity for credible, authoritative decision making. the un secretary general should create an accountability commission as an independent body comprised of civil society, academia, and independent experts doing realtime and retrospective system-wide assessment of global responses to major disease outbreaks. the accountability commission would track and analyse the contributions and results achieved by national governments, donors, un agencies, international and national nongovernmental organisations, and the private sector. all major actors would be expected to share information promptly with the accountability commission about fi nancial, in-kind, or operational contributions; the the accountability commission should publish the names of organisations unwilling to share such information. the accountability commission would assess aid eff ectiveness, including funds committed, paid, dis bursed, and spent; both short-term and long-term accomplishments achieved with those funds; and the timeliness, eff ectiveness, cultural appropriateness, and equity of the response for intended benefi ciaries. the accountability commission should liaise directly with and provide a forum for representatives of communities directly aff ected by outbreaks. finally, it should monitor eff orts to build and sustain national core capacities. the accountability commission would report to the world health assembly and the security council's global health committee (recommendation 8), and publish its fi ndings regularly during and after each public health emergency of international concern. after an open call for nominations, the secretary general would appoint the fi rst members; thereafter, the accountability commission itself would periodically vote in new members to preserve its independent character. the accountability commission would off er an important multistakeholder platform for various constituencies involved in and aff ected by disease outbreak responses. this proposal builds on analogous eff orts to strengthen system-wide accountability for other global eff orts, such as the un commission on information and accountability for women's and children's health 69 and the independent monitoring board of the global polio eradication initiative, credited with helping to reinvigorate the performance of this eff ort. 70 the accountability commission would be a more permanent institution, however, with a broader mandate than these two previous initiatives. producing and rapidly sharing knowledge during outbreaks is essential. however, reliable systems for rapid transmission of epidemiological, genomic, and clinical data were not established during the ebola epidemic. although governments in the three worst aff ected countries transmitted epidemiological information to who, robust channels were not established for direct data exchange and coordination between the three capitals. although some researchers shared genomic sequencing data early in the outbreak through an open access database, other researchers later withheld such data from the public domain. 71 and although care providers and researchers collected thousands of patient samples, now housed in laboratories in west africa and worldwide, no clear arrangements exist for scientists to access those samples, 72 for their safe handling, or to ensure that west african patients benefi t from the fi ndings or technology that might result. 73 previous epidemics show that better arrangements are feasible. during the 2003 sars outbreak, who established online systems for data sharing among a worldwide network of scientists, enabling researchers to identify the virus, sequence its genome, and understand its characteristics. 74 in 2006, an international consortium of researchers agreed to data sharing norms for infl uenza, which enabled real-time dissemination and publication of epidemiological and clinical data during h1n1 in 2009. 73 the consortium for the standardization of infl uenza seroepidemiology helps to coordinate a global community of researchers working on infl uenza serology. furthermore, after 4 years of intergovernmental negotiations, the 2011 who pandemic infl uenza preparedness framework achieved a delicate balance between sharing samples and access to the resulting technology. 76, 77 however, no analogous framework exists for other pathogens. access to knowledge embodied in the form of technologies has been a particularly diffi cult issue. as noted, no drugs, vaccines, or rapid diagnostic tests had been approved for ebola when the outbreak began. although scientists had identifi ed the virus nearly four decades earlier and basic research had advanced understanding of the disease, ebola was not an attractive target for industry investment in research and development, nor was it high on the public health research agenda. somewhat serendipitously, the us and canadian governments had years earlier made defence-related investments in ebola, which meant that university and pharmaceutical industry researchers had developed several experimental drug and vaccine candidates when the outbreak hit. as noted, clinical trials for vaccines and drugs were launched in record time (with encouraging results for one vaccine candidate reported in july, 2015). 78 nevertheless, the overall research and development eff ort could have moved faster if there had been investments beforehand to advance candidate products through phase 1 or 2 trials and a system to prioritise the most important technologies. for example, eff ective rapid point-of-care diagnostics could have enhanced contact tracing, counteracted community resistance and denial, protected health workers, reduced patient loss to follow-up, eased overburdened treatment centres, and supported the continued operation of shipping and airline services. a systematic way of posing and answering operational research questions, such as the relative merits of using intravenous fl uids for patient care, would also have strengthened the response. furthermore, who provided valuable technical leadership about the ethics of using unproven therapies, but little guidance on how strictly limited quantities of drugs should be rationed. west african health workers and patients were largely denied access to the stocks sometimes available to international staff . 79 in several instances, who proved its capacity to lead, convene, coordinate, and establish norms among a broad range of public and private actors on research and development and data sharing. additionally to its guidance about experimental therapies, who convened research and development actors in mid-2014 and late-2014, and again at a global ebola research and development summit in may, 2015. in july, 2015, who also issued guidance about accelerating regulatory approval of technologies in emergencies. who also convened a meeting in september, 2015, to build norms for open data sharing as part of an eff ort to develop a "blueprint" to guide the collective research and development eff orts of industry and governments for emergencies. these successful eff orts should be institutionalised to better govern knowledge production and sharing in future outbreaks. before the 2016 world health assembly, who should convene governments, the scientifi c research community, industry and non-governmental organisations to begin developing a framework of norms and rules for research relevant to disease outbreaks. the framework's goal would be to provide guidance on three interrelated issues: 1. access to data and samples to enable and accelerate research, which would involve rapid sharing of epidemiological surveillance and clinical data to inform outbreak control strategies; incentives and platforms for open sharing and access to genomic sequencing data; access to specimen samples (with appropriate biosafety measures). 2. appropriate conduct of research, including improved ethical standards for research and development (eg, including involving aff ected populations in setting research priorities, patient participation and consent); previous agreement about experimental protocols, such as trial design, to speed clinical trials when outbreaks strike; 80 access to clinical trial data, such as publication of negative and positive results; clear pathways for approval by stringent regulatory authorities and in countries of use; and building on and investing in research capacities in epidemicaff ected countries. 3. equitable access to the benefi ts of research, including priority, aff ordable access to newly developed health technologies for aff ected populations, including health workers; and ethical guidelines for rationing products with limited availability. an overarching framework is needed to bring coherence and fi ll gaps in the fragmented system of international rules shaping outbreak-related research (including the international health regulations, pandemic infl uenza preparedness framework, convention on biological diversity and its nagoya protocol, agreement on trade related aspects of intellectual property rights, and numerous guidelines and agreements for data ownership and sharing among scientists). the framework would include both nonbinding norms such as guidelines or codes of conduct, and binding rules such as contractual obligations or international law. further analysis is needed to specify the most appropriate instruments for each issue area. some norms would apply at all times to prepare for potential outbreaks; others could be limited to and triggered by a public health emergency of international concern declaration. establishment of such norms in advance would strengthen preparedness and reduce counter-productive competition between researchers or institutions during emergencies. ideally, such a normative framework would cover all pathogens with the potential to cause major outbreaks. however, in view of the complexity and political diffi culties reaching agreement on these issues, a feasible starting point might be to develop a pilot framework for one or several diseases such as viral haemorrhagic fevers. lessons from this pilot could subsequently be applied to expanding the framework to other pathogens. the accountability commission (recommendation 5) should monitor progress towards developing this framework and subsequently monitor adherence to it. recommendation 7: establish a global facility to fi nance, accelerate, and prioritise research and development. the un secretary general and the who director-general should convene in 2016 a high-level summit of public, private, and not-for-profi t research funders to establish a global fi nancing facility for research and development for health technology relevant for major disease outbreaks. the facility would support manufacturing, research, and development for drugs, vaccines, diagnostics, and other non-pharmaceutical supplies (such as personal protective equipment) where the commercial market does not off er appropriate incentives. for known pathogens, the facility could invest in bringing candidate drugs, vaccines, technology platforms, and other relevant products through proof of concept, phase 1, and phase 2 testing in humans, so that they are ready for wider testing, manufacturing, and distribution when an outbreak strikes. during an outbreak the facility would rapidly mobilise fi nance for priority research and development projects, such as diagnostics for novel pathogens. the establishment of a similar fund for diseases aff ecting developing countries was a central recommendation of the 2012 report of the who consultative expert working group on research and development. 81 as a result, a pooled international fund was created to support "demonstration projects" that test new research and development business models, such as open knowledge innovation and delinkage of research and development fi nancing from end product prices. with a management structure already established, the demonstration projects off er an important option for pursuing research and development for ebola or other diseases. the global fi nancing facility should be a lean, effi cient entity that mobilises and strategically deploys resources. it would not be a monolithic entity nor the sole funder for epidemic-related research and development because some pluralism and competition among funders is desirable. nevertheless, a global facility would off er the advantage of enabling coordination between diff erent research funders through a common framework, strengthening networks between researchers, estab lishing processes for priority setting, and reducing transaction costs for both grantees and smaller donors. 82, 83 it could also require information sharing between researchers as a condition of funding, thereby giving teeth to the data-sharing framework (recommendation 6). intellectual property or any other asset resulting from these investments should be managed as a public good to enable follow-on innovation, open knowledge sharing, access to technology, and a fair public return on investment. support for a global research and development fi nancing mechanism now seems to be growing, as shown in calls for a $2 billion global fund for vaccine development for pandemics, 82 a $2 billion global fund for antimicrobial resistance, 84 and a $2-3 billion global fund that would cover emerging infectious diseases, neglected diseases, and antimicrobial resistance. 85 an eff ective global system for preventing and responding to outbreaks needs well coordinated and appropriately resourced actors to fulfi l clearly defi ned roles and responsibilities and to hold each other accountable for doing so (table). many actors have crucial roles in this complex system: national governments have the main responsibility for their populations' health. national governments are also responsible for immediately sharing information with neighbouring countries and the international community in the event of a potential public health emergency of international concern. they also hold responsibility for calling for international assistance if domestic capabilities prove inadequate. in turn, international actors are responsible for supporting national governments individually and collectively. who should play a central part in monitoring, assessing, and responding to disease outbreaks. national and regional agencies for disease control and academies of science also off er important technical capacities for managing outbreaks. development banks are responsible for mobilising and disbursing fi nancing to support governments and collective action. the international humanitarian system, including the offi ce for the coordination of humanitarian aff airs, unicef, the world food programme, the un high commissioner for refugees, other un bodies, and non-governmental organisations are responsible for mounting an eff ective operational response if an outbreak escalates into a humanitarian crisis. the research community is responsible for producing relevant knowledge on the outbreak, and developing and producing technologies to intervene. civil society, including academia and the media, play a crucial part in drawing attention to unmet needs, neglected challenges, and systemic failings, and demanding accountability from responsible actors. finally, the un security council is responsible for addressing threats to international peace and security. ebola developed from a relatively small outbreak into a large-scale emergency because of the failures of multiple actors to fulfi l their mandated roles and responsibilities. our fi nal three recommendations outline the institutional changes needed to prevent such failures from recurring. in recognition of health as an essential facet of human and national security, the un security council should establish a global health committee consisting of government representatives. the com mittee's main goal would be to expedite and elevate political attention to health issues posing a serious risk to international peace and security and provide a prominent arena to mobilise political leadership. specifi cally, the committee would monitor and publish an annual report on progress in building a strong and eff ective global health security system, taking into account analyses from the accountability commission and who. the committee would also address alleged non-compliance with international health regulation provisions on trade and travel measures. the committee would not declare public health emergencies of international concern. this decision would remain technically driven and under the authority of who. the committee would not be able to strengthen core capacities within and between countries to prevent, detect, and respond to outbreaks support governments with technical and scientifi c knowledge and advice financing by major public and private donors; technical assistance by specialised agencies and non-governmental organisations mobilise external assistance when countries unable to prevent an outbreak from becoming a crisis raise awareness of major disease events; declare public health emergencies of international concern as appropriate; early-stage rapid response to outbreaks; convening for resource mobilisation who is an essential hub in the global system for health security. however, evidence of confusion and disagreement about its role is ample. 86 since the 19th century, cross-border disease control was the fi rst and most widely accepted rationale for intergovernmental health cooperation. 87 yet, in the wake of the global fi nancial crisis when who laid off more than a tenth of its headquarters staff , outbreak response capacity was deeply and disproportionately cut. 88 disease outbreaks are not the only important work for who, but they are foundational to the organisation's mandate. within a global system for disease outbreak response, what should be who's essential role? who's near-universal state membership, governance structure, and deep relationships with health ministries situate it uniquely to perform four core functions (table): support governments in building national core capacities for prevention, surveillance, and response through technical and scientifi c knowledge and advice; assess and provide rapid early response to outbreaks, raise awareness of major disease events, and declare public health emergencies of international concern when appropriate; establish technical norms, standards and guidance; and convene actors to set goals, mobilise resources, resolve confl icts, and negotiate rules. performance of these functions needs strong political, scientifi c, and normative leadership with solid backing from member states. however, who's failings on these core functions during the ebola outbreak have now produced an existential crisis of confi dence. ebola exacerbated a trend since the 1990s of many governments and other organisations working around who. decades of reducing assessed contributions in real terms has starved the organisation of resources. donors have earmarked voluntary contributions, eff ectively controlling nearly 80% of who's budget by 2015. 89 the result is an organisation that seems to have lost its way. although the budget has more than doubled from us$1·6 billion in 1998-99 to us$4 billion in 2012-13, the organisation itself controlled an ever-shrinking share. one casualty of recent decisions was who's reduced ability to control cross-border disease outbreaks, a core task for which it was created in 1948. in the wake of ebola, the organisation's traditional claims of legitimacy based on near-universal state membership no longer seem suffi cient. a true recovery will need far greater willingness by member states to entrust resources and delegate authority to who, but it has rarely been in a weaker position to command such trust and authority. confi dence in the organisation's capacity to lead is at an all-time low. calling for additional staff or a larger budget will not address this. who must fi nd a way to prioritise what it does, and regain its credibility, independence, and legitimacy to perform its core functions (table) . breaking out of this 20-year impasse will demand clear commitment and a diff erent kind of leadership by who to implement fundamental reforms under a tight timeline, matched by an equally clear commitment by member states to reward such reform with appropriate authority and resources. who performed a key coordinating function in research and development during the ebola epidemic. it was also central to controlling nine previous ebola outbreaks, sars, and other epidemics. these examples are important reminders of what who can do under determined leadership. who is in a formal reform process that was spurred by a budget crisis in 2011; in some ways, it has been in a perennial process of reform since at least the 1990s. these previous eff orts are a reminder that high-level political leadership, such as the engagement of heads of state, will be needed if the outcome is to be diff erent this time. at this point, anything less than fundamental reform will mean continued marginalisation and decline, alongside increasing vulnerability for global public health. to rebuild trust, respect, and confi dence within the international community, who should maintain its broad defi nition of health, but substantially scale back its expansive range of activities to focus on core functions. the scope of who's work would thus continue to embrace the full range of health issues, but its functions should be far more circumscribed. we restrict our analysis to core functions in infectious disease outbreaks. however, there remains the need to defi ne who's core functions in other key areas of work, such as non-communicable diseases, injuries, environmental health, health systems, and social determinants of health. for this purpose, the january 2016 executive board should launch a fundamental review of the organisation's constitution and mandate to defi ne its core functions. this review should identify and hand over non-core activities to other actors, thereby streamlining who's activities. it should also examine which core functions are not being fulfi lled or adequately funded. the fi nancing model for who is unstable and politically vulnerable. the january 2016 executive board should also begin developing a new fi nancing model for assessed contributions focused on core functions and draft a transparently implemented policy about when to accept or reject voluntary contributions at headquarters, regional, and country offi ces. if who strictly defi nes its core functions and accelerates other good governance reforms (recommendation 10), member states should shift most of its fi nancing to assessed and non-earmarked voluntary contributions. recommendation 10: good governance of who through decisive, timebound reform, and assertive leadership. restoring credibility demands that who institutionalises accountability mechanisms, strengthens and clarifi es how it works with other actors, and fosters strong leadership. the january 2016 executive board should launch a process to implement four new policies for who to meet basic principles of good governance: establish a freedom of information policy, with appropriate safeguards; create a permanent inspector general's offi ce to monitor overall performance of the organisation and its entities, reporting to the executive board; conclude continuing work on the framework of engagement with non-state actors to better govern the way who interacts with civil society, academia, foundations, and the private sector; and revise human resource policies to attract or retain well qualifi ed staff , including for leadership positions, while letting go of chronic underperformers. the executive board should seize the short window of opportunity available for such reforms by giving a strong mandate to an interim deputy for managerial reform reporting to the director-general to implement these policies by july, 2017 (before the next director-general takes offi ce). in line with the reformed approach to human resources, all upcoming leadership selection and election processes at headquarters, regional, and country offi ces should be based on personal, technical, and leadership merits. the executive board, with the participation of civil society, should do an annual appraisal of senior leadership to strengthen accountability. as the next director-general election approaches, member states should insist on a dynamic leader with a strong record of focusing on people, able to manage crises, implement reforms, and communicate strategically. a key attribute should be proven high-level political leadership with the character and capacity to challenge even the most powerful governments when necessary to protect public health. it is in the collective interest of member states to have a strong, empowered leader heading the who. taken together, the panel's ten recommendations provide a vision for a more robust, resilient global system able to manage infectious disease outbreaks (panel 3, fi gure 2). preventing small outbreaks from becoming large-scale emergencies demands investment in minimum capacities in all countries and encouragement of early international reporting of outbreaks by adhering to agreed international rules. responding eff ectively to outbreaks demands much stronger operational capacity within who and within the broader aid system if outbreaks escalate into humanitarian emergencies, a politically protected process for who's emergency declarations, and strong mechanisms for the accountability of all involved actors, from national governments to non-governmental organisations and from un agencies to the private sector. mobilisation of the knowledge needed to combat outbreaks will require an international framework of rules to enable, govern, and ensure access to the benefi ts of research, and fi nancing to develop technology when commercial incentives are inappropriate. finally, eff ective governance of this complex global system demands high-level political leadership and a who that is more focused and appropriately fi nanced and whose credibility is restored through the implementation of good governance reforms and assertive leadership. the human catastrophe of the ebola epidemic that began in 2013 shocked the world's conscience and created an unprecedented crisis. it exposed deep inadequacies in the national and international institutions responsible for protecting the public from the far-reaching human, social, economic and political consequences of disease outbreaks. the reputation and credibility of who has suff ered a particularly fi erce blow. ebola brought to the forefront a central question: is major reform of international institutions feasible to restore confi dence and prevent future catastrophes? or should leaders conclude the system is beyond repair and take ad hoc measures when the next major outbreak strikes? research: producing and sharing data, knowledge, and technology 6. develop a framework of rules to enable, govern, and ensure access to the benefi ts of research 7. establish a global facility to fi nance, accelerate, and prioritise research and development governing the global system 8. sustain high-level political attention through a global health committee of the security council 9. a new deal for a more focused, appropriately fi nanced who 10. good governance of who through decisive, time bound reform and assertive leadership international health regulation emergency committee. the standing emergency committee will meet and receive information from the emergency centre regularly, with the mandate to declare a public health emergency of international concern by a majority vote of its members. the director-general would chair this committee. a permanent inspector general's offi ce is proposed, along with other good governance reforms (not depicted in the fi gure) such as a freedom of information policy. after diffi cult and lengthy deliberation, our panel concluded major reforms are warranted and feasible. the panel refi ned its recommendations into a roadmap of ten interrelated reforms that in combination can strengthen the global system for outbreak prevention and response. the roadmap gives greatest weight to clarifi cation of the roles and responsibilities of the many actors involved in outbreak response, investing in capacities to fulfi l those roles, and demanding accountability for meeting those responsibilities. these measures are concrete, actionable, and measurable. success requires one other essential ingredient: high-level political leadership determined to translate this roadmap into enduring systemic reform so that the immense human suff ering of the ebola outbreak will not be repeated. msf addresses un security council emergency session on ebola ebola situation reports un offi ce of the special envoy on ebola. resources for results iii appeal: ebola virus outbreak-overview of needs and requirements (inter-agency plan for guinea global health security: the wider lessons from the west african ebola virus disease epidemic governance challenges in global health the next epidemic-lessons from ebola preparing for the next outbreak report of the review committee on the functioning of the international health regulations (2005) in relation to pandemic (h1n1) ground zero in guinea: the outbreak smouldersundetected-for more than 3 months pushed to the limit and beyond: a year into the largest ever ebola outbreak inside the troubled early days of guinea's ebola response emails: un health agency resisted declaring ebola emergency who says guinea ebola outbreak small as msf slams international response ebola's lessons: how the who mishandled the crisis doctors without borders canada/médecins sans frontières (msf) canada. ebola in west africa: "the epidemic is out of control investigation: bungling by un agency hurt ebola response ahf: failed global ebola response demands new leadership ebola: world bank group mobilizes emergency funding to fi ght epidemic in west africa why we fail at stopping outbreaks like ebola yale global health justice partnership and american civil liberties union. fear, politics, and ebola how quarantines hurt the fight against ebola and violate the constitution. connecticut: yale global health justice partnership who. statement on the 1st meeting of the ihr emergency committee on the 2014 ebola outbreak in west africa liberia's military tries to remedy tension over ebola quarantine. monrovia: the new york times with spread of ebola outpacing response, security council adopts resolution 2177 (2014) urging immediate action, end to isolation of aff ected states special representative of the un secretary general arrives in accra to establish the un mission for ebola emergency response headquarters ethical considerations for use of unregistered interventions for ebola virus disease ebola: the failures of the international outbreak response international donations to the ebola virus outbreak: too little, too late? as ebola rages, poor planning thwarts eff orts community-centered responses to ebola in urban liberia: the view from below we are dying of ebola; where is the world? africa review disease outbreak: finish the fi ght against ebola importation and containment of ebola virus disease-senegal and the centers for disease control and prevention (cdc) when losing track means losing lives: accountability lessons from the ebola crisis who. ebola r&d eff ort-vaccines, therapeutics, diagnostics who. ebola situation report-17 how cuba could stop the next ebola outbreak responding to health emergencies ebola: towards an international health systems fund overseeing global health implementation of the international health regulations (2005)-report of the review committee on second extensions for establishing national public health capacities on ihr implementation. geneva: world health organization who. statement on the 2nd meeting of the ihr emergency committee regarding the 2014 ebola outbreak in west africa statement on the 3rd meeting of the ihr emergency committee regarding the 2014 ebola outbreak in west africa. geneva: world health organization who. statement on the 4th meeting of the ihr emergency committee regarding the 2014 ebola outbreak in west africa statement on the 5th meeting of the ihr emergency committee regarding the ebola outbreak in west africa. geneva: world health organization the white house offi ce of the press secretary uniting in seoul to extinguish epidemic threats through the global health security agenda leaders declaration international ebola recovery conference world bank group provides new fi nancing to help guinea, liberia and sierra leone recover from ebola emergency the bill & melinda gates foundation to fund disease surveillance network in africa and asia to prevent childhood mortality and help prepare for the next epidemic train africa's scientists in crisis response clinical laboratory networks contribute to strengthening disease surveillance: the resaolab project in west africa fleming fund launched to tackle global problem of drug-resistant infection a wake up call: lessons from ebola for the world's health systems the ebola review: parts i and ii who criticizes china over handling of mystery disease. hong kong: the new york times african risk capacity insurance mechanism report of the ebola interim assessment panel ebola virus disease epidemic in west africa: lessons learned and issues arising from west african countries saving lives: the civil-military response to the 2014 ebola outbreak in west africa ebola virus outbreak -overview of needs and requirements (inter-agency plan for guinea inter-agency standing committee working group. humanitarian system-wide emergency activation: defi nitions and procedures commission on information and accountability for women's and children's health. keeping promises, measuring results the power of straight talk: the independent monitoring board of the global polio eradication initiative data sharing: make outbreak research open access ebola researchers plead for access to virus samples proposed ebola biobank would strengthen african science sars: a global response to an international threat a global initiative on sharing avian fl u data infl uenza preparedness framework advisory group technical expert working group on genetic sequence data the who pandemic infl uenza preparedness framework: a milestone in global governance for health effi cacy and eff ectiveness of an rvsv-vectored vaccine expressing ebola surface glycoprotein: interim results from the guinea ring vaccination cluster-randomised trial opting against ebola drug for ill african doctor 81 who consultative expert working group on research and development. research and development to meet health needs in developing countries: strengthening global fi nancing and coordination establishing a global vaccine-development fund demonstration fi nancing: considerations for the new international fund for r&d securing new drugs for future generations: the pipeline of antibiotics a global biomedical r&d fund and mechanism for innovations of public health importance what's the world health organization for?: fi nal report from the centre on global health security working group on health governance the world health organization. abingdon: routledge cuts at w.h.o. hurt response to ebola crisis who. proposed programme budget all authors contributed to study concept, data analysis and interpretation, and provided critical revisions of the manuscript for important intellectual content. pp, akj, map, and ds chaired and co-chaired the panel, respectively, providing high level content and directional oversight. sm supervised the study design, data collection, data analysis, and data interpretation; drafted the manuscript; and led all revisions. bh, jal, and lrw contributed to the data collection, data analysis and data interpretation; creation of fi gures; and provided administrative, technical, and material support. we thank julio frenk for initial discussions that led to the creation of the panel, and robert marten and the rockefeller foundation for supporting the london meeting of the panel, and research and dissemination eff orts. we are grateful to emily anne robinson for research and organisational support for the boston meeting, and to zoe mark lyon for research support. key: cord-024981-yfuuirnw authors: severin, paul n.; jacobson, phillip a. title: types of disasters date: 2020-05-14 journal: nursing management of pediatric disaster doi: 10.1007/978-3-030-43428-1_5 sha: doc_id: 24981 cord_uid: yfuuirnw disasters are increasing around the world. children are greatly impacted by both natural disasters (forces of nature) and man-made (intentional, accidental) disasters. their unique anatomical, physiological, behavioral, developmental, and psychological vulnerabilities must be considered when planning and preparing for disasters. the nurse or health care provider (hcp) must be able to rapidly identify acutely ill children during a disaster. whether it is during a natural or man-made event, the nurse or hcp must intervene effectively to improve survival and outcomes. it is extremely vital to understand the medical management of these children during disasters, especially the use of appropriate medical countermeasures such as medications, antidotes, supplies, and equipment. skeleton as a result of incomplete calcification and active bone growth centers. protected organs, such as the lungs and heart, may be injured due to overlying fractures. cervical spine injuries can also be pronounced, as in patients with head trauma. in fact, spinal cord injury may be present without any radiographic abnormalities of the spine. finally, vital signs will vary based on the pediatric patient's age. this may be a pitfall during rapid evaluation by any nurse or hcp not accustomed to the care of children. younger pediatric patients have higher metabolic rates and, therefore, higher respiratory rates and heart rates. this can be a distinct disadvantage versus older pediatric patients when encountering similar diseases. an example is inhaled toxins (e.g., nerve agents and lung-damaging agents). infants and children will suffer greater toxicity since they inhale at a faster rate due to higher metabolic demands and thus, distribute the toxin more rapidly to various end-organs. understanding respiratory differences is essential to the management of the acutely ill pediatric patient. the most common etiology for cardiorespiratory arrest in children is respiratory pathology, typically of the upper airway. most of the airway resistance in children occurs in the upper airway. nasal obstruction can lead to severe respiratory distress due to infants being obligate nose breathers. their relatively large tongue and small mouth can lead to airway obstruction quickly, especially when the neuromuscular tone is abnormal such as during sedation or encephalopathy. in infants, physiologic (i.e., copious secretions) and pathologic (i.e., edema, vomitus, blood, and foreign body) factors will exaggerate this obstruction. securing the airway in such events can be quite challenging. typically, the glottis is located more anterior and cephalad. appropriate visualization during laryngoscopy can be further hampered by the prominent occiput that causes neck flexion and, therefore, reduces the alignment of visual axes. the omega or horseshoeshaped epiglottis in young infants and children is quite susceptible to inflammation and swelling. as in epiglottitis, the glottis becomes strangulated in a circumferential manner leading to dangerous supraglottic obstruction. children also have a natural tendency to laryngospasm and bronchospasm. finally, due to weaker cartilage in infants, dynamic airway collapse can occur especially in states of increased resistance and high expiratory flow. along with altered pulmonary compensation and compliance, a child may rapidly progress to respiratory failure and possibly arrest. cardiovascular differences are critical in the pediatric patient. typical physiological responses tend to allow compensation with seemingly normal homeostasis. with tachycardia and elevated systemic vascular resistance, younger pediatric patients can maintain normal blood pressure despite decreased cardiac output and poor perfusion (compensated shock). since children have less blood and volume reserve, they progress to this state quickly. in pediatric patients with multiorgan injury or severe gastrointestinal losses, these compensatory mechanisms are pushed to their limits. the unaccustomed hcp may be lulled into complacency since the blood pressure is normal. all the while, the pediatric patient's organs are being poorly perfused. once these compensatory mechanisms are exhausted, the patient rapidly progresses to hypotension and, therefore, hypotensive shock. if not reversed expeditiously, this may lead to irreversible shock, ischemia, multiorgan dysfunction, and death. pediatric patients with altered mental status pose significant problems. the differential diagnosis will be very broad in the comatose patient based on development alone. for example, younger pediatric patients can present with nonconvulsive status epilepticus (ncse) instead of generalized convulsive status epilepticus (gcse). in fact, ncse is more common among younger pediatric patients than gcse, especially in those from 1 to 12 months of age. furthermore, many of them are previously well without preexisting diseases such as epilepsy. other disease states may include poisoning, inborn errors of metabolism, meningitis, and other etiologies of encephalopathy. using the modified pediatric glasgow coma scale (gcs) is the cornerstone when evaluating the young pediatric patient when they are preverbal. pupillary response, external ocular movements, and gross motor response may be challenging to evaluate in a developmentally young or delayed pediatric patient. pediatric traumatic brain injury is extremely devastating. whether considered accidental (motor vehicle crash) or nonaccidental (abusive head trauma), evaluation of the neurological status of the acutely injured pediatric patient can be problematic, especially the gcs. some prefer to use the avpu system (alert, responds to verbal, responds to pain, and unresponsive). due to the disproportionately larger head and weaker neck muscles, there is more risk of acceleration-deceleration injuries (fall from a significant height, vehicular ejection, and abusive head trauma). furthermore, the softer skull, dural structural differences, and vessel supply will place the pediatric patient at risk for brain injury and intracranial hemorrhage. finally, due to pediatric brain composition, the risk of diffuse axonal injury and cerebral edema is much higher. although spinal cord injury is rare in young pediatric patients, morbidity and mortality are significant. in pediatric patients less than 9 years of age, the most commonly seen injuries are in the atlas, axis, and upper cervical vertebrae. in young pediatric patients, spinal injuries tend to be anatomically higher (cervical) versus adolescents (thoracolumbar). furthermore, congenital abnormalities, such as atlantoaxial abnormalities (trisomy 21), may exaggerate the process. the clinical presentation of spinal cord injury varies in young pediatric patients due to ongoing development. laxity of ligaments, wedge-shaped vertebrae, and incomplete ossification centers contribute to specific patterns of injuries. finally, spinal cord injury without radiographic abnormality (sciwora) may result. because of the disproportionately larger head, weaker neck muscles, and elasticity of the spine, significant distraction and flexion injury of the spinal cord may occur without apparent ligament or bony disruption (hilmas et al. 2008; jacobson and severin 2012; severin 2011). motor skills develop from birth. gross and fine motor milestones are achieved in a predictable manner and must be assessed during each hcp encounter. cognitive development will follow a similar pattern of maturation. the development of these skills can often predict injuries and their extent. for example, consider a house fire. a young infant, preschooler, and adolescent are sleeping upstairs in house when a fire breaks out in the middle of the night. the smoke detectors begin to alarm. each child is awoken by the ensuing noise and chaos. based on the development, the adolescent will most likely make it out of the house alive. he will comprehend the threat, run down the stairs, and exit the house without delay. smoke inhalation may be minimal. if it is a middle adolescent, an attempt may be made to jump out of the window leading to multiple blunt trauma with or without traumatic brain injury. the preschooler most likely will be too scared and not understand how to escape. tragically, he may hide under a bed or in a closet. when the firefighters arrive and search the house, the preschooler may remain silent because of fear, especially of strangers in the house. he will most likely succumb to thermal injuries along with the effects of carbon monoxide and die. as far as the infant, he cannot walk, climb, crawl, or run. furthermore, he cannot scream for help or know how to escape. as the smoke engulfs the room, he will most likely suffer severe smoke inhalation injury including extensive carbon monoxide toxicity along with thermal injuries and die. this example also points out another important difference in pediatric patients: their dependence on caregivers. when considering neonates, for example, their entire existence depends on the caregiver, including feeding, changing of diapers, nurturing, and environmental safety. these dynamics are essential to the pediatric patient's health and survival, especially during a disaster. another aspect of development is the attainment of language skills. this, too, develops over time in a predictable fashion. one of the biggest challenges in pediatrics is the lack of the patient's ability to verbally convey complaints. as described above, verbal milestones vary among the different age ranges of the pediatric patient. hcps are often faced with a caregiver's subjective assessment of the problem. although it can be revealing and informative, this may not be available in an acute crisis situation. it will take the astute hcp to determine, for example, if an inconsolably crying infant is in pain from a corneal abrasion or something more life-threatening such as meningitis. this can also be a challenging task in a teenager, especially during middle adolescence. an hcp will have to determine, for example, if the seemingly lethargic middle adolescent is intoxicated with illicit drugs or has diabetic ketoacidosis. finally, the hcp will have to address developmental variances among their pediatric patients and any comorbid features. young pediatric patients can regress developmentally during any illness or injury. this is especially seen in patients with chronic medical conditions (cancer) or during prolonged hospitalization with rehabilitation (multisystem trauma). furthermore, those pediatric patients with developmental and intellectual disabilities, for example, will be difficult to evaluate based on the effects of their underlying pathology. these pediatric patients typically have unique variances in their physical exams (jacobson and severin 2012; severin 2011) . please refer to chap. 7 for more detailed information on pediatric development. pediatric patients will often reflect the emotional state of their caregiver. they take verbal and physical cues from their caregiver. at times, this may also occur in the presence of a nurse or hcp. the psychological impact of illness will vary greatly with the child's development and experience. children tend to have a greater vulnerability to post-traumatic stress disorder especially with disaster events. furthermore, they are highly prone to becoming psychiatric casualties despite the absence of physical injury to themselves. and as any pediatric hcp can tell you, the younger pediatric patients tend to also have greater levels of anxiety, especially while preparing for invasive procedures such as phlebotomy and intravenous line placement (hilmas et al. 2008; jacobson and severin 2012; severin 2011) . please refer to chap. 12 for more detailed content on mental health. the world health organization and the pan american health organization define a disaster as "an event that occurs in most cases suddenly and unexpectedly, causing severe disturbances to people or objects affected by it, resulting in the loss of life and harm to the health of the population, the destruction or loss of community property, and/or severe damage to the environment. such a situation leads to disruption in the normal pattern of life, resulting in misfortune, helplessness, and suffering, with adverse effects on the socioeconomic structure of a region or a country and/or modifications of the environment to such an extent that there is a need for assistance and immediate outside intervention" (lynch and berman 2009 ). types of disasters usually fall into two broad categories: natural and man-made. natural disasters are generally associated with weather and geological events, including extremes of temperature, floods, hurricanes, earthquakes, tsunamis, volcanic eruptions, landslides, and drought. naturally occurring epidemics, such as the 2009 h1n1, 2014 ebola, and 2019 novel coronavirus outbreaks, are often included in this category. man-made disasters are usually associated with a criminal attack such as an active shooter incident, or a terrorist attack using weapons such as explosive, biological, or chemical agents. however, man-made disasters can also refer to human-based technological incidents, such as a building or bridge collapse, or events related to the manufacture, transportation, storage, and use of hazardous materials, such as the 1986 chernobyl radiation leak and the 1984 bhopal toxic gas leak. even though disasters can be primarily placed into any of these two categories, they can often impact each other and compound the magnitude of any disaster incident (united states department of homeland security, office of inspector general 2009). a prime example is the march 2011 tohoku earthquake leading to a tsunami (natural) that triggered the fukushima daiichi nuclear disaster (man-made). disasters can also be characterized by the location of such an event. internal disasters are those incidents that occur within the health care facility or system. employees, physical plant, workflow and operations of the clinic, hospital, or system can be disrupted. external disasters are those incidents that occur outside of the health care facility or system. this impacts the community surrounding the facility, proximally or distally, but does not directly threaten the facility or its employees. as with natural and man-made disasters, internal and external disasters can impact each other. for example, an overflow of patients during a high census period may lead to the shutdown of the hospital to any new patients (internal disaster). this will place the hospital on bypass and possibly stress other hospitals in the community beyond their means (external disaster). a terrorist event, such as the release of sarin in a subway system during a busy morning commute, can lead to massive disruption in the community (external disaster). all the victims of the attack will seek medical care at nearby hospitals, possibly overwhelming the health care staff and depleting critical resources (internal disaster). characterization of disasters by geography (local, state, national, and international) can also be used. again, no matter the site of the incident, a disaster in one area could easily create a disaster in another geographical region. for example, a factory and its community could be ravaged by a hurricane (local disaster). if this is the only factory in the world to produce a certain medication, this could lead to critical shortages to hospitals all around the world (international disaster). the term "disaster preparedness" has been used over the years as a way to describe efforts to manage any disaster event. however, preparedness is only one aspect of the process. the use of the term disaster planning is more appropriate. it considers all aspects needed for an effective effort and is dependent on additional phases, not just preparedness. national preparedness efforts, including planning, are now informed by the presidential policy directive (ppd) 8 that was signed by the president in march 2011 and describes the nation's approach to preparedness (united states department of education, office of elementary and secondary education, office of safe and healthy students 2013; united states department of homeland security 2018b). a recommended method for disaster preparedness efforts is the utilization of an "all-hazards" model of emergency management (adini et al. 2012; waugh 2000) . the four overlapping phases of the model include mitigation, preparedness, response, and recovery. the mitigation phase involves "activities designed to prevent or reduce losses from a disaster" (waugh 2000) . examples include land use planning in flood plains, structural integrity measures in earthquake zones, and deployment of security cameras. the preparedness phase includes the "planning of how to respond in an emergency or a disaster, and developing capabilities for more effective response" (waugh 2000) . examples include training programs for emergency responders, drills and exercises, early warning systems, contingency planning, and development of equipment and supply caches. up to this point, all planning efforts are proactive and not reactive. often times, a hazard analysis is conducted to delineate areas of strengths and identify potential risks. it helps in "the identification of hazards, assessment of the probability of a disaster, and the probable intensity and location; assessment of its potential impact on a community; the property, persons, and geographic areas that may be at risk; and the determination of agency priorities based on the probability level of a disaster and the potential losses" (waugh 2000) . after a disaster or emergency incident occurs, the response phase, or "immediate reaction to a disaster", (waugh 2000) begins. examples include mass evacuations, sandbagging buildings and other structures, providing emergency medical services, firefighting, and restoration of public order. in some situations, the response period may be a short (e.g., house fire), intermediate (e.g., bomb detonation), or extended (e.g., pandemic influenza) duration. after a period of time, the recovery phase follows. these are "activities that continue beyond the emergency period to restore lifelines" (waugh 2000) . examples include the provision of temporary shelter, restoration of utilities such as power, critical stress debriefing for responders, and victims, job assistance and small business loans, and debris clearance. recovery always seems to be the most unpredictable; it may take days to months to years. as demonstrated with recent hurricanes harvey, irma, and maria in 2017, the most affected regions are still in the phase of recovery and may be along a prolonged track as hurricane katrina in 2005. as mentioned, the early phases of planning (mitigation and preparedness) truly hinge upon the environment or community surrounding the health care site (e.g., clinic, hospital, or long-term care facility). identification of potential hazards and risks is a key step in disaster planning. using a hazard vulnerability assessment (hva) or a threat and hazard identification and risk assessment (thira) can provide a basis for mitigation and prevention tasks. an hva/thira emphasizes which types of natural or man-made disasters are likely to occur in a community (e.g., tornado, flood, chemical release, or terrorist event). they further highlight the impact those disasters may have on the community and any capabilities that are in place that may lessen the effects of the disaster (illinois emergency medical services for children 2018). a basic principle of the hva methodology is to determine the risk of such an event or attack occurring at a given hospital or hospital system. simply, the risk is a product of the probability of an event and the severity of such an event if it occurs (risk = probability ã� severity). however, there are many complexities in quantifying terrorism risk (waugh 2005; woo 2002) . it is important to note that in some circumstances, exposure may need to be included in the equation (risk = probability ã� severity ã� exposure), but usually for operational risk management applications (mitchell and decker 2004) . at any rate, issues to consider for the probability of an event occurring include, but are not limited to, geographic location and topography, proximity to hazards, degree of accessibility, known risks, historical data, and statistics of various manufacturer/vendor products. severity, on the other hand, is dependent on the gap between the magnitude of an event and mitigation for the given event (severity = magnitude -mitigation). magnitude varies upon the impact of the event to humans, property, and/or business. mitigation varies upon the development of internal and external readiness before a disaster strikes. as one can surmise, if the magnitude of the event outstrips the mitigation, the event is considered a threatening hazard. once the hva is completed, the health care site should immediately prioritize planning efforts for the top 5-10 hazards and develop plans accordingly. all other identified hazards must also be addressed to ensure a broad and robust disaster plan. it is important to realize that local and regional entities also perform comprehensive hvas. a concerted analysis among a hospital and key community stakeholders is optimal for a coordinated plan. an hva/thira contains both quantitative and qualitative components. specific tools have been developed through private and public organizations (e.g, fema) that can help in the analysis (united states department of homeland security, federal emergency management agency 2001). using these tools as a guide, the entity can determine what types of hazards have a high, medium, or low probability of occurring within specific geographic boundaries. typically, these tools do not have components specific to children or other at-risk populations. however, the tools can be adapted either directly by adding children to specific hazards or ensuring considerations specific to children are incorporated into the hva/thira calculations. the hva/thira should be reviewed and updated minimally on an annual basis to identify changing or external circumstances. this includes conducting a pediatric-specific disaster risk assessment to identify where children congregate and their risks (e.g., schools, popular field trip designations, summer camps, houses of worship, and juvenile justice facilities) (illinois emergency medical services for children 2018). of note, hva techniques have been utilized for pediatric-specific disaster plans. having a separate pediatric hva (phva) is crucial to a well-rounded and robust health care disaster plan. first, it demonstrates the extent of the pediatric population in the community. it is estimated that 25% of the population fits within the age range of pediatric patients. in some situations, it may be more. during the performance of a phva, it was demonstrated that 29% of the community was less than 19 years of age (jacobson and severin 2012) . second, a phva increases the situational awareness of those tasked to plan for disasters that involve children and adolescents. often times, children and adolescents are excluded from local and regional disaster plans. the unique vulnerabilities of pediatric patients will demand appropriate drills, exercises, equipment, medications, and expertise. thirdly, identifying pediatric risks in a community will help prioritize efforts of planning, especially in those hospitals not accustomed to caring for pediatric patients. finally, a phva helps to develop a framework for global pediatric disaster planning. this can extend beyond a local community and actually advance city, state, regional, and national disaster planning efforts. there has been a development of web-based tools to simplify and enhance the phva process (jacobson and severin 2012) . after an hva/thira has been completed, the results should be used to help direct and plan drills/exercises based on high impact and high probability threats. it is advised to conduct an hva/thira on an annual basis to assess specific threats unique to your organization's physical structure as well as the surrounding geographic environment. it will also provide insight into whether there is an improvement in previous planning efforts. completion of a population assessment that provides a demographic overview of the community with a breakdown of the childhood population is strongly recommended in conjunction with the hva/ thira. collaborating with other community partners, such as local health departments and emergency management agencies, can assist an organization with the conduction of a comprehensive hva/thira (illinois emergency medical services for children 2018). please see chap. 13 for further information on hospital planning. pediatric supplies, equipment, and medications will be scarce during a disaster. it will become more of an issue if the health care facility is not accustomed to caring for acutely ill pediatric patients. this will be further exacerbated by a massive surge of acutely ill pediatric patients, a widespread or prolonged disaster, and supply line disruptions. to protect the health security of children and families during a public health emergency, the assistant secretary for preparedness and response (aspr) manages and maintains the strategic national stockpile (sns), a cache of medical countermeasures for rapid deployment and use in response to a public health emergency or disaster (fagbuyi et al. 2016) . various pediatric-specific supplies and countermeasures are included in the sns. maintaining a supply of medications and medical supplies for specific health threats allows the stockpile to respond with the right product when a specific disease or agent is known. if a community experiences a large-scale public health incident in which the disease or agent is unknown, the first line of support from the stockpile is to send a broad-range of pharmaceuticals and medical supplies. place and martin 2012) . the emergency equipment and supply lists can easily be adapted for any pediatric disaster emergency (place and martin 2012) or incident requiring pediatric mass critical care (desmond et al. 2011) . ageappropriate nutrition, hygiene, bedding, and toys/distraction devices should also be available (illinois emergency medical services for children 2013) (tables 5.3 and 5.4). endotracheal tubes â�¢ uncuffed: 2.5 and 3.0 mm â�¢ cuffed or uncuffed: 3.5, 4.0, 4.5, 5.0, and 5.5 mm â�¢ cuffed: 6.0, 6.5, 7.0, 7.5, and 8.0 mm feeding tubes (5f and 8f) laryngoscope blades curved: 2 and 3; straight: 0, 1, 2, and 3 laryngoscope handle magill forceps (pediatric and adult) nasopharyngeal airways (infant, child, and adult) oropharyngeal airways (sizes 0-5) stylets for endotracheal tubes (pediatric and adult) suction catheters (infant, child, and adult) tracheostomy tubes (sizes 2.5, 3.0, 3.5, 4.0, 4.5, 5.0, and 5.5 mm) yankauer suction tip bag-mask device (manual resuscitator), self-inflating (infant size: 450 ml; adult size: 1000 ml) clear oxygen masks (standard and nonrebreathing) for an infant, child, and adult masks to fit bag-mask device adaptor (neonatal, infant, child, and adult sizes) nasal cannulas (infant, child, and adult) nasogastric tubes (sump tubes): infant (8f), child (10f), and adult (14f-18f) laryngeal mask airway a vascular access arm boards (infant, child, and adult sizes) catheter over-the-needle device (14-24 gauge) intraosseous needles or device (pediatric and adult sizes) intravenous catheter-administration sets with calibrated chambers and extension tubing and/or infusion devices with ability to regulate rate and volume of infusate umbilical vein catheters (3.5f and 5.0f) b central venous catheters (4.0f-7.0f) intravenous solutions to include normal saline, dextrose 5% in normal saline, and dextrose 10% in water fracturemanagement devices extremity splints, including femur splints (pediatric and adult sizes) spine-stabilization method/devices appropriate for children of all ages c (continued) laryngeal mask airways could be shared with anesthesia but must be immediately accessible to the ed b feeding tubes (size 5f) may be used as umbilical venous catheters but are not ideal. a method for securing the umbilical catheter, such as an umbilical tie, should also be available c a spinal stabilization device is one that can stabilize the neck of an infant, child, or adolescent in a neutral position when a pediatric disaster victim presents acutely ill to the hospital, various emergency interventions will be needed to stabilize the patient. evaluation of the pediatric patient should include a primary survey (abcde), secondary survey (focused sample history and focused physical examination), and diagnostic assessments (laboratory, radiological, and other advanced tests). this will guide further therapeutic interventions. particular attention should be given to the identification of respiratory and/or circulatory derangements of the child, including airway obstruction, respiratory failure, shock, and cardiopulmonary failure. interventions will be based on physiologic derangements of the pediatric patient and determined by the scope of practice and protocols, such as standard resuscitation algorithms for neonatal (american academy of pediatrics and american heart association et al. 2016) and pediatric (american heart association 2016) victims. the hcp must be knowledgeable of various emergency medications (table 5 .1) used for children, the appropriate dosages and their mechanism of action, any potential side effects, and drug/drug interactions. other medications, such as antibiotics, antidotes, or countermeasures, may be needed as well. pharmacologic therapy should be initiated immediately based on clinical suspicion and not delayed due to pending laboratory tests (e.g., antibiotics for presumed infection/sepsis or antidotes for suspected nerve agents). dosages should be based on the patient's weight or a length-based weight system. (montello et al. 2006) or hard copy countermeasure manuals may be more practical, especially during a disaster incident when computer service or internet access may be unreliable. in 1988, the centre for research on the epidemiology of disasters (cred) launched the emergency events database (em-dat). em-dat was created with the initial support of the world health organization (who) and the belgian government. the main objective of the database is to serve the purposes of humanitarian action at national and international levels. the initiative aims to rationalize decision-making for disaster preparedness as well as provide an objective base for vulnerability assessment and priority setting. em-dat contains essential core data on the occurrence and effects of over 22,000 mass disasters in the world from 1900 to the present day. the database is compiled from various sources, including united nation agencies, nongovernmental organizations (ngos), insurance companies, research institutes, and press agencies (cred 2019). as described in the cred report entitled natural disasters 2017: lower mortality, higher cost, a disaster is entered into the database if at least one of the following criteria is fulfilled: 10 or more people reported killed; 100 or more people reported affected; declaration of a state of emergency; and/or call for international assistance (cred 2018). in economic losses, poverty and disasters 1998-2017: cred/unisdr report, the cred defines a disaster as "a situation or event which overwhelms local capacity, necessitating a request at national or international level for external assistance; an unforeseen and often sudden event that causes great damage, destruction and human suffering" (cred 2018). the cred em-dat classifies disasters according to the type of hazard that triggers them. the two main disaster groups are natural and technological disasters. there are six natural disaster subgroups. geophysical disasters originate from the solid earth and include earthquake (ground movement and tsunami), dry mass movement (rock fall and landslides), and volcanic activity (ash fall, lahar, pyroclastic flow, and lava flow). lahar is a hot or cold mixture of earthen material flowing on the slope of a volcano either during or between volcanic eruptions. meteorological disasters are caused by short-lived, micro-to meso-scale extreme weather and atmospheric conditions that last from minutes to days and include extreme temperatures (cold wave, heat wave, and severe winter conditions such as snow/ice or frost/ freeze), fog, and storms. storms can be extra-tropical, tropical, or convective. convective storms include derecho, hail, lightning/thunderstorm, rain, tornado, sand/dust storm, winter storm/blizzard, storm/surge, and wind. derecho is a widespread and usually fast-moving windstorm associated with convection/convective storm and includes downburst and straight-line winds. hydrological disasters are caused by the occurrence, movement, and distribution of surface/subsurface freshwater and saltwater and include floods, landslides (an avalanche of snow, debris, mudflow, and rockfall), and wave action (rogue wave and seiche). flood types can be coastal, riverine, flash, or ice jam. climatological disasters are caused by longlived, meso-to macro-scale atmospheric processes ranging from intraseasonal to multidecadal climate variability and include drought, glacial lake outburst, and wildfire (forest fire, land fire: brush, bush, or pasture). biological disasters are caused by the exposure to living organisms and their toxic substances or vectorborne diseases that they may carry and include epidemics (viral, bacterial, parasitic, fungal, and prion), insect infestation (grasshopper and locust), and animal accidents. extraterrestrial disasters are caused by asteroids, meteoroids, and comets as they pass near-earth, enter earth's atmosphere, and/or strike the earth, and by changes in the interplanetary conditions that affect the earth's magnetosphere, ionosphere, and thermosphere. types include impact (airbursts) and space weather (energetic particles, geomagnetic storm, and shockwave) events (cred 2019). there are three technological disaster subgroups. industrial accidents include chemical spills, collapse, explosion, fire, gas leak, poisoning, radiation, and oil spills. a chemical spill is an accidental release occurring during the production, transportation, or handling of hazardous chemical substances. transport accidents include disasters in the air (airplanes, helicopters, airships, and balloons), on the road (moving vehicles on roads or tracks), on the rail system (train), and on the water (sailing boats, ferries, cruise ships, and other boats). miscellaneous accidents vary from collapse to explosions to fires. collapse is an accident involving the collapse of a building or structure and can either involve industrial structures or domestic/nonindustrial structures (cred 2019). technological disasters are considered man-made, but as suggested by their subgroup, they are accidental and not intentional. the united nations office for disaster risk reduction (unisdr) and cred report, economic losses, poverty, and disasters 1998-2017, reviews global natural disasters during that time period, their economic impact, and the relationship with poverty. between 1998 and 2017, climate-related and geophysical disasters killed 1.3 million people and left a further 4.4 billion injured, homeless, displaced, or in need of emergency assistance. although the majority of fatalities were due to geophysical events, mostly earthquakes and tsunamis, 91% of all disasters was caused by floods, storms, droughts, heatwaves, and other extreme weather events. the financial impact was staggering. in 1998-2017, disaster-hit countries reported direct economic losses valued at us$ 2908 billion, of which climate-related disasters caused us$ 2245 billion or 77% of the total. this was up from 68% (us$ 895 billion) of losses (us$ 1313 billion) reported between 1978 and 1997. overall, reported losses from extreme weather events rose by 151% between these two 20-year periods. in absolute monetary terms, over the last 20-years, the usa recorded the biggest losses (us$ 945 billion), reflecting high asset values as well as frequent events. china, by comparison, suffered a significantly higher number of disasters than the usa (577 vs. 482) but lower total losses (us$ 492 billion) (cred 2018) (figs. 5.1, 5.2, 5.3, 5.4, 5.5, 5.6, 5.7, 5.8 and 5.9 in 2018, 281 climate-related and geophysical incidents in the world were estimated with 10,733 deaths and over 60 million people impacted. indonesia recorded approximately half of the deaths with india accounting for half of those impacted by disasters. notable features of 2018 were intense seismic activity in indonesia, a series of disasters in japan, floods in india, and an eventful year for both volcanic activity and wildfires. however, an ongoing trend of lower death tolls from previous years continued into 2018 (centre for research on the epidemiology of disasters (cred) and united nations office for disaster risk reduction (unisdr) 2019) (tables 5.5, 5.6, 5.7, 5.8, 5.9, 5.10 and 5.11 there are no specific deviations when medically managing children after a natural disaster. according to sirbaugh and dirocco (2012) "small-scale mass casualty incidents occur daily in the united states. few present unusual challenges to the local medical systems other than in the number of patients that must be treated at one time. except in earthquakes, explosions, building collapses, and some types of terrorist attacks, the same holds true for large-scale disasters. sudden violent disaster mechanisms can produce major trauma cases, including patients needing field amputations or management of crush syndrome. for the most part, medicine after a disaster is much the same as it was before the disaster, with more minor injuries, more people with exacerbations of their chronic illnesses, and number of patients seeking what is ordinarily considered primary care. this is true for children and adults." it should be noted, however, that children have a predisposition to illness and injury after natural disasters. the hcp must be able to identify any health problems and treat the child effectively and efficiently while utilizing standard resuscitation protocols as indicated. traumatic injuries may be seen after any natural disaster. the injuries can range from minor scrapes and bruises to major blunt trauma or traumatic brain injury. children are at increased risk for injury since adults are distracted by recovery efforts and may not be able to supervise them closely. the environment may not be safe due to environmental hazards, such as collapsed buildings, sinkholes, and high water levels. dangerous equipment used during relief efforts may be present, such as heavy earth moving equipment, chainsaws, and power generators. hazardous chemicals, such as gasoline and other volatile hydrocarbons, may be readily accessible or taint the environment. without suitable shelter, children are also exposed to weather, animals, and insects (sirbaugh and dirocco 2012) . infectious diseases may also pose a problem to children after a natural disaster. infectious patterns will persist during a disaster based on the season and time of year. there may be outbreaks or epidemics of highly contagious infections (e.g., influenza, respiratory syncytial virus, streptococcus pyogenes) due to mass sheltering of children and families. poor nutrition or decreased availability of food may lower their resistance against infections. various water-borne or food-borne diseases may cause illnesses in children. poor hygiene and mass shelter environments may exacerbate these illnesses. immunized children should be protected against common preventable diseases after a natural disaster but still could be a problem in mass groups that are not completely or appropriately immunized. after the 2010 haiti earthquake, there were increased cases of diarrhea, cholera, measles, and tetanus in children months after the earthquake despite some level of vaccination (sirbaugh and dirocco 2012) . children are at risk for various environmental emergencies. austere environments will impact children greatly. heat exposure coupled with minimal access to drinkable water may lead to severe dehydration. exposure to the cold may lead to frostbite or hypothermia. children are at risk for carbon monoxide toxicity due to generator use or natural gas poisoning due to disrupted gas lines. there is always a risk for thermal injury due to the use of candles and other flame sources. exposure to animals (snakes) and insects (spiders) may increase the risk of envenomation. submersion injury and drowning incidents may escalate. this will be due to lack of supervision of children around storm drains, newly formed bodies of water, or rushing waters of storm diversion systems (sirbaugh and dirocco 2012) . mental health issues are often seen in children after natural disasters. even though a child may not be injured, they may become "psychiatric casualties" due to the horrific sights they have seen during or after the disaster. children and adolescents with behavioral or psychiatric problems may experience worsening symptoms and signs due to stress, trauma, disruption of routines, or availability of medications. this is often exacerbated if the parent, guardian, caregiver, or hcp is also having difficulty coping with the stress of the disaster. in general, the most common mental health problem in children is a post-traumatic stress disorder. however, separation anxiety, obsessive-compulsive symptoms, and severe stranger anxiety can also be seen in children after a traumatic event (sirbaugh and dirocco 2012) . see chap. 12 for more detailed information. terrorism impacts children and families all around the world (tables 5.12 and 5.13). after the events of 9/11, much attention has been given to the possibility of another mass casualty act of terrorism, especially with weapons of mass destruction, that include chemical, biological, nuclear, radiological, and explosive devices (cbnre), or other forms of violence such as active shooter incidents and mass shootings (jacobson and severin 2012) . since then, other incidents, both foreign and domestic, have involved children and complicates the concept of and the response to terrorism. johnston (2017) said it best in his review of terrorist and criminal attacks targeting children: "one of the more accepted defining characteristics of terrorism is that it targets noncombatants including men, women, and children. however, terrorist attacks specifically targeting children over other noncombatants are uncommon. this is for the same reason that most terrorists have historically avoided mass casualty terrorism: the shock value is so great that such attacks erode support for the terrorists' political objectives. the 9/11 attacks represent an increasing trend in mass casualty terrorism. at the same time, policymakers are examining this evolving threat, they must increasingly consider the threat of terrorist attacks targeting children." based on historical events, it is clear infants, toddlers, children, and adolescents have been victims of terrorism. this global trend of terrorists targeting children seems to be escalating (johnston 2017) . therefore, it is imperative to understand terrorism and ways it impacts the children and families served by the health care community. combs (2018) defines terrorism as "an act of violence perpetrated on innocent civilian noncombatants in order to evoke fear in an audience". however, she goes on to argue that to become an operational definition, there must also be the addition of a "political purpose" of the violent act. therefore, "terrorism, then, is an act composed of at least four crucial elements: 1) it is an act of violence, 2) it has a political motive or goal, 3) it is perpetrated against civilian noncombatants, and 4) it is staged to be played before an audience whose reaction of fear and terror is the desired result." (combs 2018) . there are different typologies of terrorism. at least five types of terror violence have been suggested by feliks gross: "mass terror is terror by a state, where the regime coerces the opposition in the population, whether organized or unorganized, sometimes in an institutionalized manner. dynastic assassination is an attack on a head of state or a ruling elite. random terror involves the placing of explosives where people gather (such as post offices, railroads, and cafes) to destroy whoever happens to be there. focused random terror restricts the placing of explosives, for example to where significant agents of oppression are likely to gather. finally, tactical terror is directed solely against the ruling government as a part of a 'broad revolutionary strategic plan'" (combs 2018 ). an additional typology offered is "lone wolf terror which involves someone who commits violent acts in support of some group, movement, or ideology, but who does stand alone, outside of any command structure and without material assistance from any group" (combs 2018) . martin (2017) reviews eight different terrorism typologies in the ever shifting, multifaceted world of modern terrorism. the new terrorism "is characterized by the threat of mass casualty attacks from dissident terrorist organizations, new and creative configurations, transnational religious solidarity, and redefined moral justifications for political violence" (martin 2017) . state terrorism is "committed by governments against perceived enemies and can be directed externally against adversaries in the international domain or internally against domestic enemies" (martin 2017) . dissident terrorism is "committed by nonstate movements and groups against governments, ethno-national groups, religious groups, and other perceived enemies" (martin 2017) . religious terrorism is "motivated by an absolute belief that an otherworldly power has sanctioned and commanded the application of terrorist violence for the greater glory of the faithâ�¦[it] is usually conducted in defense of what believers consider to be the one true faith" (martin 2017) . ideological terrorism is "motivated by political systems of belief (ideologies), which champion the self-perceived inherent rights of a particular group or interest in opposition to another group or interest. the system of belief incorporates theoretical and philosophical justifications for violently asserting the rights of the championed group or interest" (martin 2017) . international terrorism "spills over onto the world's stage. targets are selected because of their value as symbols of international interests, either within the home country or across state boundaries" (martin 2017) . criminal dissident terrorism "is solely profit-driven, and can be some combination of profit and politics. for instance, traditional organized criminals accrue profits to fund their criminal activity and for personal interests, while criminalpolitical enterprises acquire profits to sustain their movement" (martin 2017) . gender-selective terrorism "is directed against an enemy population's men or women because of their gender. systematic violence is directed against men because of the perceived threat posed by males as potential soldiers or sources of opposition. systematic violence is directed against women to destroy an enemy group's cultural identity or terrorize the group into submission" (martin 2017) . the all-hazards national planning scenarios are an integral component of dhs's capabilities-based approach to implementing homeland security presidential directive 8: national preparedness (hspd-8). the national planning scenarios are planning tools and are representative of the range of potential terrorist and natural disasters and the related impacts that face the nation. the federal interagency community has developed 15 all-hazards planning scenarios for use in national, federal, state, and local homeland security preparedness activities. the objective was to develop a minimum number of credible scenarios to establish the range of response requirements to facilitate disaster planning (dhs 2006) (table 5 .14). twelve of the scenarios represent terrorist attacks while three represent natural disasters or naturally occurring epidemics. this ratio reflects the fact that the nation has recurring experience with natural disasters but faces newfound dangers, including the increasing potential for use of weapons of mass destruction by terrorists. the scenarios form the basis for coordinated federal planning, training, exercises, and grant investments needed to prepare for all hazards. dhs employed the scenarios as the basis for a rigorous task analysis of prevention, protection, response, and recovery missions and identification of key tasks that supported the development of essential all-hazards capabilities (united states department of homeland security, federal emergency management agency 2019) (table 5 .15). each of the 15 scenarios follows the same outline to include a detailed scenario description, planning considerations, and implications. for each of the 12 terrorismrelated scenarios, fema national preparedness directorate (npd) partnered with dhs office of intelligence and analysis (i&a) and other intelligence community and law enforcement experts to develop and validate prevention prequels. the prequels provide an understanding of terrorists' motivation, capability, intent, tactics, techniques and procedures, and technical weapons data. the prequels also provide a credible adversary based on known threats to test the homeland security community's ability to understand and respond to indications and warnings of possible terrorist attacks (united states department of homeland security, federal emergency management agency 2019). a chemical agent of terrorism is defined as any chemical substance intended for use in military operations to kill, seriously injure, or incapacitate humans (or animals) through its toxicological effects. chemicals excluded from this list are riot-control agents, chemical herbicides, and smoke/flame materials. chemical agents are classified as toxic agents (producing injury or death) or incapacitating agents (producing temporary effects). toxic agents are further described as nerve agents (anticholinesterases), blood agents (cyanogens), blister agents (vesicants), and lung-damaging agents (choking agents). incapacitating agents include stimulants, depressants, psychedelics, and deliriants (banks 2014; departments of the army, the navy, and the air force, and commandant, marine corps 1995). nerve agents are organophosphate anticholinesterase compounds. they are used in various insecticide, industrial, and military applications. military-grade agents include tabun (ga), sarin (gb), soman (gd), cyclosarin (gf), venom x (vx), and the novichok series. these are all major military threats. the only known battlefield use of nerve agents was the iraq-iran war. however, other nerve agent incidents, such as the 1995 tokyo subway attack (sarin), the chemical attacks in syria (chlorine, sarin, mustard), and the attempted assassination of sergei skripal in salisbury, uk (novichok), support that civilian threats also exist. nerve agents are volatile chemicals and can be released in liquid or vapor form. however, the liquid form can become vapor depending upon its level of volatility (e.g, g-agents are more volatile than vx). the level of toxicity depends on the agent, concentration of the agent, physical form, route and length of exposure, and environmental factors (temperature and wind) (tables 5.16 and 5.17). nerve agents exert their effects by the inhibition of esterase enzymes. acetylcholinesterase inhibition prevents the hydrolysis of acetylcholine. the clinical result is a cholinergic crisis and subsequent overstimulation of muscarinic and nicotinic receptors throughout the body including the central nervous system. clinical muscarinic responses include sludge (salivation, lacrimation, urination, defecation, gastrointestinal distress, and emesis) and dumbels (diarrhea, urinary incontinence, miosis/muscle fasciculation, bronchorrhea/bronchospasm/bradycardia, emesis, lacrimation, and salivation). nicotinic responses vary by site. preganglionic sympathetic nerve stimulation produces mydriasis, tachycardia, hypertension, and pallor. however, stimulation at the neuromuscular junction leads to muscular fasciculation and cramping, weakness, paralysis, and diaphragmatic weakness. central nervous system presentations range from anxiety and restlessness to seizures, coma, and death (banks 2014; rotenberg and newmark 2003; rotenberg 2003b ). pediatric manifestations (table 5 .19) may vary from the classic clinical responses due to their unique vulnerabilities (hilmas et al. 2008 ): â�¢ children may manifest symptoms earliest and possibly more severe presentations. â�¢ could be hospitalized for similarly related illnesses and diseases. â�¢ smaller mass. â�¢ lower baseline cholinesterase activity. â�¢ tendency to bronchospasm. â�¢ pediatric airway and respiratory differences. â�¢ altered pulmonary compensation. â�¢ lower reserves of cardiovascular system and fluids. â�¢ isolated central nervous system signs (stupor, coma). â�¢ less miosis. â�¢ vulnerability to seizures and neurotransmitter imbalances (excitability). â�¢ immature metabolic systems. differential diagnoses include upper or lower airway obstruction, bronchiolitis, status asthmaticus, cardiogenic shock, acute gastroenteritis, seizures, and poisonings (carbon monoxide, organophosphates, and cyanide). diagnostic tests include acetylcholinesterase levels, red blood cell cholinesterase levels, and an arterial blood gas. treatment (tables 5.20 and 5.21) includes decontamination (reactive skin decontamination lotion â® [potassium 2,3-butanedione monoximate], soap and water, and 0.5% hypochlorite solution), supportive care, and administration of nerve agent antidotes (atropine, pralidoxime chloride, and diazepam). atropine is a competitive antagonist of acetylcholine muscarinic receptors and reverses peripheral muscarinic symptoms. it does not restore function at the neuromuscular junction nicotinic receptors. it does, however, treat early phases of convulsions. pralidoxime chloride separates the nerve agent from acetylcholinesterase and restores enzymatic function. it also binds free nerve agent. the major goal is to prevent "aging" of the enzyme (e.g., gd). diazepam provides treatment of nerve agent-induced seizures and prevents secondary neurologic injury. typically, associated seizures are refractory to other antiepileptic drugs. the antiseizure effect of diazepam is enhanced by atropine (banks 2014; cieslak and henretig 2016; messele et al. 2018) . potential medical countermeasures include trimedoxime (tmb4), hi-6 (an h-series oxime), obidoxime, "bioscavengers" (butyrylcholinesterase, carboxylesterase, organophosphorus acid anhydride hydrolase, and human serum paraoxonase), novel anticonvulsant drugs, n-methyl-d-aspartate (nmda) receptor antagonists (ketamine, dexanabinol), and common immunosuppressants such as cyclosporine a (jokanovic 2015; merrill et al. 2015 ; national institutes of health 2007; united states department of health and human services 2017). all patients should be observed closely for electroencephalographic changes and neuropsychiatric pathologies. polyneuropathy, reported after organophosphate insecticide poisoning, has not been reported in humans exposed to nerve agents and has been produced in animals only at unsurvivable doses. the intermediate syndrome has not been reported in humans after nerve agent exposure, nor has it been produced in animals. muscular necrosis has occurred in animals after high-dose nerve agent exposure but reversed within weeks; it has not been reported in humans (banks 2014). on march 4, 2018, sergei skripal, a former russian double agent, and his daughter, yulia skripal, were found unresponsive on a park bench in salisbury, uk. they were brought to a nearby hospital and treated for signs consistent with a cholinergic crisis due to a nerve agent exposure. analysis of the skripals found the presence of a secret nerve agent called novichok. further testing found high concentrations of the agent on the front-door handle of his home. one of the investigating police officers, detective sergeant nick bailey, unknowingly touched the door-handle and also became ill. all three survived due to rapid recognition of the nerve agent exposure by hospital personnel. four months later, two other people, dawn sturgess and charlie rowley, became ill with identical symptoms in the town of amesbury, 7 miles from salisbury. they were later confirmed to have high concentrations of novichok on their hands from a perfume bottle found in a recycling bin. both were immediately treated, but dawn sturgess later died. charlie rowley survived. it was believed the discarded perfume bottle contained novichok and was discarded by the assailants after the attempt on sergei skripal. on september 5, 2018, the uk government revealed that their investigation uncovered two suspects from closed circuit television (cctv) footage near the skripal's home. the suspects entered the uk on russian passports using the names alexander petrov and ruslan boshirov, stayed in a london hotel for 2 days, visited salisbury briefly, and then returned to moscow. minute traces of novichok were also found in the london hotel where they had stayed. the uk prime minister, teresa may, said that the suspects are thought to be officers from russia's military intelligence service the glavnoye razvedyvatel'noye upravleniye (gru), and that this showed that the poisoning was "not a rogue operation" and was "almost certainly" approved at a senior level of the russian state. the two suspects later appeared on russian tv denying the accusations and saying they were just "tourists" who had traveled all the way from moscow to salisbury just to see the "famous cathedral". however, cctv of the cathedral area found no evidence of the two men visiting the cathedral, although they were captured on cctv near the skripal's home. in a development in september 2018, one of the men was revealed as actually being a russian intelligence officer named colonel anatoliy chepiga and was a decorated veteran of russian campaigns in chechnya and ukraine. and later in october, the second man was named as dr. alexander mishkin, a naval medical doctor allegedly recruited by the gru (chai et al. 2018; may 2018) . novichok (ð�ð¾ð²ð¸ñ�ð¾ñ�: russian for "newcomer") is a highly potent nerve agent developed from the russian classified nerve agent program known as foliant. almost everything known about these agents is due to a russian defector, vil mirzayanov (2009) who was an analytical chemist at the russian state research institute of organic chemistry and technology (gosniiokht). he has described the details of the novichok program in his book "state secrets: an insider's chronicle of the russian chemical weapons program". the first three nerve agents of the novichok series developed in the program were substance-33, a-230, and a-232 (table 5 .18). they were synthesized as unitary agents, like vx, tabun, soman, and sarin. unitary means that the chemical structure was produced at its maximum potency. however, the novichok agents were developed as binary agents: maximum potency when two inert substances are combined together prior to deployment to create the active nerve agent (cieslak and henretig 2003) . very little is known about the chemistry of these weaponized organophosphate agents. however, they appear to be more potent than current nerve agents. for example, the ld 50 of novichok agents is reported 0.22 î¼g/kg similar to 2-(dimethylamino)ethyl n,n-dimethylphosphoramidofluoridate (vg), a novel fourth generation nerve agent. furthermore, novichok-5 is 8ã� more effective than vx and novichock-7 is 10ã� more effective than soman (cieslak and henretig 2003; hoenig 2007) . clinically, they behave like other organophosphates by binding to acetylcholinesterase preventing the breakdown of acetylcholine thereby leading to a cholinergic crisis. there appears to be a similar "aging" process as seen with other nerve agents. in addition, the novichok agents binding to peripheral sensory nerves distinguishes this class of organophosphates. prolonged or high-dose exposure results in debilitating peripheral neuropathy. exposure to these agents is fatal unless aggressively managed (cieslak and henretig 2003) . decontamination is essential to prevent ongoing exposure to the patient and medical personnel. clothing should be removed and quickly placed in a sealed bag (prevents ongoing exposure to the emission of vapors) followed by thorough washing with soap and water. application of dry bleach powder should be avoided as it may hydrolyze nerve agents into toxic metabolites that can produce ongoing cholinergic effects. supportive care is essential. antidote therapy should be given as usual for nerve agents, including atropine, diazepam, and pralidoxime chloride (united states department of health and human services, office of the assistant secretary for preparedness and response, national library of medicine 2019; united states department of health and human services, chemical hazards emergency medical management (chemm) 2019). of note, the toxicity of the novichok agents may not rely on anticholinesterase inhibition. some have suggested that reactive oximes like potassium 2,3-butanedione monoximate are preferred oximes for antidotal therapy (cieslak and henretig 2003) . cyanide is a naturally occurring chemical. it can be found in plants and seeds. it is also used in many industrial applications and is a common product of combustion of synthetic materials. typical cyanogens include hydrogen cyanide (ac) and cyanogen chloride (ck). low levels of cyanide are detoxified by a natural reaction in the human body using the rhodanese system. there is reversible metabolism with vitamin b12a to vitamin b12 (cyanocobalamin). an irreversible reaction occurs with sulfanes to produce thiocyanates and sulfates. the former is excreted via the urinary tract. when cyanide overwhelms this natural process, cyanide binds to (1990) a vx = venom x (cieslak and henretig 2003) cytochrome oxidase within the mitochondria and disrupts cellular respiration. cyanide has an affinity for fe+3 in the cytochrome a3 complex and oxidative phosphorylation is interrupted. cells can no longer use oxygen to produce atp and lactic acidosis ensues from resultant anaerobic metabolism. when inhaled, cyanide produces rapid onset of clinical signs. findings include transient tachypnea and kussmaul breathing (from hypoxia of carotid and aortic bodies), hypertension and tachycardia (from hypoxia of aortic body), and neurologic findings such as seizures, muscle rigidity (trismus), opisthotonus, and decerebrate posturing. other findings include cherry red flush, acute respiratory failure/ arrest, bradycardia, dissociative shock, and cardiac arrest. venous blood samples exhibit a bright red color. arterial blood gas may demonstrate a metabolic acidosis with an increased anion gap due to lactic acid (banks 2014; cieslak and henretig 2016; rotenberg 2003a) . pediatric manifestations (table 5 .19) may vary from the classic clinical responses due to their unique vulnerabilities (hilmas et al. 2008 ): â�¢ thinner integument leading to shorter time from exposure to symptom development. â�¢ higher vapor density (ck) and concentration accumulation in living zone of children, â�¢ higher minute ventilation and metabolism. â�¢ abdominal pain, nausea, restlessness, and giddiness are common early findings. â�¢ cyanosis mostly noted other than classic cherry red flushing of the skin. â�¢ resilient with recovery even when just using supportive measures alone. differential diagnoses include meningitis, encephalitis, gastroenteritis, ischemic stroke, methemoglobinemia, and poisonings (nerve agents, organophosphates, methanol, hydrogen sulfide, and carbon monoxide). diagnostic tests include arterial blood gas, lactic acid, and thiocyanate levels. treatment (tables 5.20 and 5.21) includes decontamination, supportive care, and administration of cyanide antidote kit (nitrites and thiosulfate). the nitrites facilitate the production of methemoglobinemia (fe+3) which attracts cyanide molecules forming cyanmethemoglobin. amyl nitrite pearls are crushed into gauze and placed over the mouth/nose or in a mask used for bag/mask ventilation. sodium nitrite is given parenterally and dosed according to the patient's estimated hemoglobin so as to prevent severe methemoglobinemia. since the formation of cyanmethemoglobin is a reversible reaction, and sodium thiosulfate is given to extract the cyanide. dosing is also dependent upon estimated hemoglobin. along with the naturally occurring rhodanese enzymatic system, the irreversible reaction forms thiocyanate. thiocyanate is water soluble and is excreted harmlessly via the kidneys (banks 2014; cieslak and henretig 2016). potential medical countermeasures (national institutes of health 2007; united states army medical research institute of infectious diseases (usamriid) 2014) include hydroxocobalamin, cobinamide (a cobalamin precursor), dicobalt edetate, cyanohydrin-forming compounds (alpha-ketoglutarate and pyruvate), s-substituted crystallized rhodanese, sulfur-containing drugs (n-acetylcysteine), and methemoglobin inducers (4-dimethylaminophenol and others). blistering agents, or vesicants, promote the production of blisters. typical examples include sulfur mustard (hd), nitrogen mustard (hn), and lewisite (l). these agents, especially sulfur mustard, are considered capable chemical weapons since illness may not occur until hours or days later. vesicants are alkylating agents that affect rapidly reproducing and poorly differentiated cells in the body. however, they can also produce cellular oxidative stress, deplete glutathione stores, and promote immature cognitive function unable to flee emergency immature coping mechanisms inability to discern threat, follow directions, and protect self high risk for developing ptsd bbb blood-brain barrier, bsa body surface area, cns central nervous system, ptsd post-traumatic stress disorder (hilmas et al. 2008) intense inflammatory responses. clinical findings are initially cutaneous (erythema, pruritus, yellow blisters, ulcers, and sloughing), respiratory (hoarseness, cough, voice changes, pneumonia, respiratory failure, acute lung injury, and acute respiratory distress syndrome), and ophthalmologic (pain, irritation, blepharospasm, photophobia, conjunctivitis, corneal ulceration, and globe perforation) in nature. after exposure through these primary portals of entry, other sites are affected, including the gastrointestinal tract (nausea, vomiting, and mucosal injury), the hematopoietic system (bone marrow suppression), the cardiovascular system (l), reproductive system (hd, hn) , and the central nervous system (lethargy, headache, malaise, and depression) (banks 2014; yu et al. 2003) . pediatric manifestations (table 5 .19) may vary from the classic clinical responses due to their unique vulnerabilities (hilmas et al. 2008 ): â�¢ thinner integument leading to shorter time from exposure to symptom development. â�¢ higher vapor density and concentration accumulation in the living zone. â�¢ higher minute ventilation and metabolism. â�¢ greater pulmonary injury. â�¢ ocular findings more frequent (less self-protection and more hand/eye contact). â�¢ gastrointestinal manifestations more prominent. â�¢ unable to escape and decontaminate. â�¢ unable to verbalize complaints (i.e., pain). treatment (tables 5.20 and 5.21) includes decontamination and supportive care. currently, there are no antidotes for mustard toxicity (cieslak and henretig 2016) . agents under investigation include antioxidants (vitamin e), anti-inflammatory drugs (corticosteroids), mustard scavengers (glutathione, n-acetylcysteine), and nitric oxide synthase inhibitors (l-nitroarginine methyl ester). other therapeutics under investigation include the use of british anti-lewisite (bal), reactive skin protectants, and ocular therapies (national institutes of health 2007; usamriid 2014). lung-damaging agents are toxic inhalants and potentially can affect the entire respiratory tract. typical examples include chlorine (cl 2 ), phosgene (carbonyl chloride), oxides of nitrogen, organofluoride polymers, hydrogen fluoride, and zinc oxide. since many of these chemicals are readily available and have multiple industrial applications, they are considered terrorist weapons of opportunity. toxicity is dependent upon agent particle size, solubility, and method of release. large particles produce injury in the nasopharynx (sneezing, pain, and erythema). midsize particles affect the central airways (painful swelling, cough, stridor, wheezing, and rhonchi). small particles cause injury at the level of the alveoli (dyspnea, chest tightness, and rales). highly soluble agents, such as chlorine, dissolve with mucosal moisture and immediately produce strong upper airway reactions. less soluble agents, such as phosgene, travel to the lower airway before dissolving and subsequently causing toxicity. it is important, however, to realize that very few lungdamaging agents affect only the upper or lower airway (e.g., cl 2 ). if the agent is aerosolized, solid or liquid droplets suspend in the air and distribute by size. if it is a gas or vapor release, there is uniform distribution throughout the lungs and toxicity will be based on solubility and reactivity of the agent (banks 2014; burklow et al. 2003; cieslak and henretig 2016) . pediatric manifestations (table 5 .19) may vary from the classic clinical responses due to their unique vulnerabilities (hilmas et al. 2008 ): â�¢ pediatric airway and respiratory tract issues (obligate nose breathers, relatively small mouth/large tongue, copious secretions, anterior/cephalad vocal cords, omega or horseshoe-shaped epiglottis, tendency of laryngospasm and bronchospasm, and anatomically small, "floppy" airways). â�¢ high vapor density and concentration accumulation in the living zone. â�¢ unable to verbalize or localize physical complaints. â�¢ rapid dehydration and shock secondary to pulmonary edema. â�¢ increased minute ventilation and metabolism. differential diagnoses include smoke inhalation injury, cardiogenic shock, heart failure, traumatic injury, asthma, bronchiolitis, and poisoning (cyanide). treatment (tables 5.20 and 5.21) includes decontamination and supportive care. currently, there are no antidotes for lung-damaging agent toxicity (cieslak and henretig 2016) . potential countermeasures include novel positive-pressure devices, drugs to prevent lung inflammation, and treatments for chemically induced pulmonary edema (beta agonists, dopamine, insulin, allopurinol, and ibuprofen). in addition, drugs are being investigated that act at complex molecular pathways of the lung the centers for disease control and prevention (cdc) has delineated bioterrorism agents and diseases into three categories based on priority. category a agents include organisms with the highest risk because the ease of dissemination or transmission from person-to-person, result in high mortality rates, have the potential for major public health impact, promote public panic and social disruption, and require special action of public health preparedness. these agents/diseases include smallpox (variola major), anthrax (bacillus anthracis), plague (yersinia pestis), viral hemorrhagic fevers (filoviruses [ebola, marburg] and arenaviruses [lassa, macupo]), botulinum toxin (from clostridium botulinum), and tularemia (francisella tularensis). category b agents, the second highest priority, include those that are moderately easy to disseminate, result in moderate morbidity and low mortality rates, and require specific enhancements of diagnostic capacity and enhanced disease surveillance. these agents/diseases include ricin toxin (ricinus communis), brucellosis (brucella species), epsilon toxin of clostridium perfringens, food safety threats (salmonella species, escherichia coli o157:h7, shigella), glanders (burkholderia mallei), meliodosis (burkholderia pseudomallei), psitticosis (chlamydia psittaci), typhus fever (rickettsia prowazekii), q fever (coxiella burnetii), staphylococcal enterotoxin b, trichothecenes mycotoxin, viral encephalitis (alphaviruses, such as eastern equine encephalitis, venezuelan equine encephalitis, and western equine encephalitis), and water safety threats (vibrio cholera, cryptosporidium parvum). category c agents have the next priority and include emerging pathogens that could be engineered for mass dissemination because of availability, ease of production and dissemination, and have the potential for high morbidity and mortality rates and major health impact. recognition of a biologic attack is essential. there are various epidemiologic clues to consider when determining whether the outbreak is natural or man-made (markenson et al. 2006; cieslak 2018; usamriid 2014) : â�¢ the appearance of a large outbreak of cases of a similar disease or syndrome, or especially in a discrete population. â�¢ many cases of unexplained diseases or deaths. â�¢ more severe disease than is usually expected for a specific pathogen or failure to respond to standard therapy. â�¢ unusual routes of exposure for a pathogen, such as the inhalational route for disease that normally occur through other exposures. â�¢ a disease case or cases that are unusual for a given geographic area or transmission season. â�¢ disease normally transmitted by a vector that is not present in the local area. â�¢ multiple simultaneous or serial epidemics of different diseases in the same population. â�¢ a single case of disease by an uncommon agent (smallpox, some viral hemorrhagic fevers, inhalational anthrax, pneumonic plague). â�¢ a disease that is unusual for an age group. â�¢ unusual strains or variants of organisms or antimicrobial resistance patterns different from those known to be circulating. â�¢ a similar or identical genetic type among agents isolated from distinct sources at different times and/or locations. â�¢ higher attack rates among those exposed in certain areas, such as inside a building if released indoors, or lower rates in those inside a sealed building if released outside. â�¢ outbreaks of the same disease occurring in noncontiguous areas. â�¢ zoonotic disease outbreaks. â�¢ intelligence of a potential attack, claims by a terrorist or aggressor of a release, and discovery of munitions, tampering, or other potential vehicle of spread (spray device, contaminated letter). one should know the cellular, physiological, and clinical manifestations of each biologic agent. furthermore, knowledge of distinct presentation patterns of children will be helpful to diagnosis. in any event, the ten steps in the management of biologic attack victims, pediatric, or otherwise, should be applied (cieslak and henretig 2003; cieslak 2018; usamriid smallpox is caused by the orthopoxvirus variola and was declared globally eradicated in 1980. the disease is highly communicable from person-to-person and remains a threat due to its potential for weaponization. the only stockpiles are at the cdc and at the russian state centre for research on virology and biotechnology. however, clandestine stockpiles in other parts of the world are unknown. since the cessation of smallpox vaccination, the general population has little or no immunity. the three clinical forms of smallpox include ordinary, flat, and hemorrhagic. another form, modified type, occurred in those previously vaccinated who were no longer protected. the asymptomatic incubation period is from 7 to 17 days (average 12 days) after exposure. a prodrome follows that lasts for 2-4 days and is marked by fever, malaise, and myalgia. lesions start on the buccal and pharyngeal mucosa. the rash then spreads in a centrifugal fashion, and the lesions are synchronous. initially, there are macules followed by papules, pustules, and scabs in 1-2 weeks. other clinical features include extensive fluid loss and hypovolemic shock, nausea, vomiting, diarrhea, bacterial superinfections, viral bronchitis and pneumonitis, corneal ulceration with or without keratitis, and encephalitis. death, if it occurs, is typically during the second week of clinical disease. variola minor caused a mortality of 1% in unvaccinated individuals. however, the variola major type caused death in 3% and 30% in those vaccinated and unvaccinated, respectively. flat (mostly children) and hemorrhagic (pregnant women and immunocompromised) types caused severe mortality in those populations infected. the differential diagnoses for smallpox include chickenpox (varicella), herpes, erythema multiforme with bullae, or allergic contact dermatitis. varicella typically has a longer incubation period (14-21 days) and minimal or no prodrome. furthermore, the rash distributes in a centripetal fashion and the progression is asynchronous (images 5.1 and 5.2). diagnosis of smallpox is mostly clinical (centers for disease control and prevention 2019a). if considered, contact public health immediately. laboratory confirmation (cdc or who) can be done by dna sequencing, polymerase chain reaction (pcr), restriction fragment-length polymorphism (rflp), real-time pcr, and microarrays. these are more sensitive and specific than the conventional virological and immunological approaches (goff et al. 2018) . generally, treatment is largely supportive (table 5 .23). fluid losses and hypovolemic shock must be addressed. also, due to electrolyte and protein loss, replacement therapy will be required. bacterial superinfections must be aggressively treated with appropriate antibiotics. biologic countermeasures and antivirals against smallpox are under investigation, including cidofovir, brincidovir (cmx-001), and tecovirimat (st-246). these agents have shown efficacy in orthopoxvirus animal models and have been used to treat disseminated vaccinia infection under emergency use. cidofovir has activity against poxviruses in animal studies (in vitro and in vivo) and some humans (eczema vaccinatum and molluscum contagiosum). brincidovir is an oral formulation of cidofovir with less nephrotoxicity and has recently been announced as an addition to the strategic national stockpile (sns) for patients with smallpox. tecovirimat is a potent and specific inhibitor of orthopoxvirus replication. a recent study found that treatment with tecovirimat resulted in 100% survival of cynomolgus macaques challenged with intravenous variola virus. the disease was milder in tecovirimat-treated survivors and viral shedding was reduced compared to placebo-treated survivors. prophylaxis comes in the form of the smallpox vaccine (vaccinia virus), acam2000 â® , which replaced wyeth dryvaxâ�¢ in 2007. safety profile of the two vaccines appears to be similar. side effects of vaccination range from low-grade fever and axillary lymphadenopathy to inadvertent inoculation of the virus to other body sites to generalized vaccinia and cardiac events (myopericarditis). rare, but typically fatal complications include progressive vaccinia, eczema vaccinatum, postvaccination encephalomyelitis, and fetal vaccinia. modified vaccinia ankara (mva) smallpox vaccine (bavarian nordic's imvamune â® ) is a live, highly attenuated, viral vaccine that is under development as a future nonreplicating smallpox vaccine (greenberg et al. 2016; kennedy and greenberg 2009 ). passive immunoprophylaxis exists in the form of vaccinia immune globulin (vig) and is used for primarily treating complications from smallpox vaccine. limited information suggests that vig may be of use in postexposure prophylaxis of smallpox if given the first week after exposure and with vaccination. monoclonal antibodies may represent another form of immunoprophylaxis. postexposure administration of human monoclonal antibodies has protected rabbits from a lethal dose of an orthopoxvirus. as mentioned, smallpox is highly communicable person-to-person (table 5 .25). contact precautions with full personal protective equipment (ppe) are required. airborne isolation with the use of an n-95 mask is needed for baseline protection. an n-95 mask or powered airpurifying respirator (papr) is recommended for protection during high risk procedures (beigel and sandrock 2009; goff et al. 2018; rotz et al. 2005; pittman et al. 2018 ; usamriid 2014). anthrax is caused by the aerobic, spore-forming, nonmotile, encapsulated gram-positive rod bacillus anthracis. it is a naturally occurring disease in herbivores. humans contract the illness by handling contaminated portions of infected animals, especially hides and wool. infection is introduced by scratches or abrasions on the skin. there is concern for potential aerosol dispersal leading to intentional infection through inhalation: it is fairly easy to obtain, capable of large quantity production, stable in aerosol form, and highly lethal. anthrax spores enter the body via skin, ingestion, or inhalation. the spores germinate inside macrophages and become vegetative bacteria. the vegetative form is released, replicates in the lymphatic system, and produces intense bacteremia. the production of virulence factors leads to overwhelming sepsis. the main virulence factors are encoded on two plasmids. one produces an antiphagocytic polypeptide capsule. the other contains genes for the synthesis of three proteins it secretes: protective antigen, edema factor, and lethal factor. the combination of protective antigen with lethal factor or edema factor forms binary cytotoxins, lethal toxin, and edema toxin. the anthrax capsule, lethal toxin, and edema toxin act in concert to drive the disease. three clinical syndromes occur with anthrax: cutaneous, gastrointestinal, and inhalational. cutaneous anthrax is the most common naturally occurring form. after an individual is exposed to infected material or the agent itself, there is a 1-12 day (average 7 days) incubation period. a painless or pruritic papule forms at the site of exposure. the papule enlarges and forms a central vesicle, which is followed by erosion into a coal-black but painless eschar. edema surrounds the area and regional lymphadenopathy may occur. gastrointestinal anthrax is rare. typically, it develops after ingestion of viable vegetative organisms found in undercooked meats of infected animals. the two forms of gastrointestinal anthrax, oropharyngeal and intestinal, have incubation periods of 1-6 days. the oropharyngeal form is marked by fever and severe pharyngitis followed by ulcers and pseudomembrane formation. other findings include dysphagia, regional lymphadenopathy, unilateral neck swelling, airway compromise, and sepsis. the intestinal form begins with fever, nausea, vomiting, and abdominal pain. bowel edema develops which leads to mesenteric lymphadenitis with necrosis, shock, and death. endemic inhalational anthrax (woolsorters' disease) is also extremely rare and is due to inhaling spores. therefore, any case of inhalational anthrax should be assumed to be due to intentional exposure until proven otherwise. the incubation period is 1-5 days but can be up to 43 days. there is a prodrome of 1-2 days consisting of fever, malaise, and cough. within 24 h, the disease rapidly progresses to respiratory failure, hemorrhagic mediastinitis (wide mediastinum), septic shock, multiorgan failure, and death. patients with inhalational anthrax may also have hemorrhagic meningitis. mortality is greater than 80% in 24-36 h despite aggressive treatment of inhalational anthrax. the differential diagnoses of ulceroglandular lesions include antiphospholipid antibody syndrome, brown recluse spider bite, coumadin/heparin necrosis, cutaneous leishmaniasis, cutaneous tuberculosis, ecthyma gangrenosum, glanders, leprosy, mucormycosis, orf, plague, rat bite fever, rickettsial pox, staphylococcal/ streptococcal ecthyma, tropical ulcer, tularemia, and typhus. the differential diagnoses of ulceroglandular syndromes include cat scratch fever, chancroid, glanders, herpes, lymphogranuloma venereum, melioidosis, plague, staphylococcal and streptococcal adenitis, tuberculosis, and tularemia. the differential diagnoses for inhalational anthrax include influenza and influenza-like illnesses from other causes. the differential diagnoses of mediastinal widening include normal variant, aneurysm, histoplasmosis, sarcoidosis, tuberculosis, and lymphoma. the diagnosis of anthrax is by culture and gram stain of the blood, sputum, pleural fluid, cerebrospinal fluid, or skin. specimens must be handled carefully, especially by lab personnel and those performing autopsies. elisa and pcr are available at some reference laboratories. the chest radiograph of inhalational anthrax shows the classic widening of the mediastinum. additional findings include hemorrhagic pleural effusions, air bronchograms, and/or consolidation (purcell et al. 2018 ). supportive treatment is indicated, including mechanical ventilation, pleural effusion drainage, fluid and electrolyte support, and vasopressor administration. for inhalational anthrax, antibiotic treatment is unlikely to be effective unless started before respiratory symptoms develop. treatment (table 5 .22) includes ciprofloxacin (or levofloxacin or doxycycline), clindamycin, and penicillin g. raxibacumab, a monoclonal antibody, was approved by the fda in 2012 for the treatment of inhalational anthrax in combination with recommended antibiotic regimens and prophylaxis for inhalational anthrax when other therapies are unavailable or inappropriate. it works by inhibiting anthrax antigen binding to cells and, therefore, prevents toxins from entering cells (kummerfeldt 2014) . the adult dose is 40 mg/kg given iv over 2 h and 15 min. the dose for children is weight based; â�¤15 kg: 80 mg/kg; >15-50 kg: 60 mg/kg; >50 kg: 40 mg/kg. premedication with diphenhydramine iv or po is recommended 1 h before the infusion. it can also be used as postexposure prophylaxis in high risk spore exposure cases (cieslak and henretig 2016; migone et al. 2009 ; the medical letter 2013). obiltoxaximab (anthim) is a recently approved monoclonal antibody treatment for inhalational anthrax in combination with recommended antibiotic regimens and prophylaxis for inhalational anthrax when other therapies are unavailable or inappropriate. adults and children >40 kg should receive a single obiltoxaximab dose of 16 mg/kg. the recommended dose is 24 mg/kg for children >15-40 kg and 32 mg/kg for those weighing â�¤15 kg. premedication with diphenhydramine is recommended to reduce risk of hypersensitivity reactions (the medical letter 2018). in patients with inhalational anthrax, intravenous anthrax immune globulin (anthrasil) should be considered in addition to appropriate antibiotic therapy (mytle et al. 2013 ; the medical letter 2016; usamriid 2014). postexposure prophylaxis includes ciprofloxacin (or levofloxacin or doxycycline) for 60 days plus administration of vaccine; since spores can persist in human in addition to appropriate antibiotic regimen, monoclonal antibody therapy (see text for dosing) and intravenous anthrax immune globulin should be administered for inhalational anthrax c levofloxacin or ofloxacin may be an acceptable alternative to ciprofloxacin d rifampin or clarithromycin may be acceptable alternatives to clindamycin as a drug that targets bacterial protein synthesis. if ciprofloxacin or another quinolone is employed, doxycycline may be used as a second agent because it also targets protein synthesis e ampicillin, imipenem, meropenem, or chloramphenicol may be acceptable alternatives to penicillin as drugs with good cns penetration f assuming the organism is sensitive, children may be switched to oral amoxicillin (40-80 mg/kg/d divided q8 h) to complete a 60-day course. the first 14 days of therapy of postexposure prophylaxis, however, should include ciprofloxacin or levofloxacin and/or doxycycline regardless of age. vaccination should also be provided; if not, antibiotic course will need to be longer g according to most experts, ciprofloxacin is the preferred agent for oral prophylaxis h ten days of therapy may be adequate for endemic cutaneous disease. a full 60-day course is recommended in the setting of terrorism, however, because of the possibility of concomitant inhalational exposure tissues for a long time, antibiotics must be given for a longer period if vaccine is not also given. the anthrax vaccine adsorbed (ava biothraxâ�¢) is derived from sterile culture fluid supernatant taken from an attenuated strain of bacillus anthracis and does not contain any live or dead organisms. the vaccine is given 0.5 ml intramuscularly at 0 and 4 weeks then at 6, 12, and 18 months followed by yearly boosters (pittman et al. 2018; usamriid 2014) . consult with cdc for current pediatric recommendations. anthrax is not contagious in the vegetative form during clinical illness (table 5 .25). contact with infected animals increases likelihood of spread. therefore, contact should be limited and the use of appropriate ppe in endemic areas is indicated (beigel and sandrock 2009; purcell et al. 2018; usamriid 2014) . plague is caused by yersinia pestis, a nonmotile, nonsporulating gram-negative bacterium. it is a zoonotic disease of rodents. it is typically found worldwide and is endemic in western and southwestern states. humans develop the disease after contact with infected rodents, or being bitten by their fleas. after a rodent population dies off, the fleas search for other sources of blood, namely humans. this is when large outbreaks of human plague occur. pneumonic plague is a very rare disease and when it is present in a patient, it may be highly suspicious for intentional dispersal of this deadly agent. three clinical syndromes occur with plague: bubonic plague (85%), septicemic plague (13%), and primary pneumonic plague (1-2%). bubonic plague occurs after an infected flea bites a human. after an incubation period of 2-8 days, there is onset of high fever, severe malaise, headache, myalgias, and nausea with vomiting. almost 50% have abdominal pain. around the same time, a characteristic bubo forms which is tender, erythematous, and edematous without fluctuation. buboes typically form in the femoral or inguinal lymph nodes, but other areas can be involved as well (axillary, intraabdominal). the spleen and liver can be tender and palpable. the disease disseminates without therapy. severe complications can ensue, including pneumonia, meningitis, sepsis, and multiorgan failure. pneumonia is particularly concerning since these patients are extremely contagious. mortality of untreated bubonic plague is 60%, but 5% with efficient and effective treatment. septicemic plague is characterized by acute fever followed by sepsis without bubo formation. the clinical syndrome is very similar to other forms of gram-negative sepsis: chills, malaise, tachycardia, tachypnea, hypotension, nausea, vomiting, and diarrhea. in addition to sepsis, disseminated intravascular coagulation can ensue leading to thrombosis, necrosis, gangrene, and the formation of black appendages. multiorgan failure can quickly follow. untreated septicemic plague is almost 100% fatal versus 30-50% in those treated. pneumonic plague is very rare and should be considered due to an intentional aerosol release until proven otherwise. the incubation period is relatively short at 1-3 days. sudden fever, cough, and respiratory failure quickly follow. this form produces a fulminant pneumonia with watery sputum that usually progresses to bloody. within a short period of time, septic shock and disseminated intravascular coagulation develop. ards and death may occur. mortality rate of pneumonic plague is very high but may respond to early treatment. plague meningitis is a rare complication of plague. it can occur in 6% of patients with septicemia and pneumonic forms and is more common in children. usually occurring a few weeks into the illness, it affects those receiving subtherapeutic doses of antibiotics or bacteriostatic antibiotics that do not cross the blood-brain barrier (tetracyclines). fever, meningismus, and other meningeal signs occur. plague meningitis is virtually indistinguishable from meningococcemia. the differential diagnoses of bubonic plague include tularemia, cat scratch fever, lymphogranuloma venereum, chancroid, scrub typhus, and other staphylococcal and streptococcal infections. the differential diagnoses of septicemic plague should include meningococcemia, other forms of gram-negative sepsis, and rickettsial diseases. the differential diagnosis of pneumonic plague is very broad. however, sudden appearance of previously healthy individuals with rapidly progressive gram-negative pneumonia with hemoptysis should strongly suggest pneumonic plague due to intentional release. diagnosis can be made clinically as previously described. demonstration of yersinia pestis in blood or sputum is paramount. methylene blue or wright's stain of exudates may reveal the classic safety-pin appearance of yersinia pestis. culture on sheep blood or macconkey agar demonstrates beaten-copper colonies (48 h) followed by fried-egg colonies (72 h). detection of yersinia pestis f1-antigen by specific immunoassay is available, but the result is available retrospectively. chest radiograph of patients will demonstrate patchy infiltrates (centers for disease control and prevention 2018a; worsham et al. 2018) . treatment includes mechanical ventilation strategies for ards, hemodynamic support (fluid and vasopressor administration), and antimicrobial agents (table 5 .23). gentamicin or streptomycin is the preferred antimicrobial treatment. alternatives include doxycycline or ciprofloxacin or levofloxacin or chloramphenicol. in cases of meningitis, chloramphenicol is recommended due to its ability to effectively cross the blood-brain barrier. streptomycin is in limited supply and is available for compassionate use. it should be avoided in pregnant women. postexposure prophylaxis includes doxycycline or ciprofloxacin. no licensed plague vaccine is currently in production. a previous licensed vaccine was used in the past. it only offered protection against bubonic plague but not aerosolized yersinia pestis. the plague bacterium secretes several virulence factors (fraction 1 (f1) and v (virulence) proteins) that as subunit proteins are immunogenic and possess protective properties. recently, an f1-v antigen (fusion protein) vaccine developed by usamriid provided 100% protection in monkeys against high-dose aerosol challenge. there is no passive immunoprophylaxis (i.e., immune globulin) available for pre-or postexposure of plague (usamriid 2014). use of standard precautions for patients with bubonic and septicemic plague is indicated. suspected pneumonic plague will require strict isolation with respiratory droplet precautions for at least 48 h after initiation of effective antimicrobial therapy, or until sputum cultures are negative in confirmed cases. an n-95 respirator should be used for baseline protection (table 5 .25). it is also recommended to use an n-95 respirator or papr for high risk procedures (beigel and sandrock 2009; ; centers for disease control and prevention 2017; centers for disease control and prevention 2018b; pittman et al. 2018; usamriid 2014) . in a mass casualty setting, parenteral therapy might not be possible. in such cases, oral therapy (with analogous agents) may need to be used b ofloxacin (and possibly other quinolones) may be acceptable alternatives to ciprofloxacin or levofloxacin; however, they are not approved for use in children c concentration should be maintained between 5 and 20 î¼g/ml. some experts have recommended that chloramphenicol be used to treat patients with plague meningitis, because chloramphenicol penetrates the blood-brain barrier. use in children younger than 2 may be associated with adverse reactions but might be warranted for serious infections d ribavirin is recommended for arenavirus or bunyavirus infections and may be indicated for a viral hemorrhagic fever of an unknown etiology although not fda approved for these indications. for intravenous therapy use a loading dose: 30 kg iv once (max dose, 2 g), then 16 mg/kg iv q6 h for 4 days (max dose, 1 g), and then 8 mg/kg iv q8 h for 6 days (max dose, 500 mg). in a mass casualty setting, it may be necessary to use oral therapy. for oral therapy, use a loading dose of 30 mg/kg po once, then 15 mg/kg/day po in 2 divided doses for 10 days viral hemorrhagic fever has a variety of causative agents. however, the syndromes they produce are characterized by fever and bleeding diathesis. the etiologies include rna viruses from four distinct families: arenaviridae, bunyaviridae, filoviridae, and flaviviridae. the filoviridae (includes ebola and marburg) and arenaviridae (includes lassa fever and new world viruses) are category a agents. based on multiple identified characteristics, there is strong concern for the weaponization potential of the viral hemorrhagic fevers. specifically, there has been demonstration of high contagiousness in aerosolized primate models. there are five identified ebola species, but only four are known to cause disease in humans. the natural reservoir host of ebola virus remains unknown. however, on the basis of evidence and the nature of similar viruses, researchers believe that the virus is animal-borne and that bats are the most likely reservoir. four of the five virus strains occur in an animal host native to africa. marburg virus has a single species. geographic distribution of ebola and marburg is africa (fitzgerald et al. 2016 ). both diseases are very similar clinically. incubation period is typically 5-10 days with a range of 2-16 days. symptoms may include fever, chills, headache, myalgia, nausea, and vomiting. there is rapid progression to prostration, stupor, and hypotension. the onset of a maculopapular rash on the arms and trunk is classic. disseminated intravascular coagulation and thrombocytopenia develops with conjunctival injection, petechiae, hemorrhage, and soft tissue bleeding. there is a possible central nervous system and hepatic involvement. bleeding, uncompensated shock, and multiorgan failure are seen. high viral load early in course is associated with poor prognosis. death usually occurs during the second week of illness. mortality rate of marburg is 25-85% and for ebola 50-90%. in a retrospective cohort study of children during the 2014/2105 ebola outbreak in liberia and sierra leone (all less than 18 years with a median age of 7 years with one-third less than 5 years of age), the most common features upon presentation were fever, weakness, anorexia, and diarrhea. about 20% were initially afebrile. bleeding was rare upon initial presentation. the overall case fatality rate was 57%. factors associated with death included children less than 5 years of age, bleeding at any time during hospitalization, and high viral load (smit et al. 2017) . in another retrospective cohort study of children at two ebola centers in sierra leone in 2014 (all less than 5 years of age), presenting symptoms included weakness, fever, anorexia, diarrhea, and cough. about 25% were afebrile on presentation. the case fatality rate was higher in children less than 2 years (76%) versus 2-5 years of age (46%) and 9 times more likely to die if child had a higher viral load. signs associated with death included fever, emesis, and diarrhea. interestingly, hiccups, bleeding, and confusion were only observed in children who died (shah et al. 2016) . lassa virus and new world viruses (junin, machupo, sabia, and guanarito) are transmitted from person-to-person. the vector in nature is the rodent. the incubation period is from 5 to 16 days. the geographical distribution is west africa and south america, respectively. the south american hemorrhagic fevers are quite similar but differ from lassa fever. the onset of the south american viruses is insidious and results in high fever and constitutional symptoms. petechiae or vesicular enanthem with conjunctival injection is common. these fevers are associated with neurologic disease (hyporeflexia, gait abnormalities, and cerebellar dysfunction). seizures portend a poor prognosis. mortality ranges from 15% to over 30%. on the contrary, lassa viruses are mild. less than 10% of infections result in severe disease. signs include chest pain, sore throat, and proteinuria. hemorrhagic disease is uncommon. other features include neurologic disease such as encephalitis, meningitis, cerebellar disease, and cranial nerve viii deafness (common feature). mortality can be as high as 25%. differential diagnoses include malaria, meningococcemia, hemolytic uremic syndrome, thrombotic thrombocytopenic purpura, and typhoid fever. diagnosis is through detection of the viral antigen testing by elisa or viral isolation by culture at the cdc. no specific therapy is present and generally involves supportive care, especially mechanical ventilation strategies for ards, hemodynamic support, and renal replacement therapy. for the arenaviridae and bunyaviridae groups, ribavirin may be indicated ( (pittman et al. 2018) . there is no current vaccine for ebola that is licensed by the fda. an experimental vaccine called rvsv-zebov was found to be highly protective against ebola virus in a trial conducted by the world health organization (who) and other international partners in guinea in 2015. fda licensure for the vaccine is expected in 2019. until then, 300,000 doses have been committed for an emergency use stockpile under the appropriate regulatory mechanism in the event and an outbreak occurs before fda approval is received (centers for disease control and prevention 2019b; henao-restrepo et al. 2015) . another ebola vaccine candidate, the recombinant adenovirus type-5 ebola vaccine, was evaluated in a phase 2 trial in sierra leone in 2015. an immune response was stimulated by this vaccine within 28 days of vaccination and strict contact precautions (hand hygiene, double gloves, gowns, shoe and leg coverings, and face shield or goggles) and droplet precautions (private room or cohorting, surgical mask within 3 ft) are mandatory for viral hemorrhagic fevers. airborne precautions (negative-pressure isolation room with 6-12 air exchanges per h) should also be instituted to the maximum extent possible and especially for procedures that induce aerosols (e.g., bronchoscopy). at a minimum, a fit-tested, hepa filter-equipped respirator (e.g., an n-95 mask) should be used, but a battery-powered papr or a positive pressure-supplied air respirator should be considered for personnel sharing an enclosed space with, or coming within 6 ft of, the patient. multiple patients should be cohorted in a separate ward or building with a dedicated airhandling system when feasible (table 5 .25). environmental decontamination is accomplished with hypochlorite or phenolic disinfectants (beigel and sandrock 2009; radoshitzky et al. 2018; usamriid 2014; won and carbone 2005) . francisella tularensis, a small aerobic, nonmotile gram-negative coccobacillus, causes tularemia (rabbit fever). clinical disease is caused by two isolates, biovars jellison type a and b. this organism can be stabilized for weaponization and delivered in a wet or dry form. the incubation period is usually 3-6 days (range 1-21 days). initial symptoms are nonspecific and mimic the flu-like symptoms or other upper respiratory tract infections. there is acute onset of fever with chills, myalgias, cough, fatigue, and sore throat. the two clinical forms of tularemia are typhoidal and ulceroglandular diseases. typhoidal tularemia (5-15%) occurs after inhalational exposure and sometimes intradermal or gastrointestinal exposures. there is abrupt onset of fever, headache, malaise, myalgias, and prostration. it presents without lymphadenopathy. nausea, vomiting, and abdominal pain are sometimes present. untreated, there is a 35% mortality rate in naturally acquired cases (vs. 1-3% in those treated). it is higher if pneumonia is present. this form would be most likely seen during an aerosol release of the agent. ulceroglandular tularemia (75-85%) occurs through skin or mucus membrane inoculation. there is abrupt onset of fever, chills, headache, cough, and myalgias along with a painful papule at the site of exposure. the papule becomes a painful ulcer with tender regional lymph nodes. skin ulcers have heaped up edges. in 5-10%, there is focal lymphadenopathy without an apparent ulcer. lymph nodes may become fluctuant and drain when receiving antibiotics. without treatment, they may persist for months or even years. in some cases (1-2%), the primary entry port is the eye leading to oculoglandular tularemia. patients have unilateral, painful, and purulent conjunctivitis with local lymphadenopathy. chemosis, periorbital edema, and small nodular granulomatous lesions or ulceration may be found. oropharyngeal tularemia with pharyngitis may occur in 25% of patients. findings include exudative pharyngitis/tonsillitis, ulceration, and painful cervical lymphadenopathy. the differential diagnosis is antibiotic unresponsive pharyngitis, infectious mononucleosis, and viral pharyngitis. pulmonary involvement (47-94%) is seen in naturally occurring disease. it ranges from mild to fulminant. various processes include pneumonia, bronchiolitis, cavitary lesions, bronchopleural fistulas, and chronic granulomatous diseases. left untreated, 60% will die. differential diagnoses include those for typhoidal (typhoid fever, rickettsia, and malaria) or pneumonic (plague, mycoplasma, influenza, q-fever, and staphylococcal enterotoxin b) tularemia. diagnosis should be considered when there is a cluster of nonspecific, febrile, systemically ill patients who rapidly progress to fulminant pneumonitis. tularemia can be diagnosed by recovering the organism from sputum (pcr or dfa) or serology at a state health laboratory. chest radiograph is nonspecific with possible hilar adenopathy. treatment is streptomycin or gentamicin (table 5 .23). alternatives include doxycycline, ciprofloxacin, or chloramphenicol. a live-attenuated vaccine (ndbr 101) exists and typically used for laboratory personnel working with francisella tularensis. there is no passive immunoprophylaxis. ciprofloxacin or doxycycline can be given as pre-and postexposure prophylaxis (beigel and sandrock 2009; hepburn et al. 2018; pittman et al. 2018; usamriid 2014) . botulinum neurotoxins (bont) are produced from the spore-forming, gram-positive, obligate anaerobe clostridium botulinum. it is the most potent toxin known to man. a lethal dose is 1 ng per kilogram. it is 100,000 times more toxic than sarin (gb). there are seven serotypes of botulinum toxin (a through g). a new serotype (h) has been tentatively identified in a case of infant botulism but has not been fully investigated. most common are serotypes a, b, and e. the toxin acts on the presynaptic nerve terminal of the neuromuscular junction and cholinergic autonomic synapses. this disrupts neurotransmission and leads to clinical findings. there are three forms of botulism: foodborne, wound, and intestinal (infant or adult intestinal). botulinum toxin can also be released as an act of bioterrorism via ingestion or aerosol forms. incubation can be from 12 h after exposure to several days later. clinical findings of botulism include cranial nerve palsies such as ptosis, diplopia, and dysphagia. this is followed by symmetric descending flaccid paralysis. however, the victim remains afebrile, alert, and oriented. death is typically due to respiratory failure. prolonged respiratory support is often required (1-3 months). differential diagnoses include guillain-barre syndrome, myasthenia gravis, tick paralysis, stroke, other intoxications (nerve gas, organophosphates), inflammatory myopathy, congenital and hereditary myopathies, and hypothyroidism. diagnosis is mostly clinical. laboratory confirmation can be obtained by bioassay of patient's serum. other assays include immunoassays for bacterial antigen, pcr for bacterial dna, and reverse transcriptase-pcr for mrna to detect active synthesis of toxin. cerebrospinal fluid demonstrates normal protein (unlike guillain-barre syndrome). emg reveals augmentation of muscle action potential with repetitive nerve stimulation at 20-30 hz. treatment (table 5 .23) is mainly supportive including intubation and ventilator support. tracheostomy may be required due to prolonged respiratory weakness and failure. antibiotics do not play a role in treatment. botulism antitoxin heptavalent [a, b, c, d, e, f, g]-equine (bat) was approved by the fda in 2013. bat was developed at usamriid as one of two equine-derived heptavalent bont antitoxins. bat is approved to treat individuals with symptoms of botulism following a known or suspected exposure. it has the potential to cause hypersensitivity reactions in those sensitive to equine proteins. the safety of bat in pregnant and lactating women is unknown. evidence regarding safety and efficacy in the pediatric population is limited. in 2003, the fda approved botulinum immune globulin intravenous (babybig), a human botulism immune globulin derived from pooled plasma of adults immunized with pentavalent botulinum toxoid. it is indicated for the treatment of infants with botulism from toxin serotypes a and b. immediately after clinical diagnosis of botulism, adults (including pregnant women) and children should receive a single intravenous infusion of antitoxin (bat or, for infants with botulism from serotypes a or b, babybig) to prevent further disease progression. the administration of antitoxin should not be delayed for laboratory testing to confirm the diagnosis. the pentavalent toxoid vaccine (previously for protection against a, b, c, d, and e; but not f or g) is no longer available as of 2011. no replacement vaccine is currently available. standard isolation precautions (table 5 .25) should be followed (beigel and sandrock 2009; dembek et al. 2018; pittman et al. 2018; timmons and carbone 2005; usamriid 2014 ). ricin is a potent cytotoxin derived from the castor bean plant ricinus communis. it is related in structure and function to shiga toxins and shiga-like toxin of shigella dysenteriae and escherichia coli, respectively. it consists of two glycoprotein subunits, a and b, connected by a disulfide bond. the b-chain allows the toxin to bind to cell receptors and gain entrance into the cell. once ricin enters the cell, the disulfide chemical linkage is broken. the free a chain then acts as an enzyme and inactivates ribosomes thereby disrupting normal cell function. cells are incapable of survival and soon die. ricin has a high terrorist potential due to it characteristics: readily available, ease of extraction, and notoriety (maman and yehezkelli 2005) . three modes of exposure exist: oral, inhalation, and injection. four to eight hours after inhalation exposure, the victim develops fever, chest tightness, cough, dyspnea, nausea, and arthralgias. airway necrosis and pulmonary capillary leak ensues within 18-24 h. this is followed quickly by severe respiratory distress, ards, and death due to hypoxemia within 36-72 h. injection may cause minimal pulmonary vascular leak. pain at the site and local lymphadenopathy may occur. however, it may be followed by nausea, vomiting, and gastrointestinal hemorrhage. ingestion leads to necrosis of the gastrointestinal mucosa, hemorrhage, and organ necrosis (spleen, liver, and kidney). diagnosis is suspected when multiple cases of acute lung injury occur in a geographic cluster. serum and respiratory secretions can be checked for antigen using elisa. pulmonary intoxication is managed by mechanical ventilation. gastrointestinal toxicity is managed by gastric lavage and use of cathartics. activated charcoal has little value due to the size of ricin molecules. supportive care is indicated for injection exposure. in general, treatment is largely supportive, especially for pulmonary edema that can result from the capillary leak. there is no vaccine available or prophylactic antitoxin for human use. however, there are two ricin vaccines in the development that focus on the ricin toxin a (rta) chain subunit. a mutant recombinant rta chain vaccine, rivax, has been shown to be safe and immunogenic in humans. the other vaccine is another recombinant rta chain vaccine, rvec . it has shown effectiveness in animal models by producing protective immunity against aerosol challenge with ricin in animal models. standard precautions are advised for health care workers (pittman et al. 2018; roxas-duncan et al. 2018; traub 2005 ; usamriid 2014). recent events which include the nuclear reactor meltdown at fukushima and international tension between nuclear powers, spark concern over potential devastation from nuclear catastrophes. there are numerous examples of radiation disasters in history. sixty-six thousand people were killed in hiroshima and thirty-nine thousand people were killed in nagasaki from nuclear bombs detonated over these cities in 1945 (avalon project-documents in law, history and diplomacy n.d.). many other people suffered from long-term consequences of radiation poisoning. in 1986, 21,000 square kilometers of land in russia, ukraine, and belarus were contaminated with radiation from a meltdown at a nuclear power plant in chernobyl, ukraine. one hundred and thirty-five thousand people were permanently evacuated from their homes (likhtarev et al. 2002) . long-term health consequences included many children who developed thyroid cancer several years later. many of these children died. a tsunami pummeled the east coast of japan in march of 2011. the power outage that ensued at the fukushima power plant led to a failure of the cooling system of the fuel rods, leading to a meltdown of four of the reactors at the plant. a massive quantity of radiation was released into the atmosphere, forcing people to evacuate their homes indefinitely. creative thinking and heroic actions by the tokyo fire department prevented entire populations of cities from being poisoned with radiation. terrorism experts are concerned that terrorist organizations will produce and detonate a radiological dispersion device (rdd), sometimes referred to as a dirty bomb. this is a conventional explosive, loaded with radioactive material which would be dispersed upon detonation. this would likely involve only one radioisotope. fewer people would be exposed and a smaller area would be contaminated than what would transpire with the detonation of a nuclear weapon. spreading fear and panic would be the primary purpose of such a device (mettler jr and voelz 2002) . radiation is the emission and propagation of energy through space or through a medium in the form of waves. radiation can be ionizing or nonionizing depending on the amount of energy released. most radiation that people encounter is low energy and, therefore, nonionizing with no biological effects. ionizing radiation emits enough energy to strip electrons from an atom, which provokes cellular changes and thereby, results in biological effects. radiation emitted from nuclear decay is always ionizing (radiation emergency assistance center/training site (react/s-cdc) 2006). atomic nuclei are held together by a very powerful binding energy despite positively charged protons repelling each other. this energy is released from unstable nuclei in the form of electromagnetic waves or particles. when ionizing radiation reaches biological tissue, chemical bonds are disrupted, free radicals are produced, and dna is broken. electromagnetic waves are of two types, x-rays and gamma rays. x-rays are relatively low energy and less penetrating. gamma rays have a shorter wavelength and contain relatively higher energy, making them more penetrating of biological tissue. ionizing radiation in the form of particles consists of alpha particles, beta particles, and neutrons. alpha particles are the largest of the forms of particulate radiation. they are composed of two neutrons and two protons. they do not easily penetrate solid surfaces, including clothes and skin. however, they can cause severe damage to an organism if internalized. in 2006, in the united kingdom, alexander litvienko, an ex kgb agent was poisoned with a radioactive element called polonium (mcphee and leikin 2009). a small amount of polonium was sprinkled into his food. polonium releases alpha particles when it decays. it was relatively safe for the assassin to carry this element with him because of the relatively poor ability of alpha particles to penetrate clothing and skin. once it is ingested, however, alpha particles have profound biological effects. mr. litvienko became very ill, and ultimately died. beta particles are high energy electrons discharged from the nucleus and are highly penetrating. neutrons emitted from a nucleus are also highly penetrating. in general, neutrons are only released by the detonation of a nuclear weapon. ionizing radiation of any form cannot be detected by our senses. it is not smelled, felt by touch, tasted, or seen. it is possible to be exposed to a lethal dose of radiation without realizing it. in goiania, brazil, in 1987, children found a canister of radioactive cesium ( 137 cs) that had been looted from a medical center and left in the street. the children liked the appearance of the substance but were not able to sense any abnormalities or danger with it. they began to rub it on their bodies because they liked the way it made them glow in the dark. the children all became ill. ultimately, 250 people were exposed to this radioisotope. it took 10 days before physicians recognized that the people had radiation poisoning. four people died of acute radiation syndrome. four factors determine the severity of exposure to ionizing radiation: time, distance, dose, and shielding. time is the time of exposure to the radiation source. distance is the distance from the radiation source. based on the inverse square law, exposure is reduced exponentially with increasing distance from the radiation source. dose is measured by the amount of energy released by the source and is numerically described by how many disintegrations per second occur, in curies (ci) or becquerels (bq). shielding is the efficacy of the barrier to the radioactive source. lead is well-known to be a very effective shield to x-rays. in a radiation exposure, injury to skin from trauma or burns may cause a greater degree of contamination because of loss of the shielding of the skin. there are four important principles for the nurse or hcp to understand with regard to exposure to ionizing radiation: external exposure, external contamination, internal contamination, and incorporation. external contamination occurs when radioactive material is carried on a person after exposure. this person can then contaminate others. removing contaminated clothing eliminates 90% of the toxin. others are then less vulnerable to exposure. internal contamination is when a radioactive substance enters the body through inhalation, ingestion, or translocation through open skin. incorporation is internalization of the toxin into body organs. incorporation is dependent on the chemical and not the radiological properties of the radioactive toxin. radioactive iodine, 131 i, is taken up by the thyroid gland because iodine enters the gland as part of normal physiology (advanced hazmat life support (ahls) 2003). ionizing radiation can damage chromosomes directly and indirectly, causing ravaging biological effects. indirect damage comes from the production of h + and oh â�� . free radical formation upsets biochemical processes and causes inflammation. these effects can take anywhere from seconds to hours to be expressed. clinical changes can take from hours to years to be realized (zajtchuk et al. 1989 ). immediately after a major radiation exposure, the clinical matters of most concern are those related to trauma from blast and thermal injuries. these injuries may be life-threatening and must be addressed first. after thermal and traumatic injuries are addressed, attention should be paid to the severity of radiation exposure. severe exposure can cause acute radiation syndrome. "the acute radiation syndrome is a broad term used to describe a range of signs and symptoms that reflect severe damage to specific organ systems and that can lead to death within hours or up to several months after exposure" (national council on radiation protection (ncrp) and measurements 2001; national council on radiation protection (ncrp) and measurements 2009). the mechanism of cell death from toxic radiation exposure is related to the inhibition of mitosis. organs with the most rapidly dividing cells are the most susceptible. the gastrointestinal and the hematopoietic are the organ systems most notably affected. the organs of pediatric patient have a higher mitotic index, in general, to those of adults and are more vulnerable to injury from radiation poisoning. the time of onset and the severity of acute radiation syndrome are controlled by the total radiation dose, the dose rate, percent of total body exposed, and associated thermal and traumatic injuries. there is a 50% death rate (ld 50 ) within 60 days for people exposed to a dose of radiation of 2.5-4.0 gy. the ld 50 is lower for the pediatric population. the acute radiation syndrome is composed of four phases: prodromal, latent, manifest illness, and death or recovery. inflammatory mediator release during the prodromal phase causes damage to cell membranes. this phase occurs during the first 48 h after exposure to radiation. nausea and vomiting and fever can occur during this time. if these symptoms occur during the first 2 h after exposure, there is a poor prognosis. the onset of the latent phase is usually in the first 4 days post exposure but can ensue anytime during the first 21 days thereafter. all cell lines of the hematopoietic system are affected. lymphocytes and platelets, the most rapidly dividing cells of the bone marrow, are most severely affected. the illness phase manifests after 30 days since radiation exposure. infection, impaired wound healing, anemia, and bleeding occur during this time of illness. the hematopoietic, gastrointestinal, central nervous, and integumentary are the organ systems affected. there is a marked reduction of cells from all cell lines of the bone marrow. there is a direct correlation with the drop in absolute lymphocyte count with the dose of radiation received. the absolute lymphocyte count is commonly used to estimate the dose of radiation received. the gastrointestinal (gi) epithelial lining, one of the most rapidly dividing cell lines of the body is the second most vulnerable to radiation poisoning. the radiation dose required to affect the gi system is 8 gy. vomiting, diarrhea, and a capillary leak syndrome for gi tract are common manifestations. hypovolemia and electrolyte instability ensue. translocation of bacteria into the bloodstream, combined with the diminished immunity caused by the decimation of the hematopoietic system, place victims at high risk for septic shock. another organ system affected by the acute radiation syndrome is the central nervous system. this requires a large dose of at least 30 gy. manifestations include cerebral edema, disorientation, hyperthermia, seizures, and coma. acute radiation syndrome that involves the central nervous system is always fatal. the integumentary system is frequently affected by the acute radiation syndrome, especially if the skin is in direct contact with a radioisotope. epilation, erythema, dry desquamation, wet desquamation, and necrosis occur respectively with increasing severity associated with increasing doses of radiation. radiation burns can be distinguished from thermal or chemical burns by their delayed onset. it can take days to weeks for radiation burns to affect victims. thermal and chemical burns cause signs and symptoms more acutely. hospitals that anticipate victims of radiation should prepare areas of triage with decontamination supplies and techniques ready to be deployed. an emergency department (ed) should be divided into "clean" and "dirty" areas. the dirty area is created for the purpose of decontamination to prevent the spread of radioisotopes. all health care personnel should wear ppe including surgical scrubs and gowns, face shields, shoe covers, caps, and two pairs of gloves. the inner pair of gloves is taped to the sleeves of the gown. each health care worker should be monitored for the exposure of the radiation and its dose with a dosimeter worn underneath the gown. the radiation safety officer of the hospital should take a leadership role in health care worker protection and decontamination procedures. consultation from the radiation emergency, assistance center (react/ts) is imperative. react/ts is a subsidiary of the u.s. department of energy. its contact information is as follows: phone number during business hours is 865-576-3131. the phone number is 865-576-1005 after business hours. the react/ts website is http://orise.orau. gov/reac/ts/. as victims arrive, triage protocols of mass casualty scenarios should be implemented. it should be noted that radiation exposure is not "immediately" lifethreatening. initial clinical management should focus on the abcde (airway, breathing, circulation, disability, and exposure) of basic trauma protocol. the "d" in the above acronym can also be a symbol for decontamination. after airway, breathing, and circulation are addressed, initial phase of decontamination entails careful removal of potentially contaminated clothing. caution should be exercised to remove the clothing gently, while rolling garments outward to prevent the release of dust of radioactive material that could contaminate people in the treatment area. further decontamination procedures take place after initial stabilization. skin decontamination procedures are identical to those of toxic chemical exposure with the following exceptions: â�¢ ppe are slightly different as described above. â�¢ gentle skin rubbing is done to prevent provocation of an inflammatory response and further absorption of the radioactive toxin. â�¢ only soap and water are used. rubbing alcohol and bleach should be avoided. it is advisable to shampoo the hair first, because it is usually the site of the highest level of contamination of the body, and runoff onto the body can then be cleansed during skin decontamination (radiation event medical management (remm) of the u.s. dept. of health and human services n.d.). it should be noted that health care workers are not at risk for contamination if they wear proper ppe during the resuscitation and decontamination process. the lack of knowledge of this point may lead to reluctance to treat patients and increase morbidity and mortality for victims. "no hcp has ever received a significant dose of radiation from handling, treating, and managing patients with radiation injuries and/or contamination."(react/s-cdc 2006). when initial resuscitation and decontamination have been completed, attention should be paid to ongoing support of ventilation, oxygenation, the management of fluid and electrolytes, and treatment of traumatic and burn injuries. infection control procedures are important due to the impending immunocompromised state of the victims. it is important to ascertain the details of the catastrophic event. data on the nature and size of the exposure and the types of radioactive agents involved are vital for ongoing management and decontamination. after the details of the nature of the exposure are uncovered, diagnostic tests should be done, including serial cbc and cytogenetic analysis of lymphocytes, otherwise known as cytogenic dosimetry (react/s-cdc 2006). measurements of change in lymphocyte counts and cytogenetic dosimetry are sensitive markers for the dose of radiation received by a victim. measurements of internal decontamination are done by the sampling and analysis of nasal and throat swabs, stool, and 24 h urine. wound samples and irrigation fluid should also be sampled. after initial stabilization, external decontamination, and diagnostic testing, internal decontamination is performed. external decontamination involves removal of clothes and cleaning the skin and hair. internal decontamination removes radioisotopes that are internalized via inhalation, ingestion, and entry into open wounds. because ionizing radiation is being released inside the body, internal decontamination must be performed promptly after initial resuscitation. since radioisotopes behave identically to their nonradioactive counterparts, antidotes are chosen based on the chemical, and not the radiological properties of the element. basic strategies of internal decontamination include chelation, competitive inhibition, enhanced gastrointestinal elimination, and enhanced renal elimination. specific agents are used for chelation of different radioisotopes. dtpa (diethyenetriaminepentaacetic acid) is administered for the elimination of heavy metals such as americium, californium, curium, and plutonium. dtpa comes in two forms, calcium dtpa (ca-dtpa) and zinc-dtpa (zn-dtpa). ca-dtpa is ten times more effective than zn-dtpa. for adults and adolescents, administration is as follows: â�¢ 1 g of ca-dtpa iv initially in the first 24 h, followed by 1 g zn-dtpa iv daily for maintenance. â�¢ for children less than 12 years of age administer: â�¢ fourteen mg/kg ca-dtpa iv initially, followed by fourteen mg/kg of zn-dtpa iv daily thereafter (national council on radiation protection (ncrp) and measurements 2009). â�¢ the initial dose of dtpa may be administered via inhalation to adolescents and adults if the contamination occurred via inhalation. this method of administration is not approved for pediatric use. chelation with dimercaprol (bal) is used to eliminate polonium. bal is a highly toxic drug and should be administered with caution. the dose is 2.5 mg per kg im four times a day for 2 days, then twice a day on the third day and once a day for 5-10 days, thereafter (national council on radiation protection (ncrp) and measurements 2009). alkalinization of the urine is renal protective during administration. a less toxic alternative to bal, dimercaptosuccinic acid (dmsa), otherwise known as chemet â® is also available. the dose of dmsa is ten mg per kg po every 8 h for 5 days. the same dose is given every 12 h for 14 days, thereafter (national council on radiation protection (ncrp) and measurements 2009). another mechanism for internal decontamination is competitive inhibition. the radioisotope, 131 i, is released during a meltdown of a reactor at a nuclear power plant. potassium iodide (ki) is widely recognized as a competitive inhibitor to its radioactive counterpart, 131 i, from being incorporated into the thyroid gland. ki blocks 90% of 131 i uptake into the thyroid gland if ki is given within the first hour of exposure. it will block 50% of incorporation if given within 5 h of exposure. its protective effect lasts for 24 h. with administration of this drug, thyroid function should be monitored closely. dosing guidelines (table 5 .26) are included in the table below (u.s. food and drug administration n.d.). gastrointestinal elimination is another mechanism of internal decontamination (table 5.27 ). an ion exchanger, prussian blue, (ferric ferrocyanide), binds elements that circulate through the enterohepatic cycle. since it is not absorbed through the gastrointestinal tract, prussian blue carries the toxins into the stool. it is highly effective in the elimination of 137 cs or thallium and was used during the 137 cs incident in goiania, brazil. the dosing of prussian blue is as follows: â�¢ infants: 0.2-0.3 mg per kg po three times a day (not fda approved). â�¢ children 2-12 years of age: 1 g po three times a day. â�¢ children â�¥12 years of age: 3 g po three times a day. â�¢ prussian blue is administered for at least 30 days, and can be adjusted based on the degree of poisoning (national council on radiation protection (ncrp) and measurements 2009). urinary elimination is another useful method of internal decontamination. tritium can be eliminated with excess fluid administration. uranium is eliminated by alkalinizing the urine to a ph of 8-9. sodium bicarbonate is given at a dose of 1 meq/kg iv every 4-6 h and is titrated to effect. if renal injury occurs, dialysis may be required. the basic approach to treating acute radiation syndrome is supportive therapy. gi losses from gastrointestinal difficulties are treated with iv fluids and electrolyte replacement. 5-ht3 antagonists can be used to suppress vomiting and benzodiazepines for anxiety. a patient suffering from acute radiation syndrome may be severely immunocompromised and requires a room with positive pressure isolation. colony stimulating agents for granulocytes and erythrocytes can be used for bone anemia and leukopenia. bone marrow transplant may be required for severe cases. a patient with skin contamination with radiation should be decontaminated with soap and water. a geiger counter can be helpful to identify areas of contamination. scrubbing is performed in a concentric matter, beginning at the outer layers of contamination and moving into the center since the area of greatest contamination is in the center. in this way, the area of contamination remains contained. attention should be paid to good nutrition and pain control. burn and plastic surgery service should also be consulted. more details on decontamination can be found in chap. 9. the psychological impact of a radiation catastrophe on the pediatric victims is likely to be devastating (american academy of pediatrics (aap) 2003). sleep disturbances, social withdrawal, altered play, chronic fear and anxiety, and developmental regression can occur. a correlation between the parent's psychological response and that of the child would occur as with other types of disaster. mental health professionals should be consulted in the event of this type of situation. please refer to chap. 12 for more information. a lot of concern has been expressed over the possibility of terrorist attacks involving explosive devices in recent years (depalma et al. 2005) . explosive devices are relatively simple to manufacture and easy to detonate. they can injure and kill many people and spread fear over large populations. victims of bomb blasts sustain more body regions injured, have more body injury severity scores, and require more surgeries than victims of nonexplosive trauma incidents. victims of explosives also have a higher mortality (kluger et al. 2004) . these observations are also true of pediatric victims (daniel-aharonson et al. 2003) . many factors influence the number of people injured and the severity of the injuries in an explosion. the magnitude of the explosion and its proximity to people and the number of people in the area affect the severity and number of injuries. other factors include the collapse of building or structure from the blast, promptness of the rescue operation, and the caliber and proximity of medical resources in the vicinity. victims who experience explosions in closed spaces are especially vulnerable to more severe injuries. twenty-nine case reports of injuries from terrorist bombings were reviewed (arnold et al. 2004a) . the investigators compared the injury severity of victims of explosions who sustained injuries from structural collapse, closed space explosions without structural collapse, and open space explosions. the mortality rate for these victims was 25%, 8%, and 4%, respectively. hospitalization rates were 25%, 36%, and 15%, respectively. ed visits were 48%, 36%, and 15%, respectively. victims of closed space explosions without structural collapse experienced greater hospitalizations rates than those involved in a structural collapse, because many of the victims involved in the structural collapse experienced immediate death. an explosion is defined as a rapid chemical conversion of a liquid or solid into a gas with energy release. substances that are chemically predisposed to explosion, called explosives, are characterized as low or high order, depending on the speed and magnitude of energy release. low-order explosives release energy at a relatively slow pace and explosions from these substances tend not to produce large air pressure changes or a "blast." the energy release is caused by combustion, producing heat. the involved material "goes up in flames." gunpowder, liquid fuel, and molotov cocktails are examples of low-order explosives (centers for disease control and prevention 2010). explosions from high-order materials cause a blast with a pressure wave in addition to causing the release of heat and light. the blast pressure wave causes compression of the surrounding medium which is physically transformed in all directions from the exact point of explosion. when an explosion occurs on land, air is the surrounding medium compressed. in bodies of water, the surrounding medium is water. the degree of medium compression and the distance that the energy wave travels is determined by the magnitude of the explosion. the power of the blast is measured in pounds per square inch (psi). the pressure blast wave has distinctive characteristics. the amplitude of the wave reaches its highest point immediately after the blast. the blast wave then rapidly decays as it travels through space. as the blast wave propagates, and compresses the surrounding medium, it leaves a vacuum because of displaced molecules in the surrounding medium and a negative phase of the wave ensues. in a land explosion, air molecules are displaced by the initial positive pressure, after which a negative pressure occurs in the vacated space. a wave that propagates through a confined space rebounds off of the wall and reverberates. it may interact with victims in the confined space many times, causing more severe injuries (stuhmiller et al. 1991) (fig. 5.10 ). four kinds of injury occur in high energy explosions. primary blast injuries occur directly from the pressure wave of the blast. secondary injuries occur from being struck by flying objects from the blast. these injuries can be blunt or penetrating. tertiary injuries occur when victims are displaced from a location and strike other objects or surfaces. all other injuries related to the blast are called quarternary. they include burns, inhalational injuries, toxic exposures, and traumatic injuries from structural collapse. primary injuries from blast waves affect bodily tissues with a tissue gas interface. when a pressure wave enters the body, tissue of gas filled organs compress slower than the air inside the tissue, causing stress in the tissue, possibly damaging it. this baseline positive phase originally described by friedlander, a blast wave consists of a short, high-amplitude overpressure peak followed by a longer depression phase. injury potential depends on the wave's amplitude as well as the slopes of its increase and decrease in pressure. x-axis refers to time and y-axis refers to pressure. (jacobson and severin 2012) also known as the "spalling effect." as the negative pressure phase of the blast wave propagates through, it causes more stress on the tissue and further damage. in addition to damaging tissues with an air tissue interface, pressure blasts can cause injury to the brain and can lead to limb detachments. despite the fact that primary blast injuries can be ravaging, they are less common than other types of injury from blasts. the tympanic membranes, lungs, and gastrointestinal tract are the most common organs sustaining injury from pressure waves. the tympanic membrane is the most vulnerable of these three organ systems (depalma et al. 2005; garth 1997) . five psi, which is considered a weak blast, will rupture 50% of tympanic membranes. to put this in perspective, c4, a commonly used explosive generates a pressure of four million psi. otoscopy can reveal ruptured tympanic membranes. neuropraxia, deafness, tinnitus, and vertigo are symptoms that can be experienced. severe blast injuries of the ear can result in damage to the organ of corti, resulting in permanent hearing loss. the second most common organ injured from a blast wave is the lung. fifteen psi are required to cause injury to this organ. lung injuries are more likely to occur from a blast within a closed space, or when victims sustain burns (burns commonly cause acute lung injury from release of inflammatory mediators). direct alveolar damage, blood vessel with bleeding, and inflammation are the three different manifestations of lung injury from blasts. alveolar damage can cause pneumothorax and pulmonary interstitial emphysema. when air dissects along the bronchovascular sheath, pneumomediastinum, pneumopericardium, and subcutaneous emphysema can occur. air that enters the pulmonary venous system can result in a systemic arterial air embolism, and possibly, a stroke. inflammation of the lungs from direct pressure damage to the tissue, cause acute lung injury and possibly, disseminated intravascular coagulation. clinical signs of lung injury include tachypnea, chest pain, hypoxia, rales, and dyspnea. if there is vascular disruption, hemoptysis can occur. air leaks from alveolar injury can result in diminished breath sounds, subcutaneous crepitance, increased resonance, and tracheal deviation. hemodynamic compromise will occur with tracheal deviation. alveolar damage, leading to air in the pulmonary venous system, can lead to a systemic arterial air embolism. air in the coronary arteries can lead to coronary ischemia with st and/or t waves changes on ecg. air embolism to cerebral arteries leads to cerebral vascular accidents (strokes) with focal neurological deficits. other manifestations of systemic air embolism include mottling of the skin, demarcated tongue blanching, and/or air in the retinal vessels (the most common sign of arterial air embolus). rapid death after initial survival is most often caused by arterial air embolus. initiation of positive pressure ventilation may trigger this event (ho and ling 1999) . a lung injury from a blast can also precipitate a vagal reflex resulting in bradycardia and hypotension. it is postulated that this occurs from the stimulation of c fibers in the lungs (guy et al. 1998 ). the gastrointestinal system is the third most common organ system affected by primary blast injury. physical stress and/or mesenteric infarct leads to weakening of the bowel wall with possible rupture. hemorrhage can also occur (paran et al. 1996; sharpnack et al. 1991) . the most common site of injury is the colon. injury to the bowel can be delayed and occur up to several days after the inciting incident. solid organs are spared because of their homogeneity and lack of air tissue interface. brain injury is becoming increasingly recognized as a result of primary blast. shearing injuries of the brain occur as a result of wave reverberation in the skull. hippocampal injury causing cognitive impairment has been shown in animal studies (cernak 2017; cernak et al. 2001; singer et al. 2005) . observations in humans have revealed electroencephalographic abnormalities and attention deficit disorder (born 2005) . human autopsies have revealed punctate hemorrhages and disintegration of nissl substance in victims who sustained blast injury without direct head trauma (guy et al. 1998) . research involving yucatan minipigs revealed that the brain sustains neuronal loss in the hippocampus after being subjected to primary blast injury. brain injury also occurred from the inflammation that ensued post blast (goodrich et al. 2016) . novel therapeutic approaches may be on the horizon for treatment of traumatic brain injury, including that caused by primary blast. intranasal insulin administered to rats subjected to traumatic brain injury resulted in enhanced neuronal glucose uptake and utilization, and subsequently improved motor function and memory. decreased neuroinflammation and preservation of the hippocampus were also noted (brabazon et al. 2017) . in a different investigation, a neuroprotective nucleotide, guanosine, was administered to rats subjected to traumatic brain injury. the treatment group of rats had better locomotor and cognitive outcomes than did the placebo group. programmed cell death and inflammation were also attenuated in the treatment group (gerbatin et al. 2017) . the leading cause of death from blast is from flying objects striking victims (secondary blast injury). eyes are particularly vulnerable. injuries resulting from displacement of the victims who strike objects are known as tertiary injuries. lighter weight children are particularly susceptible to this type of injury. burns, toxic exposures, and crush injuries constitute quaternary injuries. crush injuries commonly occur in explosions with structural collapse. the "crush syndrome" can occur when a trapped limb sustains prolonged compromise to the circulation, leading to rhabdomyolysis. tissue destruction and inflammatory response then occur. lifethreatening electrolyte abnormalities including hyperkalemia, renal failure, hyperuricemia, metabolic acidosis, acute respiratory distress syndrome, disseminated intravascular coagulation, and shock can result from crush syndrome (gonzalez 2005) . the crush syndrome is commonly seen in natural disasters that result in a lot of structural collapse. structural collapse and fires can cause the release of toxic materials such as carbon monoxide and cyanide. knowledge of the details of a blast can greatly enhance the ability of nurses and hcps to care for victims of a blast in a hospital setting. knowledge of whether a blast occurred in a closed or open space, whether structural collapse occurred, or if a victim was rescued from a collapsed area are details that can alert nurses and hcps as to what kind of injuries that they may anticipate. if toxic substances are released with a blast, nurses and hcps can prepare for decontamination techniques and antidote therapies. it would be advantageous for a hospital to be aware of the number of victims that are arriving for care. a mass casualty incident will stress the resources of the institution. hospital personnel should take stock of the resources that are available. the number of available ventilators and o-blood are examples of finite resources that should be considered. advanced trauma life support (atls) principles should be applied to all blast injury victims. abcd of initial resuscitation is applied. the "d" stands for disability as well as decontamination. decontamination techniques should be deployed if there is uncertainty about toxic exposure as described elsewhere in this chapter. on completion of abcd of initial resuscitation a secondary survey is performed, as described by atls protocol. attention should be paid to potential injuries that occur with blast injuries. ruptured tympanic membranes should alert the nurse or hcp of problems from primary blast injury. impaled objects should remain in place and removed in the operating room by surgical staff so that bleeding may be controlled. a thoracoscopy tube should be placed with an open three point seal over a wound on the side of the chest with an open pneumothorax. a hemothorax is also treated with a thoracoscopy tube. an autotransfusion setup can be applied to recirculate the blood from the pleural cavity of a hemothorax (wightman and gladish 2001 ) that would help preserve donor blood for other victims. for severe respiratory distress and/or impending respiratory failure, endotracheal intubation should be performed and positive pressure ventilation should be instituted. because lung tissue could be weakened from primary blast injury, caution should be exercised because of a high risk of pneumothorax, hemorrhage, or arterial air embolus. gentle application of positive pressure ventilation should be applied to avoid these complications. if only one lung is injured unilateral lung ventilation can be considered for larger children and adults. this technique is not suitable for babies and small children. supplemental oxygen with an fio 2 of 100% should be administered to patients suspected of having an arterial air embolus. hyperbaric oxygen therapy could even be considered to help accelerate the removal of air from the arteries. placement of the patient in the left lateral recumbent position may reduce the likelihood of the air lodging in the coronary arteries. victims of blast injuries should be treated identically to those of other types of trauma after initial resuscitation is completed. if primary blast injury occurred, frequent chest and abdominal x-rays should be performed in consideration of the possibility of lung or gastrointestinal injuries. limbs with open fractures should be immobilized and covered with sterile dressings. systemic, broad spectrum antibiotics should be administered to patients with open limb injuries. eyes that sustained chemical injury should be irrigated with water for an hour. all injured eyes should be covered. most ruptured tympanic membranes will heal spontaneously. victims with tympanic membrane injury should be advised to avoid swimming for some time. topical antibiotics are prescribed if dirt or debris is seen in the ear canal. oral prednisone is prescribed for hearing loss. victims with crush injuries should be treated with large volumes of iv fluids to treat inflammatory shock and possibly rhabdomyolysis. electrolytes should be monitored carefully as these patients are at risk for hyperkalemia, hyperphosphatemia, hyperuricemia, hypocalcemia, and acidosis. smoke inhalation, burns, and toxic exposures should be treated according to guidelines of burn, trauma, and toxicology protocols. mass casualty incidents (i.e. mass shootings, active shooter events, bombings, and other multifatality crimes) often attract extensive media coverage as well as the attention of policy makers. many agencies and organizations record and publish data on these incidents. the measurement and reporting does vary based on the absence of a common definition. however, it is clearly evident that mass casualty incidents (mcis) continue to increase in both number and scope (federal bureau of investigation 2017; office for victims of crime, office of justice programs, u.s. department of justice 2019). in the u.s., mass shootings are the most common and most closely tracked. the congressional research service (crs) defines mass shootings as events where more than four people are killed with a firearm "within one event, and in one or more locations in close proximity." congress uses the term mass killings and describes these events as "three or more killings in a single incident." the federal bureau of investigation (fbi) uses the term active shooter, which it defines as "an individual actively engaged in killing or attempting to kill people in a populated area." it is important to realize that nongovernmental ( ranking third of all locations for 2016 and 2017, seven of the 50 incidents occurred in educational environments resulting in five killed and 19 wounded. two incidents occurred in elementary schools, resulting in two killed (including a firstgrade student) and eight wounded (one teacher shot, three students shot, and four wounded from shrapnel). one incident occurred in a junior/senior high school, resulting in none killed and four wounded (two from shrapnel, all students). four incidents occurred at high schools (one outside a school during prom), resulting in three killed (all students) and seven wounded (all students). fortunately, no incident occurred at institutions of higher learning during 2016 or 2017 (advanced law enforcement rapid response training (alerrt) center, texas state university and federal bureau of investigation, u.s. department of justice 2018). notably, two of the 50 incidents occurred in houses of worship, resulting in 27 killed and 27 wounded. one of these incidents occurred at the first baptist church in sutherland springs, texas, and had the third highest number of casualties (26 killed and 20 wounded) in 2017. the dead included 10 women, 7 men, 8 children (7 girls and 1 boy), and an unborn child (goldman et al. 2017) . a summary report has also been developed for all 250 active shooter incidents from 2000 to 2017, including incidents per year (fig. 5.11 ), casualties per year (fig. 5.12) , and location ( fig. 5.13 ) categories (federal bureau of investigation 2017; federal bureau of investigation 2018). overall, there was an increase in number of active shooter incidents and casualties per year. location categories with number of incidents and statistics of their contribution were provided: areas of educational environments account for a large portion of locations for active shooter incidents, ranking only second to commercial areas. of the 37 incidents (14.8%) occurring at schools, one took place at a nursery (pre-k) school and one incident occurred during a school board meeting that was being hosted on school property but no students were involved (neither perpetrator or victim). the remainder (35 incidents) were perpetrated by or against students, faculty, and/or staff at k-12 schools (federal bureau of investigation 2018). finally, 15 active shooter incidents (6%) did occur at institutions of higher learning. as a reminder, no incident occurred at institutions of higher learning during 2016 or 2017. table 5 .31 provides a detailed summary of educational environment incidents from 2000 to 2017. since the beginning of 2018, other tragic active shooter attacks have occurred in the u.s. and greatly impacted children and adolescents. two of these such events have occurred in educational environments (united states secret service national threat assessment center 2018). on february 14, 2018, a gunman opened fire at marjory stoneman douglas high school. fourteen students and three staff members were killed while fourteen others were injured (follman et al. 2019) . twelve victims died inside the building, three died just outside the building on school premises, and two died in the hospital. the shooter was a former student of the school. another active shooter event occurred on may 18, 2018 at santa fe high school in santa fe, texas. the shooter killed ten individuals including eight students and two teachers while injuring 13 others. the shooter was an enrolled student at the school (follman et al. 2019) . based on the statistics of active shooter incidents, casualties, and locations, it is vital to prepare schools and plan for such events. national preparedness efforts, including planning, are now informed by the presidential policy directive (ppd) 8 that was signed by the president in march 2011 and describes the nation's approach to preparedness. this directive represents an evolution in our collective understanding of national preparedness based on the lessons learned from terrorist attacks, hurricanes, school incidents, and other experiences. ppd-8 defines preparedness around five mission areas and can be applied to school active shooter incidents. on march 21, 2005, at 2:49 p.m., jeffery james weise, 16, armed with a shotgun and two handguns, began shooting at red lake high school in red lake, minnesota. before the incident at the school, the shooter fatally shot his grandfather, who was a police officer, and another individual at their home. he then took his grandfather's police equipment, including guns and body armor, to the school. a total of nine people were killed, including an unarmed security guard, a teacher, and five students; six students were wounded. the shooter committed suicide during an exchange of gunfire with police campbell county comprehensive high school (education) on november 8, 2005, at 2:14 p.m., kenneth s. bartley, 14, armed with a handgun, began shooting in campbell county comprehensive high school in jacksboro, tennessee. before the shooting, he had been called to the office when administrators received a report that he had a gun. when confronted, he shot and killed an assistant principal and wounded the principal and another assistant principal. the shooter was restrained by students and administrators until police arrived and took him into custody pine middle school (education) on march 14, 2006, at 9:00 a.m., james scott newman, 14, armed with a handgun, began shooting outside the cafeteria at pine middle school in reno, nevada. no one was killed; two were wounded. the shooter was restrained by a teacher until police arrived and took him into custody essex elementary school and two residences (education) on august 24, 2006, at 1:55 p.m., christopher williams, 26, armed with a handgun, shot at various locations in essex, vermont. he began by fatally shooting his ex-girlfriend's mother at her home and then drove to essex elementary school, where his ex-girlfriend was a teacher. he did not find her, but as he searched, he killed one teacher and wounded another. he then fled to a friend's home, where he wounded one person. a total of two people were killed; two were wounded. the shooter also shot himself twice but survived and was apprehended when police arrived at the scene orange high school and residence (education) on august 30, 2006, at 1:00 p.m., alvaro castillo, 19, armed with two pipe bombs, two rifles, a shotgun, and a smoke grenade, began shooting a rifle from his vehicle at his former high school, orange high school in hillsborough, north carolina. he had fatally shot his father in his home that morning. one person was killed; two were wounded. the shooter was apprehended by police weston high school (education) on september 29, 2006, at 8:00 a.m., eric jordan hainstock, 15, armed with a handgun and a rifle, began shooting in weston high school in cazenovia, wisconsin. one person was killed; no one was wounded. the shooter was restrained by school employees until police arrived and took him into custody west nickel mines school (education) on october 2, 2006, at 10:30 a.m., charles carl roberts, iv, 32, armed with a rifle, a shotgun, and a handgun, began shooting at the west nickel mines school in bart township, pennsylvania. after the shooter entered the building, he ordered all males and adults out of the room. after a 20-min standoff, he began firing. the shooter committed suicide as the police began to breach the school through a window. five people were killed; five were wounded on april 2, 2012, at 10:30 a.m., su nam ko, aka one l. goh, 43, armed with a handgun, began shooting inside oikos university in oakland, california. he then killed a woman to steal her car. seven people were killed; three were wounded. the shooter was arrested by police later that day on august 27, 2012, at 10:45 a.m., robert wayne gladden jr., 15, armed with a shotgun, shot a classmate in the cafeteria of perry hall high school in baltimore, maryland. the shooter had an altercation with another student before the shooting began. he left the cafeteria and returned with a gun. no one was killed; one person was wounded. the shooter was restrained by a guidance counselor before being taken into custody by the school's resource officer sandy hook elementary school and residence (education) on december 14, 2012, at 9:30 a.m., adam lanza, 20, armed with two handguns and a rifle, shot through the secured front door to enter sandy hook elementary school in newtown, connecticut. he killed 20 students and six adults, and wounded two adults inside the school. prior to the shooting, the shooter killed his mother at their home. in total, 27 people were killed; two were wounded. the shooter committed suicide after police arrived taft union high school (education) on january 10, 2013, at 8:59 a.m., bryan oliver, 16, armed with a shotgun, allegedly began shooting in a science class at taft union high school in taft, california. no one was killed; two people were wounded. an administrator persuaded the shooter to put the gun down before police arrived and took him into custody new river community college, satellite campus (education) on april 12, 2013, at 1:55 p.m., neil allen macinnis, 22, armed with a shotgun, began shooting in the new river community college satellite campus in the new river valley mall in christiansburg, virginia. no one was killed; two were wounded. the shooter was apprehended by police after being detained by an off-duty mall security officer as he attempted to flee santa monica college and residence (education) on june 7, 2013, at 11:52 a.m., john zawahri, 23, armed with a handgun, fatally shot his father and brother in their home in santa monica, california. he then carjacked a vehicle and forced the driver to take him to the santa monica college campus. he allowed the driver to leave her vehicle unharmed but continued shooting until he was killed in an exchange of gunfire with police. five people were killed; four were wounded sparks middle school (education) on october 21, 2013, at 7:16 a.m., jose reyes, 12, armed with a handgun, began shooting outside sparks middle school in sparks, nevada. a teacher was killed when he confronted the shooter; two people were wounded. the shooter committed suicide before police arrived arapahoe high school (education) on december 13, 2013, at 12:30 p.m., karl halverson pierson, 18, armed with a shotgun, machete, and three molotov cocktails, began shooting in the hallways of arapahoe high school in centennial, colorado. as he moved through the school and into the library, he fired one additional round and lit a molotov cocktail, throwing it into a bookcase and causing minor damage. one person was killed; no one was wounded. the shooter committed suicide as a school resource officer approached him berrendo middle school (education) on january 14, 2014, at 7:30 a.m., mason andrew campbell, 12, armed with a shotgun, began shooting in berrendo middle school in roswell, new mexico. a teacher at the school confronted and ordered him to place his gun on the ground. the shooter complied. no one was killed; 3 were wounded: 2 students and an unarmed security guard. the shooter was taken into custody (continued) on june 5, 2014, at 3:25 p.m., aaron rey ybarra, 26, armed with a shotgun, allegedly began shooting in otto miller hall at seattle pacific university in seattle, washington. he was confronted and pepper sprayed by a student as he was reloading. one person was killed; 3 were wounded. students restrained the shooter until law enforcement arrived reynolds high school (education) on june 10, 2014, at 8:05 a.m., jared michael padgett, 15, armed with a handgun and a rifle, began shooting inside the boy's locker room at reynolds high school in portland, oregon. one student was killed; 1 teacher was wounded. the shooter committed suicide in a bathroom stall after law enforcement arrived marysville-pilchuck high school (education) on october 24, 2014, at 10:39 a.m., jaylen ray fryberg, 15, armed with a handgun, began shooting in the cafeteria of marysville-pilchuck high school in marysville, washington. four students were killed, including the shooter's cousin; 3 students were wounded, including one who injured himself while fleeing the scene. the shooter, when confronted by a teacher, committed suicide before law enforcement arrived florida state university (education) on november 20, 2014, at 12:00 a.m., myron may, 31, armed with a handgun, began shooting in strozier library at florida state university in tallahassee, florida. he was an alumnus of the university. no one was killed; 3 were wounded. the shooter was killed during an exchange of gunfire with campus law enforcement. umpqua community college (education) on october 1, 2015, at 10:38 a.m., christopher sean harper-mercer, 26, armed with several handguns and a rifle, began shooting classmates in a classroom on the campus of umpqua community college in roseburg, oregon. nine people were killed; 7 were wounded. the shooter committed suicide after being wounded during an exchange of gunfire with law enforcement. madison junior/ senior high school (education) on february 29, 2016, at 11:30 a.m., james austin hancock, 14, armed with a handgun, allegedly began shooting in the cafeteria of madison junior/senior high school in middletown, ohio. he shot two students before fleeing the building. no one was killed; four students were wounded (two from shrapnel). the shooter was apprehended near the school by law enforcement officers antigo high school (education) on april 23, 2016, at 11:02 p.m., jakob edward wagner, 18, armed with a rifle, began shooting outside a prom being held at his former school, antigo high school in antigo, wisconsin. two law enforcement officers, who were on the premises, heard the shots and responded immediately. no one was killed; two students were wounded. the shooter was wounded in an exchange of gunfire with law enforcement officers and later died at the hospital townville elementary school (education) on september 28, 2016, at 1:45 p.m., jesse dewitt osborne, 14, armed with a handgun, allegedly began shooting at the townville elementary school playground in townville, south carolina. prior to the shooting, the shooter, a former student, killed his father at their home. two people were killed, including one student; three were wounded, one teacher and two students. a volunteer firefighter, who possessed a valid firearms permit, restrained the shooter until law enforcement officers arrived and apprehended him on january 20, 2017, at 7:36 a.m., ely ray serna, 17, armed with a shotgun, allegedly began shooting inside west liberty salem high school, in west liberty, ohio, where he was a student. after assembling the weapon in a bathroom, the shooter shot a student who entered, then shot at a teacher who heard the commotion. the shooter shot classroom door windows before returning to the bathroom and surrendering to school administrators. no one was killed; two students were wounded. school staff members subdued the shooter until law enforcement arrived and took the shooter into custody freeman high school (education) on september 13, 2017, at 10:00 a.m., caleb sharpe, 15, armed with a rifle and a pistol, allegedly began shooting at freeman high school in rockford, washington, where he was a student. one student was killed; three students were wounded. a school employee confronted the shooter, ordered him to the ground, and held him there until law enforcement arrived and took him into custody rancho tehama elementary school and multiple locations in tehama county, california (education) on november 14, 2017, at 7:53 a.m., kevin janson neal, 44, armed with a rifle and two handguns, began shooting at his neighbors, the first in a series of shootings occurring in rancho tehama reserve, tehama county, california. after killing three neighbors, he stole a car and began firing randomly at vehicles and pedestrians as he drove around the community. after deliberately bumping into another car, the shooter fired into the car and wounded the driver and three passengers. the shooter then drove into the gate of a nearby elementary school. he was prevented from entering the school due to a lockdown, so he fired at the windows and doors of the building, wounding five children. upon fleeing the school, the shooter continued to shoot at people as he drove around rancho tehama reserve. law enforcement pursued the shooter; they rammed his vehicle, forced him off the road, and exchanged gunfire. the shooter's wife's body was later discovered at the shooter's home; the shooter apparently had shot and killed her the previous day. in total, five people were killed; 14 were wounded, eight from gunshot injuries (including one student) and six from shrapnel injuries (including four students). the shooter committed suicide after being shot and wounded by law enforcement during the pursuit aztec high school (education) on december 7, 2017, at approximately 8:00 a.m., william edward atchison, 21, armed with a handgun, began shooting inside aztec high school in aztec, new mexico. the shooter was a former student. two students were killed; no one was wounded. the shooter committed suicide at the scene, before police arrived a in a study of active shooter incidents in the united states between 2000 and 2013, the fbi identified 11 locations where the public was most at risk during an incident. these location categories include commercial areas (divided into business open to pedestrian traffic, businesses closed to pedestrian traffic, and malls), education environments (divided into schools [prekindergarten through 12th grade] and institutions of higher learning), open spaces, government properties (divided into military and other government properties), residences, houses of worship, and health care facilities. in 2018, the fbi added a new location category, other location, to capture incidents that occurred in venues not included in the 11 previously identified locations (federal bureau of investigation 2017). this table only includes educational environments. an entire list of all incidents from 2000 to 2017 at all locations can be found at https://www.fbi.gov/file-repository/activeshooter-incidents2000 .pdf/view (federal bureau of investigation 2018 prevention means the capabilities necessary to avoid, deter, or stop an imminent crime or threatened/actual mass casualty incident. prevention is the action schools take to prevent a threatened or actual incident from occurring. protection means the capabilities to secure schools against acts of violence and man-made or natural disasters. protection focuses on ongoing actions that protect students, teachers, staff, visitors, districts, networks, and property from a threat or hazard. mitigation means the capabilities necessary to eliminate or reduce the loss of life and property damage by lessening the impact of an event or emergency at the school. it also means reducing the likelihood that threats and hazards will happen. response means the school's or school district's capabilities necessary to stabilize an emergency once it has already happened or is certain to happen in an unpreventable way, establish a safe and secure environment, save lives and property, and facilitate the transition to recovery. recovery means the capabilities necessary to assist schools affected by an event or emergency in restoring the learning environment. it also means teaming with community partners to restore educational programming, the physical environment, business operations, and social, emotional, and behavioral health. the majority of prevention, protection, and mitigation activities generally occur before an incident, although these three mission areas do have ongoing activities that can occur throughout an active shooter incident. response activities occur during an incident, and recovery activities can begin during an incident and occur after an incident (united states department of education, office of elementary and secondary education, office of safe and healthy students 2013; united states department of homeland security 2018b; united states department of homeland security 2018). in the k-12 school security guide, the u.s. department of homeland security (dhs) focuses on prevention and protection since the activities and measures associated with them occur prior to an incident (2018). effective preventative and protective actions decrease the probability that schools (or other facilities) will encounter incidents of gun violence or should an incident occur, it reduces the impact of that incident. the guide emphasizes that the level of security at a facility will be based on hazards relevant to the facility, people, or groups associated with it. it also warns that as new or different threats become apparent, the perception of the relative security changes and insecurity should drive change to reflect the level of confidence of the people of groups associated with the facility. the dhs utilizes a hometown security approach that emphasizes the process of connect, plan, train, and report (cptr) with the objective to realize effective, collaborative outcomes (united states department of homeland security 2018b). the initial phase is connect and occurs by a school or district reaching out and developing relationships in the community, including local law enforcement. having these relationships before an incident or event can help speed up the response when something happens. each school must begin with identification or development of a security team, group, or organization. this phase also emphasizes outreach, collaboration, and building of a coalition. there should be coalition members from within a school and may include district/school administrators, teachers, aides, facility operations personnel, human resources, administrative, counseling, and student groups. external groups directly related to the school might include boards of education, parent organizations, mental health groups/agencies, and teacher and bus driver unions. external groups indirectly related to the school include all responder organizations such as police and fire departments, sheriff's office, emergency medical services, emergency management, and the local dhs protective security advisor (psa). other tangential groups such as volunteer organizations, utility providers, and facilities in close geographic proximity should also be considered. core and advisory members of the coalition are established. a coalition champion is also identified and is the person who owns the majority of the responsibility for achieving a school's security goals. the champion organizes the coalition as it grows and matures (united states department of homeland security 2018b). the next phase is plan. this will bring the coalition together. the guide for developing high quality school emergency operations plans (united states department of education, office of elementary and secondary education, office of safe and healthy students 2013) is an excellent resource for the coalition. a school security survey for gun violence can be completed and the coalition or user can quickly and effectively determine a facility's security proficiency (united states department of homeland security. 2018). specific portions of or topics within a school plan should be assigned to individuals, committees, or working groups most qualified to address them. the planning process must be sustainable. the amount of time spent in the planning phase should be commensurate with the amount of effort expended on the other phases (united states department of homeland security 2018b). the next phase of the process is to train on the plan developed by the coalition. determining who is responsible for what and how it should be done is the basic function of planning. in fact, telling various members of the team what is expected of them and when to do that activity is the function of training. it is vital to utilize the curricula development expertise possessed by the k-12 community. school administrators should take advantage of this skill set and find creative ways to address difficult topics, such as gun violence. it should be carried out in an effective and nontraumatic way. presenting the training in pieces or steps allows for a more comprehensive learning experience. it is important to validate training through exercises and drills, all of which should include the students. the training event should be followed by the completion and implementation of an after-action improvement plan with adjustment of the cptr as indicated (united states department of homeland security 2018b). the final phase in the process is report. the reporting phase is arguably the most important of all the phases. reporting principles underlie the other three phases and have profound prevention and protection impacts by driving forward information. dhs models the reporting phase using the "if you see something, say something â® " campaign (u.s. dhs, 2018) and the nationwide suspicious activity reporting (sar) initiative (nationwide suspicious activity reporting initiative (nsi) 2019). "if you see something, say something â® " focuses on empowering anyone who sees suspicious activity to do something about it by contacting local law enforcement, or if an emergency to call 9-1-1 (united states department of homeland security 2018a). this is a compelling capability when well organized and managed. a good plan for reporting, especially for a k-12 school, involves training staff and students on what is considered suspicious. there are many methods in which schools can employ to facilitate this, such as dedicated telephone numbers, websites for anonymous reporting, email or text messaging, and mobile phone applications. conducting simple drills for reporters and receivers keeps skills sharp and reinforces the importance of the effort with the goal to save lives. if the plan includes sharing all suspicious activity calls with the local fusion center then the probability of higher fidelity reporting increases (united states department of homeland security 2018b). when making changes to a school's plans, procedures, and protective measures, it is imperative the needs of individuals with special health care needs be addressed throughout the process. planning, training, and execution should always consider accessible alert systems for those who are deaf or hard of hearing; students, faculty, and staff who have visual impairments or are blind; individuals with limited mobility; alternative notification measures; people with temporary disabilities; visitors; people with limited english proficiency; sign cards with text-and picture-based emergency messages/symbols; and involving people with disabilities in all planning (united states department of homeland security, interagency security committee 2015). it is important to understand that no "profile" exists for an active shooter (united states department of education, office of elementary and secondary education, office of safe and healthy students 2013). however, research indicates there may be signs or indicators. o'toole (2000) presents an in depth, systematic procedure for school shooter threat assessment and intervention. the model was designed to be used by educators, mental health professionals, and law enforcement agencies. its fundamental building blocks are the threat assessment standards, which provide a framework for evaluating a spoken, written, and symbolic threat, and the fourpronged assessment approach which provides a logical, methodical process to examine the threatener and assess the risk that the threat will be carried out. schools should learn the signs of a potentially volatile situation that may develop into an active shooter situation and proactively seek ways to prevent an incident with internal resources, or additional external assistance (united states department of education, office of elementary and secondary education, office of safe and healthy students 2013). potential warning signs of a school shooter may include increasingly erratic, unsafe, or aggressive behaviors; hostile feelings of injustice or perceived wrongdoing; drug and alcohol abuse; marginalization or distancing from friends and colleagues; changes in performance at work or school; sudden and dramatic changes in home life or in personality; pending civil or criminal litigation; and observable grievances with threats and plans of retribution (united states department of homeland security 2018b). at a minimum, schools should establish and enforce policies that prohibit, limit, or determine unacceptable behaviors and consequences of weapons possession/use, drug possession/use, alcohol/tobacco possession/use, bullying/harassment, hazing, cyber-bullying/harassment/stalking, sexual assault/misconduct/harassment, bias crimes, social media abuse, and any criminal acts (united states department of homeland security 2018b). in addition to policies and positive school climates, school districts and administrators should establish dedicated teams to evaluate threats, such as a threat assessment team (tat). the team should include mental health professionals (e.g., forensic psychologist, clinical psychologist, and school psychologist) to contribute to the threat assessment process (united states department of homeland security 2018b). it is the responsibility of the tat to investigate and analyze communications and behaviors to make a determination on whether or not an individual poses a threat to him/herself or others (united states department of education, office of elementary and secondary education, office of safe and healthy students 2013). as well as tats, some schools have even opted to establish social media monitoring teams which look for keywords that may indicate bullying or other concerning statements. if a school opts to create such a team, it should work very closely with the tat to ensure that applicable privacy, civil rights and civil liberties, other federal, state and local laws, and information sharing protocols are followed. please refer to chap. 14 for further information. after an active shooter incident, field triage (e.g., jumpstart) must commence and the patient must be evaluated by an experienced emergency medicine or trauma surgeon, preferably by a pediatric specialist in those disciplines. if an active shooter incident is coupled with detonation of an explosive device, the child must be screened and decontaminated for radiation exposure ("dirty bomb"). triage tags are extremely helpful when multiple victims present in a short period of time. medical response to an active shooter event will focus on control of external hemorrhage along with circulatory stabilization. operative emergencies will be common and receive the highest priority. severe extremity injuries may be controlled with tourniquet application or other forms of hemorrhage control. re-evaluation is paramount to prevent ischemia to distal regions. however, thoracic or abdominal (truncal) injuries will need immediate surgical exploration and intervention. penetrating trauma will cause more vascular injuries than blunt trauma, and vascular surgical trays may be in short supply at a hospital. major procedure or surgical trays may become short in supply based on the increased operative demand. resuscitative blood transfusion therapy may utilize a massive blood transfusion protocol. since whole blood may be short in supply, some will simply use the 1:1:1 rule (administer one unit of packed cells: one unit of fresh frozen plasma: one unit of platelets). a unit for children may be substituted as an aliquot based on size of the patient (e.g., administer 10 ml/kg of packed cells: 10 ml/kg of fresh frozen plasma: 10 ml/kg of platelets). calcium must also be replaced when there is a large volume transfusion. due to extensive blood product utilization, there may be a heavy impact on institutional or regional blood supplies. plans should be in place to address these problems, including the implementation of allocation of scarce 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placebo-controlled, phase 2 trial key: cord-022736-38q8jbcl authors: coppola, damon p. title: participants – multilateral organizations and international financial institutions date: 2015-02-06 journal: introduction to international disaster management doi: 10.1016/b978-0-12-801477-6.00010-1 sha: doc_id: 22736 cord_uid: 38q8jbcl multilateral organizations are composed of sovereign governments. they may be regional, organized around a common issue or function, or global. international financial institutions (ifis) are international banks composed of sovereign member states that use public money from the member states to provide technical and financial support for developing countries. the united nations is the organization most involved in the mitigation of, preparedness for, response to, and recovery from disasters around the world. it is considered the best equipped to do so because of its strong relationships with most countries, especially the developing countries where assistance is most needed. when disasters strike, the un is one of the first organizations to mobilize, and it remains in the affected countries during the recovery period for many years after. the consolidated appeal process is one way the un garners international support for relief and reconstruction. in many regions, governments have formed smaller international organizations, many of which address risk, as well. the ifis provide nations with low capital reserves funding in the aftermath of disasters recovery reconstruction. the world bank is regarded as one of the largest sources of development assistance. a multilateral organization is an organization composed of the central governments of sovereign nations. multilateral organizations are also called intergovernmental organizations and international organizations. member states come together under a charter of rules and responsibilities they have drawn up and agreed on. multilateral organizations may be regionally based (e.g., the european union [eu] , the association of south east asian nations [asean]), organized around a common issue or function (e.g., the north atlantic treaty organization [nato] , the organization of the petroleum exporting countries [opec]), or globally based (e.g., the united nations [un] ). like sovereign states, they are recognized as having an established legal status under international law. the un is the most well-known and largest of all of the multilateral organizations because its membership draws from nearly every nation, and because it covers a wide range of issues. the first international organization to address the topic of disaster management was the international relief union (iru), which was founded in italy in 1921 and later integrated into the league of single vote, with key issues decided by two-thirds majority. (less significant matters are decided by simple majority.) as mentioned earlier, the general assembly cannot force its decisions on a sovereign state, although they generally receive wide support. the assembly holds regular sessions from september to december, and special/emergency sessions may be called at any time. when not in session, the assembly's work is carried out by its six main committees, other subsidiary bodies, and the secretariat. the un security council's primary responsibility is maintaining international peace and security in accordance with the un charter. this council, which convenes at will, consists of 15 members, five of which are permanent members (china, france, the russian federation, the united kingdom, and the united states). all un member states are obligated to carry out the council's decisions. decisions require nine affirmative votes, including all five votes of the permanent members. when the council source: un, 2014a. considers threats to international peace, it first explores peaceful settlement options. if fighting is under way, the council attempts to secure a cease-fire, and it may send a peacekeeping mission to help the parties maintain the truce and keep opposing forces apart. the council can take measures to enforce its decisions, such as imposing economic sanctions or arms embargoes. on rare occasions, the council has authorized member states to use "all necessary means," including collective military action, to see that its decisions are carried out. these are referred to as "peacemaking operations." the economic and social council is the central mechanism by which international economic and social issues are addressed and by which policy recommendations are created. it also consults with non-governmental organizations (ngos) to create and maintain working partnerships between the un and civil society. the council has 54 members, elected by the general assembly for three-year terms. it meets throughout the year, but its main session is held in july, during which major economic, social, and humanitarian issues are discussed. the council has several subsidiary bodies that regularly meet to address issues such as human rights, social development, the status of women, crime prevention, narcotic drugs, and environmental protection. the trusteeship council originally provided international supervision for 11 trust territories administered by seven member states and ensured that adequate steps were taken to prepare the territories for self-government or independence. by 1994, all trust territories had attained self-government or independence. its work completed, the trusteeship council now consists of the five permanent members of the security council. it has amended its rules of procedure to allow it to meet as and when the occasion may require. the international court of justice, also known as the world court, is the un's main judicial organ. the world court consists of 15 judges elected jointly by the general assembly and the security council. it serves to settle disputes between countries. participation is voluntary, but when a state agrees to participate, it must comply with the court's decision. the court also provides advisory opinions to the general assembly and the security council on request. the secretariat carries out the day-to-day work of the un as directed by the general assembly, the security council, and the other organs. at its head is the secretary general, who provides overall administrative guidance. the secretariat is made up of various departments and offices and maintains a total staff of about 40,000 people throughout the world. duty stations include the un headquarters in new york and offices in geneva, vienna, and nairobi, as well as other locations. the secretariat's functions are diverse, ranging from "administering peacekeeping operations to mediating international disputes, from surveying economic and social trends and problems to preparing studies on human rights and sustainable development" . the secretariat staffs also work to publicize the un's work through the world media and to organize conferences on issues of global concern. secretariat staffs are considered international civil servants and answer only to the un for their activities. disaster-response-oriented projects to disaster mitigation, the un adopted the international strategy for disaster reduction to promote disaster reduction and risk mitigation as part of its central mission. this initiative continues to evolve in its pursuit of disaster risk reduction, promoting global resilience to the effects of natural hazards, and reducing human, economic, and social losses by: • increasing public awareness of the hazard risks faced and the options to address them • obtaining commitment from public authorities to mainstream risk reduction into their work • stimulating interdisciplinary and intersectoral partnership and expanding risk-reduction networking at all levels • enhancing scientific research on the causes of natural disasters and the effects of natural hazards and related technological and environmental disasters on societies these strategies are integrated into the work carried out by each un country office and promoted to the national and local governments in each member country where the un works. hazard mitigation and disaster preparedness strategies are communicated to members of all levels of society via public awareness campaigns, and promoted by obtaining commitment from public authorities, facilitating cooperation and communication between various government and non-governmental sectors, and enabling the provision or transfer of technical knowledge. because the un is such a complex organization, it can be difficult to illustrate the myriad ways in which it addresses disaster management other than to describe the role of each organization and agency in this area. the un general assembly does not partake in any operational disaster management activities. however, as the main deliberative organ of the un, it is responsible for launching many influential and effective disaster management programs that are ultimately carried out by the various un offices and by the un member state governments. examples include the endorsement of the undp capacity for disaster reduction initiative (cadri) and the launching of the international decade for natural disaster reduction and its subsequent international strategy for disaster reduction. the general assembly is also responsible for organizing and reorganizing the un system to maximize its disaster management capabilities, as in 1997 under the un program for reform (1997) , which created the office for the coordination of humanitarian affairs (ocha) and the un office for disaster risk reduction (unisdr). the un secretariat is the international working staff of un employees located at duty stations throughout the world. the un secretariat employees carry out the diverse day-to-day work of the various un offices. it services the principal un organs and administers the programs and policies laid down by them. at its head is the secretary-general, who is appointed by the general assembly on the recommendation of the security council for five-year renewable terms. the secretariat has approximately 43,000 employees. as international civil servants, staff members and the secretary-general answer only to the un and take an oath not to seek or receive instructions from any government or outside authority. under the charter, each member state agrees to respect the appointed valerie amos of guyana to replace mr. john holmes of the united kingdom as under-secretary-general for humanitarian affairs/un emergency relief coordinator. ocha regional offices monitor the onset of natural and technological disasters. staff are trained in disaster assessment and post-disaster evaluation methods before disasters strike. once an impending or actual disaster event is identified, ocha initiates response and generates a situation report to provide the international response community with detailed information, including damage assessment, actions taken, needs assessment, and current assistance provided. if necessary, ocha may then deploy a un disaster assessment and coordination (undac) team to assist relief activity coordination and assess damages and needs. if a disaster appears inevitable or is already unfolding, the erc in consultation with iasc may designate a humanitarian coordinator (hc), who becomes the most senior un humanitarian official on the ground for the emergency. the hc is directly accountable to the erc, increasing the likelihood that the humanitarian assistance provided is quick, effective, and well-coordinated. the hc appointment generally signals that the event merits a long-term humanitarian presence. the criteria used by the erc to determine whether to appoint an hc center on the need for intensive and extensive political ocha organizational chart source: ocha, 2010a. management, mediation, and coordination to enable the delivery of humanitarian response, including negotiated access to affected populations; massive humanitarian assistance requiring action by a range of participants beyond a single national authority; and a high degree of external political support, often from the un security council. an on-site operations coordination center (osocc) may be set up in the field to assist local firstresponse teams to coordinate the often overwhelming number of responding agencies. the osocc has three primary objectives: (1) to be a link between international responders and the government of the affected country; (2) to provide a system for coordinating and facilitating the activities of international relief efforts at a disaster site; and (3) to provide a platform for cooperation, coordination, and information management among international humanitarian agencies. finally, ocha can set up communications capabilities if they have been damaged or do not exist at an adequate level, as required by the un responding agencies. ocha generally concludes its responsibilities when the operation moves from response to recovery. overall, ocha coordination is performed to maximize the response and recovery capabilities that converge on the disaster scene, and to minimize duplications and inefficiencies. the structures and policies that have been established to support this function include (adapted from ocha 2005): • developing common strategies. humanitarian assistance is most effective when common priorities and goals exist among stakeholders and responders agree on tactics and jointly monitor progress. ocha works with its partners to develop a common humanitarian action plan and to establish clear divisions of responsibility. • assessing situations and needs. ocha staff assume responsible for assessing damages and identifying needs, developing a plan of action to meeting those needs, and monitoring progress. responses are adjusted, if necessary, using ongoing analysis of political, social, economic, and military environments and by assessing humanitarian needs to help the responding agencies better understand the situation. • convening coordination forums. in its role as coordinator, ocha holds a wide range of meetings to bring together the various disaster management players for planning and information exchange. these meetings help the participants to more accurately analyze the overall status of humanitarian relief efforts as well as network and share lessons learned and best practices. • mobilizing resources. through the cap, ocha leads the drive to get governments to commit funding and resources necessary to address the identified needs. allocation of funds has been found to be more efficient within this centralized system. • addressing common problems. every crisis is unique, and both new and old problems arise. as coordinator, ocha analyzes and addresses problems common to humanitarian actors, such as negotiating with warring parties to gain access to civilians in need, or working with un security officials to support preparedness and response measures in changing security situations. • administering coordination mechanisms and tools. ocha, and the un in general, have several tools with which they can better address the humanitarian needs of disaster victims. these include the iasc; rapid-response tools, such as the un disaster assessment and coordination teams and the international search and rescue advisory group; and smaller forums such as the geographic information support team. ocha also assists with civil-military cooperation, ensuring a more efficient use of military and civil defense assets in humanitarian operations. the field coordination support unit in geneva manages ocha's human, technical, and logistical resources. these resources are primarily provided by the danish and norwegian refugee councils, the danish emergency management agency, the swedish rescue services agency, and the emergency logistics management team of the united kingdom overseas development administration. the under-secretary-general for humanitarian affairs/emergency relief coordinator advises the un secretary-general on disaster-related issues, chairs the executive committee on humanitarian affairs (echa), and leads the iasc. the coordinator is assisted by a deputy, who holds the position of deputy emergency relief coordinator (derc) and is responsible for key coordination, policy, and management issues. the inter-agency standing committee (iasc) was established in 1992 under un resolution 46/182. it serves as a platform within which the broad range of un and non-un humanitarian partners (including un humanitarian agencies, the international organization for migration, three consortia of major international ngos, and the red cross movement) may come together to address the humanitarian needs resulting from a disaster. the iasc's primary role is to formulate humanitarian policy that ensures a coordinated and effective response to all kinds of disaster and emergency situations. the primary objectives of the iasc are to: • develop and agree on system-wide humanitarian policies • allocate responsibilities among agencies in humanitarian programs • develop and agree on a common ethical framework for all humanitarian activities • advocate common humanitarian principles to parties outside the iasc • identify areas where gaps in mandates or lack of operational capacity exist • resolve disputes or disagreement about and between humanitarian agencies on system-wide humanitarian issues (ocha 2005) iasc members (both full members and standing invitees) include: • the ocha donor relations section (drs), separated from the cap in 2003, is the focal point for all relations with donors, particularly for funding-related issues. drs advises the senior management team on policy issues related to interaction with donors and resource mobilization. in addition, it plays a key role in facilitating the interaction of all ocha entities with donors, both at headquarters and in the field level. the coordination and response division (crd) was created in 2004 by joining the former new yorkbased humanitarian emergency branch and the geneva-based response coordination branch. crd is responsible for providing disaster-related direction, guidance, and support to the erc, the un resident/humanitarian coordinators, and ocha's field offices (including the deployment of extra personnel as necessary, or providing emergency cash grants). based in geneva, the ocha emergency services board (esb) was created to expedite the provision of international humanitarian assistance. esb develops, mobilizes, and coordinates the deployment of ocha's international rapid response "toolkit"-the expertise, systems, and services that aim to improve humanitarian assistance in support of disaster-afflicted countries. esb's humanitarian response activities include the coordination of disaster response and assessment (undac; see in the following section), the setting of international urban search and rescue standards (insarag; see in the following section), and the establishment of osoccs. esb supports ocha field offices through the following: • surge capacity and standby partnerships • military and civil liaison and mobilization of military and civil defense assets • dispatch of relief supplies and specialized assistance in environmental emergencies • dissemination of disaster-related information by means of reliefweb, the central register of disaster management capacities, and the virtual onsite operations coordination center. within the esb are seven separate sections, established to manage particular aspects of disaster response: 1. civil-military coordination section 2. emergency preparedness section 3. environmental emergencies unit 4. emergency relief coordination centre 5. field coordination support section 6. logistics support unit 7. surge capacity section established by the iasc in 1995, the civil military coordination section (cmcs), previously named military and civil defense unit (mcdu), is the focal point for the efficient mobilization of military and civil defense assets for use in humanitarian emergencies and for liaison with governments, international organizations, regional organizations, and military-civil defense establishments deploying these assets. it also coordinates un agency participation and participates in major military exercises comprising significant humanitarian scenarios. this section is responsible for the overall management of the ocha central register of disaster management capacities, with specific maintenance of the mcda directory of military and civil defense assets and expertise. cmcs acts as a facilitator and secretariat to the development of documents involving the broad international humanitarian community and is custodian of the "oslo" and "mcda" guidelines detailing the use of mcda in support of un humanitarian operations in natural, technological, and environmental disasters and complex emergencies, respectively. the emergency preparedness section (eps) helps to maintain ocha's operational readiness and to reinforce disaster preparedness work. eps works with stakeholders at the national government level in un member countries in order to help build disaster response and recovery capacity in advance of disasters. much of the work performed by this unit is guided by the hyogo framework for action, which recommends the strengthening of disaster preparedness for effective response at all levels. the environmental emergencies unit, or the joint un environmental programme (unep)/ocha environment unit, serves as the integrated un emergency response mechanism that provides international assistance to countries experiencing environmental disasters and emergencies. this joint unit can rapidly mobilize and coordinate emergency assistance and response resources to countries facing environmental emergencies and natural disasters with significant environmental impacts. the unit performs several key functions geared toward facilitating rapid and coordinated disaster response: • monitoring. the unit performs continuous monitoring and ongoing communication with an international network of contacts and permanent monitoring of news services and websites for early notification of environmental occurrences. • notification. when disasters strike, the unit alerts the international community and issues "information and situation" reports to a comprehensive list of worldwide contacts. • brokerage. the unit is able to quickly establish contact between the affected country and donor governments ready and willing to assist and provide needed response resources. • information clearinghouse. the unit serves as an effective focal point to ensure information on chemicals, maps, and satellite images from donor sources and institutions are channeled to relevant authorities in the affected country. • mobilization of assistance. the unit mobilizes assistance from the international donor community when requested by affected countries. • assessment. the unit can dispatch international experts to assess an emergency's impacts and to make impartial and independent recommendations about response, cleanup, remediation, and rehabilitation. • financial assistance. in certain circumstances, the unit can release ocha emergency cash grants of up to $50,000 to meet immediate emergency response needs. the emergency relief coordination center (ercc) is the physical facility where ocha centralized coordination activities are focused. the facility enables closer collaboration between internal and external humanitarian stakeholders and has the capacity to serve as an ocha situation centre, providing updates on humanitarian relief activities worldwide. the centre consists of a main task force room, a small conference room that can also be used for a second task force, and a technical room to control all facility capabilities. the ercc allows ocha to coordinate two response teams simultaneously. the field coordination support section (fcss) was established within esb in 1996 to support national governments and the un resident coordinators in developing, preparing, and maintaining "standby capacity" for rapid deployment to sudden-onset emergencies to conduct rapid needs assessments and coordination. fcss manages several programs and offices to improve international disaster coordination and cooperation, including: • the united nations disaster assessment and coordination (undac) team. the undac team is made up of disaster management specialists selected and funded by the governments of un member states, ocha, undp, and operational humanitarian un agencies (such as wfp, unicef, and who). it provides rapid needs assessments and supports national authorities and the un resident coordinator in organizing international relief. undac teams are on permanent standby status so that they can deploy within hours. • the international search and rescue advisory group (insarag) . insarag is an intergovernmental network within the un that manages urban search and rescue (usar) and related disasterresponse issues. it promotes information exchange, defines international usar standards, and develops methodologies for international cooperation and coordination in earthquake response. • the virtual on-site operations coordination centre (virtual osocc). the internet has made it possible for humanitarian relief agencies to share and exchange disaster information continuously and simultaneously, and between any locations where internet access can be obtained. the virtual osocc is a central repository of information maintained by ocha that facilitates this exchange of information with ngos and responding governments. the information is stored on an interactive web-based database, where users can comment on existing information and discuss issues of concern with other stakeholders. the logistics support unit (lsu) manages stocks of basic relief items that can be dispatched immediately to disaster-or emergency-stricken areas. the stockpile, which is located at the un humanitarian response depot in brindisi, italy, includes nonfood, nonmedical relief items (such as shelter, water purification and distribution systems, and household items) donated by un member governments. the lsu is also involved in other logistical challenges, such as designing contingency plans for the rapid deployment of emergency relief flights and providing interface on logistical matters with other humanitarian agencies (such as wfp, who, unhcr, ifrc, and icrc). the lsu participates in the operation of a un joint logistics center (see exhibit 10.1) and has co-sponsored an effort to adopt a un-wide system for tracking the un joint logistics center (unjlc) is an interagency facility reporting to the humanitarian coordinator [within a che], and overall to the iasc. its mandate is to coordinate and optimize the logistics capabilities of humanitarian organizations in large-scale emergencies. unjlc operates under the direction of the world food programme (wfp), who is responsible for the administrative and financial management of the centre. the unjlc is funded from voluntary contributions channeled through wfp. the requirement to establish [the unjlc] was born out of the humanitarian response to the 1996 eastern zaire crisis, which demanded intensified coordination and pooling of logistics assets among unhcr, wfp, and unicef. the interagency logistics coordination model was applied on subsequent unjlc interventions in somalia, kosovo, east timor, mozambique, india, and afghanistan. in march 2002, unjlc concept was institutionalized as a un humanitarian response mechanism, under the aegis of wfp, by the inter-agency standing committee working group (iasc-wg). the unjlc core unit was subsequently established in rome. in case of major disaster with substantial humanitarian multi-sector involvement during the immediate relief phase, the un agencies involved may consider that the establishment of a joint logistics centre would contribute to the rapid response, better coordination, and improved efficiency of the humanitarian operation at hand. . . . a standby capacity will be developed for facilitating, if required, the timely activation and deployment in the field of a united nations joint logistics centre-unjlc. the unjlc will support the united nations agencies and possibly other humanitarian organisations that operate in the same crisis area. the capacity includes the option to establish satellite joint logistic centres (jlc) dispersed at critical locations in the [affected area] and offering logistics support on a reduced scale. . . . upon [unjlc] activation, agencies will establish a deployment requirements assessment (dra) team to carry out a quick evaluation of the logistics situation and determine the requirements to deploy the unjlc in the crisis area. this dra team will work in close coordination with the humanitarian authorities and, if deployed, with the united nations disaster assessment and coordination (undac) team. it will take all necessary measures for installing the unjlc and draft ad hoc terms of reference (tor) for endorsement by the relevant humanitarian authorities. in case of peacekeeping operations or in a complex environment, the unjlc activation will be coordinated with the department of peacekeeping operations (dpko) or the relevant military entities. • the role of the unjlc will be to optimise and complement the logistics capabilities of cooperating agencies within a well-defined crisis area for the benefit of the ongoing humanitarian operation. • the unjlc will provide logistics support at operational planning, coordination, and monitoring levels. unless specified otherwise, the un agencies and other humanitarian bodies, which are established in the area, will continue (continued) relief supplies and common procedures for air operations. finally, the lsu contributes information related to stockpiles and customs facilitation agreements (which helps speed up the delivery of relief items). the surge capacity section (scs) works to ensure ocha always has the means and resources to rapidly mobilize and deploy staff and materials to address the needs of countries affected by suddenonset emergencies. scs operates using a number of distinct surge capacity resources, which include: • the emergency response roster (err). err, which became active in june 2002, aims to rapidly deploy ocha staff to sudden-onset emergencies to conduct assessments and establish initial coordination mechanisms. the 35 staff included in the err are deployable within 48 hours of a request for their services through a deployment methodology based on the undac model. staff serve on the roster for about six months. • the stand-by partnerships programme (sbpp). sbpp is structured on legal agreements with 12 partner organizations that provide short-term staffing to field operations free of charge when gaps arise. partners maintain their own rosters of trained and experienced humanitarian professionals, many of whom have ocha or other un humanitarian experience. sbpp staff can usually be deployed within four weeks of the formal request, and an average deployment lasts five to six months. • associates surge pool (asp). asp, which was created in late 2010, helps to bridge the gap between the immediate response surge and the arrival of regular staff. asp comprises external disaster management staff who can be deployed for up to six months upon the issuance of a temporary appointment. contracting and deployment preparations take an average of three to four to exercise their normal responsibilities. as a result, the unjlc will not be involved in policy and establishment of humanitarian needs and priorities. • responsibilities will be defined as per the requirements on a case-by-case basis but will, in principle, be limited to logistic activities between the points of entry and distribution in the crisis area. detailed responsibilities . . . would be: • collecting, analysing, and disseminating logistics information relevant to the ongoing humanitarian operation; • scheduling the movement of humanitarian cargo and relief workers within the crisis area, using commonly available transport assets; • managing the import, receipt, dispatch, and tracking of non-assigned food and nonfood relief commodities; • upon specific request, making detailed assessments of roads, bridges, airports, ports, and other logistics infrastructure and recommending actions for repair and reconstruction. • the scope of the unjlc activities may vary with the type of emergency, the scale of involvement of the cooperating partners, and the humanitarian needs. the reso and roso positions were created following a need to have senior surge staff available to deploy to new and escalating emergencies for up to three months to provide leadership and stability to ocha operations. they spend 80 percent of their time in the field and 20 percent at headquarters. when not in the field, resos and rosos work with the surge staff development team to develop and deliver trainings and support lesson learning and other exercises to improve ocha emergency response during non-deployment periods. although ocha's efforts primarily focus on coordinating the response to major disasters, the agency also performs various tasks related to disaster risk reduction. for instance, ocha representatives work with disaster management agencies to develop common policies aimed at improving how the wider stakeholder community of responders prepare for and respond to disasters. it also works to promote preparedness and mitigation efforts in member states to decrease vulnerability. crd and esb work closely with the un development programme, other un programs as necessary, and outside organizations on various projects and activities to increase working relationships with national governments and apply lessons learned from completed disaster responses. ocha's geneva offices are continually monitoring geologic and meteorological conditions, as well as major news services, for early recognition or notification of emerging disasters. working with un resident coordinators, country teams, and regional disaster response advisers, ocha maintains close contact with disaster-prone countries in advance of and during disaster events. ocha's regional disaster response advisers work with national governments to provide technical, strategic, and training assistance. they also provide this assistance to other un agencies and regional organizations to improve international disaster management capacity. • it facilitates the negotiations of member states in many intergovernmental bodies on joint courses of action to address ongoing or emerging global challenges. • it advises national governments on translating un-developed policy frameworks into countrylevel programs and, through technical assistance, helps build national capacities. this final area is where desa addresses disaster management activities within its division for sustainable development. as part of this effort, desa launched a plan of action during the 2002 world summit on sustainable development in johannesburg, south africa, that included commitments to disaster and vulnerability reduction. see exhibit 10.2 for more information on this plan of action. the un center for regional development (uncrd) is another component of desa that addresses disaster management issues. through its headquarters in nagoya, japan, and its regional offices in nairobi, kenya, and bogotá, colombia, uncrd supports training and research on regional an integrated, multi-hazard, inclusive approach to address vulnerability, risk assessment, and disaster management, including prevention, mitigation, preparedness, response, and recovery, is an essential element of a safer world in the twenty-first century. actions are required at all levels to: 1. strengthen the role of the international strategy for disaster reduction and encourage the international community to provide the necessary financial resources to its trust fund; 2. support the establishment of effective regional, subregional, and national strategies and scientific and technical institutional support for disaster management; 3. strengthen the institutional capacities of countries and promote international joint observation and research, through improved surface-based monitoring and increased use of satellite data, dissemination of technical and scientific knowledge, and the provision of assistance to vulnerable countries; 4. reduce the risks of flooding and drought in vulnerable countries by, [among other things], promoting wetland and watershed protection and restoration, improved land-use planning, improving and applying more widely techniques and methodologies for assessing the potential adverse effects of climate change on wetlands and, as appropriate, assisting countries that are particularly vulnerable to those effects; 5. improve techniques and methodologies for assessing the effects of climate change, and encourage the continuing assessment of those adverse effects by the intergovernmental panel on climate change; 6. encourage the dissemination and use of traditional and indigenous knowledge to mitigate the impact of disasters and promote community-based disaster management planning by local authorities, including through training activities and raising public awareness; 7. support the ongoing voluntary contribution of, as appropriate, ngos, the scientific community, and other partners in the management of natural disasters according to agreed, relevant guidelines; 8. develop and strengthen early warning systems and information networks in disaster management, consistent with the international strategy for disaster reduction; 9. develop and strengthen capacity at all levels to collect and disseminate scientific and technical information, including the improvement of early warning systems for predicting extreme weather events, especially el niño/la niña, through the provision of assistance to institutions devoted to addressing such events, including the international center for the study of the el niño phenomenon; 10. promote cooperation for the prevention and mitigation of, preparedness for, response to, and recovery from major technological and other disasters with an adverse impact on the environment in order to enhance the capabilities of affected countries to cope with such situations. development issues and facilitates information dissemination and exchange. uncrd maintains a disaster management planning office in hyogo, japan, that researches and develops communitybased, sustainable projects for disaster management planning and capacity-building in developing countries. the hyogo office also runs the global earthquake safety initiative, designed to improve risk recognition and reduction in 21 cities around the world. five regional economic commissions are within the economic and social council. the secretariats of these regional commissions are part of the un secretariat and perform many of the same functions (including the disaster management functions listed earlier). the five commissions promote greater economic cooperation in the world and augment economic and social development. as part of their mission, they initiate and manage projects that focus on disaster management. while their projects primarily deal with disaster preparedness and mitigation, they also work in regions that have been affected by a disaster to ensure that economic and social recovery involves adequate consideration of risk reduction measures. the five regional commissions are: • in response periods of disasters, the united nations development programme (undp) sees that development does not cease during emergencies. if relief efforts are to contribute to lasting solutions, sustainable human development must continue to be vigorously supported, complementing emergency action with new curative initiatives that can help prevent a lapse into crisis. (un, 2000) the undp was established in 1965 during the un decade of development to conduct investigations into private investment in developing countries, to explore the natural resources of those countries, and to train the local population in development activities such as mining and manufacturing. as the concept and practice of development expanded, the undp assumed much greater responsibilities in host countries and in the un as a whole. the undp was not originally considered an agency on the forefront of international disaster management and humanitarian emergencies because, while it addressed national capacities, it did not focus specifically on the emergency response systems (previously considered to be the focal point of disaster management). however, as mitigation and preparedness received their due merit, undp gained increased recognition for its vital risk reduction role. capacity building has always been central to the undp's mission in terms of empowering host countries to be better able to address issues of national importance, eventually without foreign assistance. international disaster management gained greater attention as more disasters affected larger populations and caused greater financial impacts. developing nations, where the undp worked, faced the greatest inability to prepare for and/or respond to these disasters, largely as a result of the development trends described in chapter 1. undp's projects have shifted toward activities that indirectly fulfill mitigation and preparedness roles. for instance, projects seeking to strengthen government institutions also improve those institutions' capacities to respond with appropriate and effective policy, power, and leadership in the wake of a disaster. undp fully recognizes that disaster management must be viewed as integral to their mission in the developing world as well as to civil conflict and che scenarios. there are implicit similarities between undp ideals and those of agencies whose goals specifically aim to mitigate and manage humanitarian emergencies. undp work links disaster vulnerability to a lack of or a weak infrastructure, poor environmental policy, land misuse, and growing populations in disaster-prone areas. when disasters occur, a country's national development, which the undp serves to promote, can be set back years, if not decades. even small-to medium-size disasters in the least developed countries can "have a cumulative impact on already fragile household economies and can be as significant in total losses as the major and internationally recognized disasters" (undp 2001) . it is the undp's objective to "achieve a sustainable reduction in disaster risks and the protection of development gains, reduce the loss of life and livelihoods due to disasters, and ensure that disaster recovery serves to consolidate sustainable human development" (un 2000) . in 1995, as part of the un's changing approach to humanitarian relief, the emergency response division (erd) was created within the undp, augmenting the organization's role in disaster response. additionally, 5 percent of undp budgeted resources were allocated for quick response actions in special development situations by erd teams, thus drastically reducing bureaucratic delays. the erd was designed to create a collaborative framework among the national government, un agencies, donors, and ngos that immediately respond to disasters, provide communication and travel to disaster management staff, and distribute relief supplies and equipment. it also deploys to disaster-affected countries for 30 days to create a detailed response plan on which the undp response is based. in 1997, under the un programme for reform, the mitigation and preparedness responsibilities of the ocha emergency relief coordinator were formally transferred to the undp. in response, the undp created the disaster reduction and recovery programme (drrp) within the erd. soon after, the undp again reorganized, creating the bureau of crisis prevention and recovery (bcpr) with an overarching mission of addressing a range of non-response-related issues: • disaster risk reduction and climate change management • conflict prevention • rule of law, justice, and security in countries affected by crises • women in conflict prevention, peacebuilding, and recovery • immediate crisis response • livelihoods and economic recovery • crisis governance bcpr helps undp country offices prepare to activate and provide faster and more effective disaster response and recovery. it also works to ensure that undp plays an active role in the transition between relief and development. undp's disaster management activities focus primarily on the development-related aspects of risk and vulnerability and on capacity-building technical assistance in all four phases of emergency management. it emphasizes: • incorporating long-term risk reduction and preparedness measures in normal development planning and programs, including support for specific mitigation measures where required; • assisting in the planning and implementation of post-disaster rehabilitation and reconstruction, including defining new development strategies that incorporate risk-reduction measures relevant to the affected area; • reviewing the impact of large settlements of refugees or displaced persons on development, and seeking ways to incorporate the refugees and displaced persons in development strategies; • providing technical assistance to the authorities managing major emergency assistance operations of extended duration (especially in relation to displaced persons and the possibilities for achieving durable solutions in such cases). undp spends between $150 and $200 million each year on disaster risk reduction projects. the focus of these projects has included the establishment or strengthening of early warning systems, the conduct of risk assessments and drafting of hazard maps, and the establishment of national disaster management agencies. through their projects, undp staff help to strengthen national and regional capacities by ensuring that new development projects consider known hazard risks, that disaster impacts are mitigated and development gains are protected, and that risk reduction is factored into disaster recovery. following conflict, crises, and disasters, countries must transition from response to recovery. many countries are unable to manage the difficult and widespread needs of recovery on their own, as they may have experienced widespread loss of infrastructure and services. displaced persons and refugees may have little to return to, and economies may be damaged or destroyed. bcpr operates during the period when the response or relief phase of the disaster has ended but recovery has not fully commenced (sometimes referred to as the "early recovery period"). sustainable risk reduction is central to the undp recovery mission. the bureau recognizes that local expertise in risk management and reduction may not be available, and that the technical assistance they provide may be the only option these communities have to increase their resilience to future disasters. this program has proved effective in many countries' recovery operations, including cambodia after three decades of civil war, afghanistan after the 2001 conflict, and gujarat, india, after the 2001 earthquake. the top recipients of undp crisis prevention and recovery funding include: to meet these recovery priorities, five support services have been developed to assist the undp country offices and other undp/un agencies to identify areas where bcpr can provide assistance. these support services include: • early assessment of recovery needs and the design of integrated recovery frameworks. this includes assessing development losses caused by conflict or natural disaster, the need for socioeconomic and institutional recovery, identification of local partners, and the need for capacity building and technical assistance. • planning and assistance in area-based development and local governance programs. area-based development and local governance programs play key roles in recovery from conflict because they tailor emergency, recovery, and development issues across a country area by area, based on differing needs and opportunities. area-based development helps bring together different actors at the operational level, promoting enhanced coordination, coherence, and impact at field level. areabased development is often seen as the core mechanism that most benefits reintegration. • developing comprehensive reintegration programs for idps, returning refugees, and ex-combatants. internal displacement, returning refugees, and demobilized former combatants create a huge need for in-country capacity building on different levels. protection and security become serious issues, and efforts to sustainably reintegrate these populations into their host communities are critical. bcpr provides expertise on reintegration of idps, returnees, and ex-combatants, including capacity building benefiting both the returnees and the formerly displaced, as well as their host communities, through activities such as income generation, vocational training, and other revitalization activities. • supporting economic recovery and revitalization. one main characteristic of disasters and conflict is their devastating impact on the local and national economies. livelihoods are destroyed through insecurity, unpredictability, market collapse, loss of assets, and rampant inflation. for recovery to be successful, these issues need to be well understood from the outset and addressed accordingly. • supporting capacity building, coordination, resource mobilization, and partnerships. protracted conflict and extreme disasters tend to create political stressors that temporarily exceed the capacities of un country offices and other ngo partners. however, many recovery needs must be addressed right away to ensure that recovery sets out on a sustainable course. bcpr offers several services to accommodate the needs of this intense phase through the provision of surge capacity and short-to medium-term staff, assistance in resource mobilization within specific fundraising and coordination frameworks (such as the cap), and partnership building. when required to assist in recovery operations, bcpr may deploy a special transition recovery team (trt) to supplement undp operations in the affected country. the focus for these teams varies according to specific needs. for instance, when neighboring countries have interlinked problems (such as cross-border reintegration of ex-combatants and displaced persons), the trt may support a subregional approach to recovery. it is important to note that the undp has no primary role in the middle of a che peacekeeping response, only a supportive one in helping to harmonize development with relief. during recovery and reconstruction, together with others, they take the lead. in addition to the previously mentioned roles and responsibilities, the undp leads several interagency working groups. one such group (which consists of representatives from the wfp, who, the food and agriculture organization [fao] , the un populations fund, and unicef) develops principles and guidelines to incorporate disaster risk into the common country assessment and the un development assistance framework. the international strategy for disaster reduction working group on risk, vulnerability, and disaster impact assessment sets guidelines for social impact assessments. undp also coordinates a disaster management training programme in central america, runs the conference "the use of microfinance and micro-credit for the poor in recovery and disaster reduction," and has created a program to elaborate financial instruments to enable the poor to manage disaster risks. the undp has several reasons for its success in fulfilling its roles in the mitigation, preparedness, and recovery for natural and man-made disasters. first, as a permanent in-country office with close ties to most government agencies, activities related to coordination and planning, monitoring, and training are simply an extension of ongoing relationships. the undp works in the country before, during, and long after the crisis. it is able to harness vast first-hand knowledge about the situations leading up to a crisis and the capacity of the government and civil institutions to handle a crisis, and can analyze what weaknesses must be addressed by the responding aid agencies. in addition, its neutrality dispels fears of political bias. second, the undp functions as a coordinating body of the un agencies concerned with development, so when crisis situations appear, there is an established, stable platform from which it may lead. from this leadership vantage, it can (theoretically) assist in stabilizing incoming relief programs of other responding un bodies, such as the wfp, unicef, the department of humanitarian affairs, and the unhcr. once the emergency phase of the disaster has ended and ocha prepares to leave, undp is in a prime position to facilitate the transition from response efforts to long-term recovery. and third, the undp has experience dealing with donors from foreign governments and development banks, and can therefore handle the outpouring of aid that usually results during the relief and recovery period of a disaster. this contributes greatly to reducing levels of corruption and increasing the cost-effectiveness of generated funds. in several recent events, the undp has established formalized funds to handle large donor contributions, which have been used for long-term post-disaster reconstruction efforts. (see exhibits 10.3 and 10.4). when a major disaster operation requires extended efforts, the undp may accept and administer special extra-budgetary contributions to provide the national government with both technical and material assistance, in coordination with ocha and other agencies involved in the un disaster management team (dmt). an example of such assistance includes the establishment and administration of a un dmt emergency information and coordination (eic) support unit. special grants of up to $1.1 million also may be provided, allocated from the special programme resources funds for technical assistance to post-disaster recovery efforts following natural disasters. see exhibit 10.5 for information about the undp capacity for disaster reduction initiative (cadri). like most major un agencies, unicef (formerly known as the united nations international children's emergency fund) was established in the aftermath of world war ii. its original mandate was to aid children suffering in postwar europe, but this mission has been expanded to address the needs of women and children throughout the world. unicef is mandated by the general assembly to advocate for children's rights, to ensure that each child receives at least the minimum requirements for survival, and to increase children's opportunities for a successful future. under the convention on the rights of on may 19, 2009, the government of sri lanka declared military victory over the rebel liberation tigers of tamil eelam, formally ending a decades-long armed conflict. in the wake of the war, undp demonstrated that developing and building on strong partnerships is key to ensuring a fast and well-targeted response. an estimated 300,000 idps gathered in camps during the first half of 2009. many of them lacked basic documentation, making it difficult to access basic services and prove claims to land and assets. undp assisted the registrar general to establish a temporary office inside one of the largest camps with capacity to process 50 birth and marriage certificates per day, complemented by additional staffing capacity in colombo to handle the increased number of document requests. between july and december the camp office processed close to 10,000 requests, prioritizing those from children who needed identification to sit for national school exams. undp also supported mine action coordination and management. survey and clearance activities advanced rapidly, and by the end of 2009 a total of 879 square kilometers of land had been released for resettlement. this allowed the pace of returns and resettlements to increase exponentially in the fourth quarter of 2009, with over 150,000 idps returning or resettling. in the eastern province, fao, ilo, wfp, unhcr, and undp continued to champion the "delivering as one" approach to support community-based recovery and contribute to the stability of returnees in selected divisions of the east. as the funding conduit, undp was in charge of the overall coordination of project implementation while also directly implementing small-scale infrastructure construction such as roads, wells, and community centers (which provided a space for cooperatives and trading groups to come together). the selection of target communities was informed through village profile maps and data generated by unhcr, while wfp provided six months' worth of food supply rations, until the foundations for agricultural self-reliance and food security for resettled families were laid. undp also launched a new initiative in 2009 to foster partnerships between sri lanka's manufacturers and resettled communities. undp, with its presence in the field, played a catalytic role, identifying the resettled communities, facilitating meetings with the large consumer companies, securing fair and long-term contracts, and supporting training as well as supply of equipment to improve production. through this project, 450 farming and fishing families in the north and the east have secured income for the next two to three years. on may 25, 2009, cyclone aila hit southern bangladesh, resulting in widespread tidal flooding and the destruction of large parts of the region's protective embankment network. economic losses were estimated at $106 million and more than 29,000 families were affected in satkhira, the district that had also suffered the most from cyclone sidr in 2007. many of the affected were still recovering from the impact of the earlier disaster. the government of bangladesh provided emergency relief and planned for the reconstruction of the damaged embankment network, but many of the most vulnerable families have been unable to return to their homes, which remain submerged. with funding from the undp bureau of crisis prevention and recovery (bcpr), an early recovery program focused on livelihoods was developed, covering all villages in the worst-affected part of satkhira. the program included a cash-forwork component that built on self-recovery efforts of affected families. this resulted in the creation of an estimated 37,400 work days devoted to road repair and ground elevation. the program also included support for the restoration of essential community infrastructure; support to local small enterprises through working capital grants for carpentry tools, sewing machines, and tea stall equipment; and assistance for home-based income-generating activities, such as vegetable cultivation, crab fattening, handicrafts, poultry rearing, and fish drying. this effort benefited more than 4,000 families. the child (crc), a treaty adopted by 191 countries, the unhcr holds broad-reaching legal authority to carry out its mission. as of late 2014, unicef maintains country offices in more than 190 different nations. this is probably its greatest asset in terms of the agency's disaster management capacity. preparedness and mitigation for disasters among its target groups is a priority, with programs able to address both local-level action and national-level capacity building. in keeping with the recommendations laid out by the yokohama strategy and plan of action for a safer world, unicef incorporates disaster reduction into its national development plans. it also considers natural hazard vulnerability and capacity assessments when determining overall development needs to be addressed by un country teams. through public education campaigns, unicef works to increase public hazard awareness and knowledge and participation in disaster management activities. unicef country offices include activities that address these pre-disaster needs in their regular projects. for example, they develop education materials required for both children and adults, and then design websites so educators and program directors can access or download these materials for use in their communities. in situations of disaster or armed conflict, unicef is well poised to serve as an immediate aid provider to its specific target groups. its rapid-response capacity is important because vulnerable groups are often the most marginalized in terms of aid received. unicef works to ensure that children have access to education, health care, safety, and protected child rights. in the response and recovery periods of humanitarian emergencies, these roles expand according to victims' needs. (in countries where uni-cef has not yet established a permanent presence, the form of aid is virtually the same; however, the timing and delivery are affected, and reconstruction is not nearly as comprehensive.) the unicef office of emergency programmes (emops), which has offices in new york and geneva, maintains overall responsibility for coordinating unicef's emergency management activities. cadri was created in 2007 as a joint program of the undp bureau for crisis prevention and recovery (undp/bcpr), the united nations office for the coordination of humanitarian affairs (ocha), and the secretariat of the international strategy for disaster reduction (isdr). recognizing that capacity development is a cross-cutting activity for disaster risk reduction as stipulated in the hyogo framework (hf), cadri's creation is designed to support all five priorities of the hf. cadri was formally launched by the three organizations at the global platform for disaster risk reduction meeting, june 2007, geneva. cadri succeeds the un disaster management training programme (dmtp), a global learning initiative, which trained united nations, government, and civil society professionals between 1991 and 2006. dmtp is widely known for its pioneering work in developing high-quality resource materials on a wide range of disaster management and training topics. more than 20 trainers' guides and modules were developed and translated. cadri's design builds on the success and lessons learned from the dmtp and reflects the significant evolution in the training and learning field since the start of the dmtp, particularly regarding advances in technology for networking and learning purposes. cadri's design also reflects the critical role that the un system plays at the national level in supporting governments' efforts to advance disaster risk reduction. in the context of the un's increasingly important role, cadri provides capacity enhancement services to the un system at the country level as well as to governments. these include learning and training services and capacity development services to support governments to establish the foundation for advancing risk reduction. emops works closely with the unicef programme division, managing the unicef emergency programme fund (epf; see the following section) and ensuring close interagency coordination with other participating humanitarian organizations. in this role, unicef is also in the position to act as coordinator in specific areas in which it is viewed as the sector leader. for instance, unicef was tasked with leading the international humanitarian response in the areas of water and sanitation, child protection, and education for the 2004 asia tsunami and earthquake response. (in aceh province alone, more than 250 agencies addressed water and sanitation issues.) unicef maintains that humanitarian assistance should include programs aimed specifically at child victims. its relief projects generally provide immunizations, water and sanitation, nutrition, education, and health resources. women are recipients of this aid as well, because unicef considers women to be vital in the care of children. (see exhibit 10.6.) to facilitate an immediate response to an emergency situation, unicef is authorized to divert either $200,000 or $150,000 from country program resources (depending on whether the country program's annual budget is above or below $2 million, respectively) to address immediate needs. if the disaster is so great it affects existing unicef programs operating in the country, the unicef representative can shift these programs' resources once permission is received from the national government and unicef headquarters. unicef also maintains a $75 million global epf, which provides funding for initial emergency response activities. by the end of the three weeks of fighting in early 2009 in gaza, 350 children had been killed and 1,600 injured, and much of gaza's infrastructure, including schools, health facilities, and vital infrastructure for water and sanitation, had been damaged. unicef was on hand to provide humanitarian support. it led the collective efforts of un agencies on the ground to restore education, provide emergency water supplies and sanitation, maintain nutritional standards, and protect children from further harm. from the early days, unicef made sure that first aid and emergency medical kits, essential drugs, and water purification tablets flowed into gaza. emergency education supplies such as classroom tents and school-in-a-box kits maintained some sense of continuity and normalcy for children. unicef and its partners were able to reach more than 200,000 school-age children. unicef raised global awareness of the harm being done to children through extensive media coverage and advocacy. attention was also raised by the visits of the special representative of the secretary-general for children and armed conflict, radhika coomaraswamy-who called for the protection of children-and unicef executive director ann m. veneman, as well as goodwill ambassadors mia farrow and mahmoud kabil. unicef also extended psychosocial services, including in-depth counselling and structured recreational activities, across gaza. training reinforced the capacities of psychosocial workers to protect children and help them heal. radio programmes and 200,000 leaflets designed for children warned of the risks of mines and unexploded ordnance left behind. unicef water tankers ensured a steady supply of clean drinking water to 135 schools with 110,000 students, while desalination units were installed to rid water of dangerous concentrations of chlorides and nitrates. to thwart the risk of acute malnutrition, unicef worked through 53 health clinics for mothers and children to offer supplements of micronutrients and fortified food. the quality and supply of teaching materials were improved through unicef's provision of math and science teaching kits. programmes for vulnerable adolescents concentrated on supporting remedial learning, relieving stress, and providing life skills-based education and opportunities to engage in civic activities. through unicef's systematic advocacy with partner organizations, almost half the attendees were girls. the world food programme (wfp) is the un agency tasked with addressing hunger-related emergencies. it was created in 1961 by a resolution adopted by the un general assembly and the un fao. today, the program operates in 75 countries and maintains eight regional offices. in the year 2013 alone, the wfp provided 3.1 million metric tons of food aid to 80.9 million people in 75 countries through its relief programs. over the course of its existence, the wfp has provided more than 70 million metric tons of food to countries worldwide. wfp was an early member of the former inter-agency task force for disaster reduction (see below) and maintains disaster risk reduction as one of its priority areas, focusing on reducing the impact of natural hazards on food security, especially for the vulnerable. the wfp policy on disaster risk reduction and management, approved in 2011, highlights this role as being central to the organization's work. wfp drr programs seek to build resilience and reduce risk through such activities as soil and water conservation, rehabilitating infrastructure, and training community members in disaster risk management and livelihood protection. the meret project in ethiopia is one example. this program targets food-insecure communities in degraded fragile ecosystems prone to drought-related food crises. other programs maintained by wfp include: • r4 resilience initiative: the rural resilience initiative (r4) is a partnership between wfp and oxfam america, with support from global reinsurance company swiss re, to test a new, comprehensive disaster risk reduction and climate change adaptation approach. the program allows cash-poor farmers and rural households to pay for index insurance with their own labor, so they can both manage and take risks to build resilient livelihoods. • livelihoods early assessment and protection (leap): wfp has been assisting the government of ethiopia to develop an integrated risk management system through the livelihoods early assessment and protection (leap) project. leap provides early warning data on food security that allows a rapid scale-up of the "national productive safety net programme" by activating contingency plans. when a serious drought or flood is detected, resources from a us$160 million contingency fund are made immediately available to ensure early and more effective emergency response, thereby protecting livelihoods and saving lives. • the joint wfp/ifad weather risk management facility (wrmf): wrmf supports the development of innovative weather and climate risk management tools, such as weather index insurance (wii). the goal of these programs is to improve quality-of-life issues and to reduce the incidence of food shortages. this program was launched in 2008 through funding from the bill and melinda gates foundation. it has been piloted in china and ethiopia. wfp has established a steering committee for disaster mitigation to help its offices integrate these activities into regular development programs. examples of mitigation projects that focus on food security include water harvesting in sudan (to address drought), the creation of grain stores and access roads in tanzania, and the creation of early warning and vulnerability mapping worldwide. because food is a necessity for human survival and is considered a vital component of development, a lack of food is, in and of itself, an emergency situation. the wfp works throughout the world to assist the poor who do not have sufficient food so they can survive "to break the cycle of hunger and poverty." hunger crises are rampant-more than 1 billion people across the globe receive less than the minimum standard requirement of food for healthy survival. hunger may exist on its own, or it may be a secondary effect of other hazards such as drought, famine, and displacement. the wfp constantly monitors the world's food security situation through its international food aid information system (fais). using this system, wfp tracks the flow of food aid around the world (including emergency food aid) and provides the humanitarian community with an accurate inventory and assessment of emergency food-stock quantities and locations. this database also includes relevant information that would be needed in times of emergency, such as anticipated delivery schedules and the condition and capabilities of international ports. in rapid-onset events such as natural disasters, the wfp is a major player in the response to the immediate nutritional needs of the victims. food is transported to the affected location and delivered to storage and distribution centers. (see figure 10 .3.) the distribution is carried out according to preestablished needs assessments performed by ocha and the undp. the wfp distributes food through contracted ngos that have the vast experience and technical skills to plan and implement transportation, storage, and distribution. the principal partners in planning and implementation are the host rice donated by japan is loaded by the world food programme onto 72 wfp trucks to feed survivors of the 2004 asia tsunami and earthquake events sources: skullard, 2005; wfp, 2005. governments, who must request the wfp aid, unless the situation is a che without an established government, in which case the un secretary-general makes the request. the wfp works closely with all responding un agencies to coordinate an effective and broad-reaching response, because food requirements are so closely linked to every other vital need of disaster victims. during the reconstruction phase of a disaster, the wfp often must continue food distribution. rehabilitation projects are implemented to foster increased local development, including the provision of food aid to families, who, as a result, will have extra money to use in rebuilding their lives; and food-for-work programs, which break the chains of reliance on aid as well as provide an incentive to rebuild communities. wfp administers the international emergency food reserve (iefr), which was originally designed to store a minimum of 500,000 tons of cereals. this program has not enjoyed the full support of donors as agreed in its creation, however, and as such, annual funding levels have fluctuated significantly. if supported, iefr would manage separate resources provided by donors to address long-term operations such as ches, and would dedicate $15 million from its general resources for emergency assistance in addition to $30 million for long-term emergency assistance. the program's immediate response account is a cash account maintained for rapid purchase and delivery of food in emergency situations. resources would be purchased from local markets (whenever possible), thereby ensuring food arrives sooner than other aid, which must move through regular channels. wfp response begins at the request of the affected country's government. 1. in the early days of an emergency, while the first food supplies are being delivered, emergency assessment teams are sent in to quantify exactly how much food assistance is needed for how many beneficiaries and for how long. they must also work out how food can best be delivered to the hungry. 2. equipped with the answers, wfp draws up an emergency operation (emop), including a plan of action and a budget. [the emop] lists who will receive food assistance, what rations are required, the type of transport wfp will use, and which humanitarian corridors lead to the crisis zone. 3. next, wfp launches an appeal to the international community for funds and food aid. the agency relies entirely on voluntary contributions to finance its operations, with donations made in cash, food, or services. governments are the biggest single source of funding. [more than 60 governments support wfp's worldwide operations.] 4. as funds and food start to flow, wfp's logistics team works to bridge the gap between the donors and the hungry. [in 2012, the agency delivered 4.8 million metric tons of food aid by air, land, and sea.] (wfp 2014) ships carry the largest wfp cargo, their holds filled to the brim with 50,000 tons or more of grain, cans of cooking oil, and canned food; the agency has 40 ships on the high seas every day, frequently rerouting vessels to get food quickly to crisis zones. in extreme environments, wfp also uses the skies to reach the hungry, airlifting or airdropping food directly into disaster zones. before the aid can reach its country of destination, logistics experts often need to upgrade ports and secure warehouses. trucks usually make the final link in wfp's food chain, transporting food aid along the rough roads that lead to the hungry. where roads are impassable or nonexistent, wfp relies on less conventional forms of transport: donkeys in the andes, speedboats in the mozambique floods, camels in sudan, and elephants in nepal. at this stage, local community leaders work closely with wfp to ensure rations reach the people who need it most: pregnant mothers, children, and the elderly. the world health organization (who) was proposed during the original meetings to establish the un system in san francisco in 1945. in 1946, at the united health conference in new york, the who constitution was approved, and it was signed on april 7, 1946 (world health day). who proved its value by responding to a cholera epidemic in egypt months before the epidemic was officially recognized. who serves as the central authority on sanitation and health issues throughout the world. it works with national governments to develop medical and health care capabilities and assist in the suppression of epidemics. who supports research on disease eradication and provides expertise when requested. it provides training and technical support and develops standards for medical care. who was an early member of the former interagency task force for disaster reduction (see below), and continues to assist local and national governments as well as regional government associations with health-related disaster mitigation and preparedness issues. it does this primarily by providing education and technical assistance to government public health officials about early detection, containment, and treatment of disease and the creation of public health contingency plans. who activities address primary hazards, such as epidemics (e.g., avian influenza, malaria, dengue fever, sars, swine flu, and mers/cov), and the secondary health hazards that accompany most major disasters. through their website and collaboration with various academic institutions, who has also worked to advance public health disaster mitigation and preparedness research and information exchange. the who director-general is a member of the iasc and the iasc working group. in those capacities, the who recommends policy options to resolve the more technical and strategic challenges of day-to-day emergency operations in the field. to incorporate public health considerations in un interagency contingency planning and preparedness activities, the who also participates in the iasc task force on preparedness and contingency planning. the who emergency risk management and humanitarian response department was created to enable who to work closely with member states, international partners, and local institutions in order to help communities prepare for, respond to, and recover from emergencies, disasters, and crises. the emergency response framework (erf) was developed in 2013 to clarify the who role and their responsibilities in emergency situations (who 2013). in the event of a disaster, who responds in several ways to address victims' health and safety. most important, it provides ongoing monitoring of diseases traditionally observed within the unsanitary conditions of disaster aftermath. who also provides technical assistance to responding agencies and host governments establishing disaster medical capabilities and serves as a source of expertise. it assesses the needs of public health supplies and expertise and appeals for this assistance from its partners and donor governments. per the erf, who is obligated to respond to emergencies under several conventions and agreements, including the international health regulations and the interagency steering committee. the key functions of hac in times of crises are: • measure health-related problems and promptly assess health needs of populations affected by crises, identifying priority causes of disease and death; • support member states in coordinating action for health; • ensure that critical gaps in health response are rapidly identified and filled; and • revitalize and build capacity of health systems for preparedness and response. when other government agencies, private medical facilities, or ngos cannot meet the public health needs of the affected population, who's country-level emergency response team and international emergency support teams bring together expertise in epidemics, logistics, security coordination, and management, collaborating with un agencies participating in response and recovery. who has several bilateral agreements with other un agencies and ngos (including the red cross and red crescent movement) and coordinates the interagency medical/health task force (imtf), an informal forum that provides guidance on technical and operational health challenges in humanitarian crises. the who global emergency management team (gemt) was created in 2011 to lead the planning, management, implementation, monitoring, and evaluation of who's emergency work (including national preparedness, institutional readiness, and emergency response for disasters that exhibit public health consequences.) the gemt is made up of staff from both who headquarters and regional office directors responsible for disaster risk management issues (e.g., preparedness, surveillance, alert, and response). as needed, other relevant staff are invited to join gemt efforts. gemt focuses on all-hazards emergency risk management, notably that of leadership on the health cluster. when technical expertise beyond that held by the team's members is needed, the global emergency network (gen), comprising directors (or delegates) of departments and programs that have various emergency management functions, is consulted. the gemt continuously tracks global health events and the organization-wide use of internal and external resources in all emergencies, and reports on all major emergencies. during an actual emergency or disaster, a subset of the gemt, known as the gemt-response (gemt-r), is mobilized to grade and manage the response to a specific emergency. for larger-scale emergencies, the gemt-r is responsible for making recommendations to executive management on the best use of who resources given the event's scale, scope, duration, and complexity (given other existing requirements in ongoing events). since its inception, six regional offices have been established. these offices focus on the health issues in each region: • regional office for africa • pan american health organization • regional office for south-east asia • regional office for europe • regional office for eastern mediterranean • regional office for the western pacific the food and agriculture organization (fao) was established as a un agency in 1945 in quebec city, canada. the organization's mandate is to "raise levels of nutrition, improve agricultural productivity, better the lives of rural populations and contribute to the growth of the world economy" (fao 2006) . it provides capacity-building assistance to communities that need to increase food production. in 2000, fao pledged to help current and future generations achieve food security by 2015. in spite of their work, more than 800 million people worldwide continue to suffer the effects of food shortages, including more than 160 million children under five years of age who show signs of malnutrition-based growth stunting. fao is headquartered in rome, italy. the organization also maintains five regional, five subregional, and 80 country offices, each of which works with un member countries and other partners to coordinate various activities, including disaster management. it has 194 member nations, two associate member nations, and one member organization (the european union). fao was an early member of the interagency task force on disaster reduction prior to its becoming the global platform for disaster risk reduction. the 1996 world food summit mandated fao to assist un member countries in developing national food security, vulnerability information, and specialized mapping systems to cut worldwide malnutrition. a key component of this strategy is strengthening the capacity of communities and local institutions to prepare for natural hazards and respond to food emergencies during disasters and crises. this objective focuses on: • strengthening disaster preparedness and mitigation against the impact of emergencies that affect food security and the productive capacities of rural populations; • forecasting and providing early warning of adverse conditions in the food and agricultural sectors and of impending food emergencies; • strengthening programs for agricultural relief and rehabilitation and facilitating the transition from emergency relief to reconstruction and development in food and agriculture; and • strengthening local capacities and coping mechanisms by guiding the choice of agricultural practices, technologies, and support services to reduce vulnerability and enhance resilience. in 2009, fao released strategic objective i, which guided the organization in conducting "preparedness for, and effective response to, food and agricultural threats and emergencies." this strategy laid out three specific results that were sought, including: 1. countries' vulnerabilities to crises, threats, and emergencies is reduced through better preparedness and integration of risk prevention and mitigation into policies, programs, and interventions; 2. countries and partners respond more effectively to crises and emergencies with food-and agriculture-related interventions; and 3. countries and partners have improved transition and linkages between emergency, rehabilitation, and development. within fao, the emergency coordination group is the organizational mechanism for the overall coordination of emergency and disaster reduction issues. this group strengthens fao's capacity to perform food-based disaster management activities in support of member countries and partners in a more integrated way. ecg is chaired by the director of the office for coordination of normative, operational and decentralized activities and has a secretariat provided by the office of the special advisers to the director-general. key units of this group include: the investment centre division prepares investment programs and projects for funding by major multilateral development banks during the rehabilitation and reconstruction and the recovery phases. fao field offices are in 110 developing countries. regional and subregional offices are also maintained. at any time, fao is involved in some 1,500 agricultural projects in the developing world. experts working on these projects in affected countries are frequently called upon to help with emergency needs assessments and field operations. in a disaster, fao representatives in developing countries respond by coordinating with the government and other partners. in countries with ches, fao coordinates actions that address emergency agricultural needs and assists in the development and implementation of strategies for creating conditions conducive to recovery and sustained development. fao's approach is to set up coordination units that: • provide technical assistance to help the impacted government and its citizens to manage agricultural relief; • monitor the ongoing crisis relative to food; • advise ngos and other organizations involved in food and agriculture; • help build the necessary national capacity to transition from response to recovery; and • establish information collection and database management systems. examples of countries where fao emergency coordination units have been set up include bosnia, tajikistan, rwanda, burundi, liberia, sierra leone, somalia, iraq, and angola. fao also maintains a website of disaster reduction information through its world agricultural information center (waicent). this online portal provides access to the global information and early warning system, information on crop prospects, and other relevant documents and data. fao also works to help countries adopt sustainable agricultural and other land-use practices. its land and water division has helped to reverse land loss, thus increasing disaster resilience, by promoting the development of disaster-resistant agro-ecosystems and the sound use of land and water resources. in times of disaster, the emergency operations and rehabilitation division helps communities recover. while other agencies, such as wfp, address immediate food needs by providing the actual food aid to victims, fao provides assistance to restore local food production and reduce dependency on food aid. the fao's first action following disasters, in partnership with wfp, is to send missions to the affected areas to assess crops and food supply status. the emergency operations service of the emergency operations and rehabilitation division leads these missions, sending fao experts to consult with farmers, herders, fisheries, and local authorities to gather disaster and recovery data. using their assessment, fao designs an emergency agricultural relief and rehabilitation program and mobilizes the funds necessary for its implementation. the emergency operations and rehabilitation division distributes material assets such as seeds, fertilizer, fishing equipment, livestock, and farm tools. in a che, fao helps affected communities bolster overall resources and restore and strengthen agricultural assets to make them less vulnerable to future shocks. for example, fao has been working in regions outside government authority in the sudan to conduct community-based training of animal health workers aimed at keeping their livestock-a vital part of local livelihoods-from dying. when a disaster occurs, the emergency operations and rehabilitation division of fao establishes an emergency agriculture coordination unit consisting of a team of technical experts from a wide range of fields (including crop and livestock specialists). this field-level team provides information and advice to other humanitarian organizations and government agencies involved in emergency agricultural assistance in the affected area. fao coordination units also facilitate operational information exchange, reducing duplications of and eliminating gaps in assistance. fao's primary beneficiaries include: • subsistence farmers • pastoralists and livestock producers • artisan "fisherfolk" • refugees and internally displaced people • ex-combatants • households headed by women or children and/or afflicted by hiv/aids the special emergency programmes service (tces), also within the emergency operations and rehabilitation division, is responsible for the effective implementation of specially designed emergency programs. these programs require particular attention because of the political and security context surrounding their interventions and the complexity of the institutional setup. tces was responsible for fao's intervention in the framework of the oil for food program in iraq and fao's emergency and early rehabilitation activities in the west bank and gaza strip. the rehabilitation and humanitarian policies unit (tcer) is the final component of the emergency operations and rehabilitation division. tcer is responsible for making recommendations regarding disaster preparedness, post-emergency, and rehabilitation initiatives. the unit coordinates fao's position on humanitarian policies and ensures that fao addresses the gap between emergency assistance and development. tcer also liaises with other un entities dealing with humanitarian matters. the fao's disaster-and emergency-related projects are funded by contributions from governmental agencies, ngos, other un agencies, and by the fao technical cooperation programme (tcp). each year, approximately 75 percent of fao emergency funds are raised through the cap. fao expenditure on emergency efforts has grown significantly during the past few years, indicative of the greater role the organization has assumed in disaster management. current emergency-related projects include: • improved food security for hiv/aids-affected households in africa's great lakes region • rehabilitation of destroyed greenhouses in the west bank and gaza strip • land-tenure management in angola • emergency agricultural assistance to food-insecure female-headed households in tajikistan • consolidation of peace through the restoration of productive capacities of returnee and host communities in conflict-affected areas in sudan • rehabilitation of irrigation systems in afghanistan • rehabilitation of farm-to-market roads in the democratic republic of the congo the position of united nations commissioner for refugees (unhcr) was created by the general assembly in 1950 to provide protection and assistance to refugees. the agency was given a three-year mandate to resettle 1.2 million european world war ii refugees. today, unhcr is one of the world's principal humanitarian agencies, operating through the efforts of more than 8,600 personnel and addressing the needs of 33.9 million people in more than 125 countries. unhcr promotes international refugee agreements and monitors government compliance with international refugee law. unhcr programs begin primarily in response to an actual or impending humanitarian emergency. in complex humanitarian disasters and in natural and other disasters that occur in areas of conflict, there is a great likelihood that refugees and idps will ultimately result. the organization's staffs work in the field to provide protection to refugees and displaced persons and minimize the threat of violence many refugees are subject to, even in countries of asylum. the organization seeks sustainable solutions to refugee and idp issues by helping victims repatriate to their homeland (if conditions warrant), integrate in countries of asylum, or resettle in third countries. unhcr also assists people who have been granted protection on a group basis or on purely humanitarian grounds, but who have not been formally recognized as refugees. unhcr works to avert crises by anticipating and preventing huge population movements from recognized global areas of concern ("trouble spots"). one method is to establish an international monitoring presence to confront problems before conflict breaks out. for example, unhcr mobilized a "preventive deployment" to five former soviet republics in central asia experiencing serious internal tensions following independence. unhcr also promotes regional initiatives and provides general technical assistance to governments and ngos addressing refugee issues. in times of emergency, unhcr offers victims legal protection and material help. the organization ensures that basic needs are met, such as food, water, shelter, sanitation, and medical care. it coordinates the provision and delivery of items to refugee and idp populations, designating specific projects for women, children, and the elderly, who comprise 80 percent of a "normal" refugee population. the blue plastic sheeting unhcr uses to construct tents and roofing has become a common and recognizable sight in international news. unhcr maintains an emergency preparedness and response section (eprs), which has five emergency preparedness and response officers (epro) who remain on call to lead emergency response teams into affected areas. the epros may be supported by a range of other unhcr human resources, including: • emergency administrative officers and emergency administrative assistants, for quickly establishing field offices • the 130 members of the emergency roster, which includes staff with diverse expertise and experience, are posted throughout the world and are available for rapid emergency deployment • staff (by existing arrangement) from the danish refugee council, the norwegian refugee council, and un volunteers, to provide specialized officials on short notice as needed (more than 500 people are available at any given time) • individuals registered on a roster of "external consultant technicians," who are specialized in various fields often required during refugee and idp emergencies (including health, water, sanitation, logistics, and shelter) • select ngos that have been identified as capable of rapid deployment to implement assistance in sectors of need (e.g., health, sanitation, logistics, and social services) unhcr has the capacity to respond to a new emergency impacting up to 500,000 people. the agency can also mobilize more than 300 trained personnel within 72 hours. these experts come from its emergency response team (ert) roster. unhcr has also developed mechanisms for the immediate mobilization of financial resources to help meet the response to an emergency without delay. unhcr staff may be supported under an agreement with the swedish rescue services agency, which is prepared to establish a base camp and office in affected areas within 48 hours' notice. other supplies and resources, such as vehicles, communications equipment, computers, personal field kits, and prepackaged office kits are maintained for rapid deployment to support field staff. unhcr maintains stockpiles of relief aid, including prefabricated warehouses, blankets, kitchen sets, water storage and purification equipment, and plastic sheeting. these are stored in regional warehouses or may be obtained on short notice from established vendors that guarantee rapid delivery. unhcr also maintains agreements with stockpiles outside the un system from which they may access items, such as the swedish rescue board and various ngos. unhcr developed a quick impact project (qip) initiative. qips are designed to bridge the gap between emergency assistance provided to refugees and people returning home and longer-term development aid undertaken by other agencies. these small-scale programs are geared toward rebuilding schools and clinics, repairing roads, and constructing bridges and wells. unhcr is funded almost entirely by voluntary contributions from governments, intergovernmental organizations, the private sector, and individuals. it receives a limited subsidy of less than 2 percent of the un budget for administrative costs and accepts "in-kind" contributions, including tents, medicines, trucks, and air transportation. as the number of people protected or of concern by unhcr has reached record highs, its annual budget has likewise jumped several fold in just a few years. in 2008, the unhcr budget was a record $1.8 billion, yet by 2013 that number rose to over $5.3 billion-a rate that has been maintained ever since. (see figure 10.5.) in 2006, unhcr established a new global emergency stockpile in dubai, united arab emirates. the new stockpile is the largest of several unhcr global stockpiles. it is used to store relief items such as tents, blankets, plastic sheeting, mosquito nets, kitchen sets, and jerry cans, among other items, for up to 350,000 people. prefabricated warehouses and other safety and security equipment for staff and office support are also available. in 2013, items from the stockpile were sent to 36 countries, including syria, jordan, lebanon, turkey, and others in africa and asia. the items shipped included 1,266,815 blankets, 73,850 buckets, 238,486 jerry cans, 197,972 kitchen sets, 310,515 sleeping mats, 60,736 mosquito nets, 283,053 plastic tarpaulins, and 25,226 family tents (unhcr 2014). although unhcr does not often become involved in natural disaster response, rather focusing on areas of conflict, its expertise and assistance were required in the aftermath of the october 2005 earthquake that severely impacted south asia. during the response phase of this disaster, unhcr provided 12 flights loaded with supplies from its global and regional stockpiles and contributed 15,145 family tents, 220,000 blankets, 69,000 plastic sheets, and thousands of jerry cans, kitchen sets, stoves, and lanterns. the aid items were drawn from its existing warehouses in pakistan and afghanistan, as well as other locations throughout the world. because of the earthquake, roads used to access 45,000 afghan refugees affected by the earthquake were severely damaged, but unhcr was able to quickly assess damages and needs and meet those needs through their existing networks (unhcr 2005) . in the event of a large-scale disaster, the un may form a disaster management team (dmt) in the affected country. if the disaster clearly falls within the competence and mandate of a specific un agency, that organization will normally take the lead, with the un dmt serving as the forum for discussing how other agencies will work to support that lead agency. the un dmt is convened and chaired by the un resident coordinator and comprises country-level representatives of fao, undp, ocha, unicef, wfp, who, and, where present, unhcr. specific disaster conditions may merit participation by other un agencies. the leader of the undac team, assigned by ocha, automatically becomes a member of the un dmt. a undp official called the disaster focal point officer often serves as the un dmt secretary, but the team is free to choose another person, if necessary. undp is also responsible for providing a venue for the team and any basic administrative support needs. the un dmt's primary purpose is to ensure that in the event of a disaster, the un is able to mobilize and carry out a prompt, effective, and concerted response at the country level. the team is tasked with coordinating all disaster-related activities, technical advice, and material assistance provided by un agencies, as well as taking steps to avoid wasteful duplication or competition for resources by un agencies. the un dmt interfaces with the receiving government's national emergency management team, from which a representative may, where practical, be included in the un dmt. the central emergency response fund (cerf) was created in 1991 through un general assembly resolution 46/182 to allow for faster operational action by un agencies. the fund, which was originally called the central emergency revolving fund but renamed in 2005 under resolution 60/124, is administered on behalf of the un secretary-general by the emergency relief coordinator. during times of disaster, cerf provides agencies involved in the humanitarian response with a constant source of funding to cover their activities. its purpose is to shorten the amount of time between the recognition of needs and the disbursement of funding. agencies that have received pledges from donors but have not yet received actual funds, or agencies that expect to receive funds from other sources in the near future, can borrow equivalent amounts of cash, interest free, through cerf. voluntary contributions from 125 donor nations and private-sector donors have raised billions since the inception of cerf, of which more than $3 billion has been allocated in the form of grants to almost 100 countries. the program's goal is to have $500 million replenished annually. (see table 10 .1 for a full list of donors.) at the outset, cerf was designed only for ches, but in 2001 the general assembly voted 1. the lending agency submits a request for an advance to the erc, which includes a descriptive justification on the project or activities to be funded. if a future pledge for funding has been promised by a donor or if the agency has other means for repaying the loan, this information is included in the request. 2. an ocha officer reviews the request. if it is accepted (statistics show that the majority are accepted), the erc informs the agency and sets out the loan use and repayment terms. 3. disbursement usually occurs within 72 hours. payment is made through an internal un "voucher." 4. loans must be repaid within six months. this entire process is conducted at ocha's new york office. figure 10 .6 illustrates patterns of use by the various un agencies. the consolidated appeals process (cap), which began in 1991, allows humanitarian aid organizations to plan, implement, and monitor their activities. these organizations can work together to produce a common humanitarian action plan (chap; see the following section) and an appeal for a specific disaster or crisis, which they present to the international community and donors. the cap fosters closer cooperation between governments, donors, aid agencies, and many other types of humanitarian organizations. it allows agencies to demand greater protection and better access to vulnerable populations, and to work more effectively with governments and other actors. the cap is initiated in three types of situations: 1. when there is an acute humanitarian need caused by a conflict or a natural disaster 2. when the government is either unable or unwilling to address the humanitarian need 3. when a single agency cannot cover all the needs on november 8, 2013, typhoon haiyan (yolanda) hit the philippines. the humanitarian situation in the areas devastated by the typhoon was catastrophic. an estimated 13 million people were affected, including 5 million children. close to 2 million people were displaced and in dire need of humanitarian assistance. in response, the united nations emergency relief coordinator, valerie amos, released us$25 million to seven united nations agencies and the international organization for migration (iom) on 11 november. • the united nations children's fund (unicef) received $5,331,408 to ensure water, sanitation, and hygiene facilities. unicef also provided child protection, including protective learning environments, and reduced the risk of outbreaks of vaccine-preventable diseases among children aged 0 to 59 months. finally, unicef provided nutrition interventions to children aged 0 to 59 months as well as to pregnant and lactating women. • with an allocation of $500,004, the food and agriculture organization (fao) provided emergency food assistance. • the united nations population fund (fpa) received $748,319 to ensure access to reproductive health services and to prevent gender-based violence. • to support the internally displaced persons (idps), the united nations high commissioner for refugees (unhcr) provided emergency shelter assistance through an allocation of $3,002,469. • the world food programme (wfp) received $6,713,810 to provide emergency food assistance. wfp also coordinated the humanitarian operations in the areas affected. • the world health organization (who) provided health services through an allocation of $2,491,667. • the united nations development programme (undp) received $1,804,055 to manage time-critical debris disposal. • through an allocation of $5,492,378, iom supported evacuation centers and idp sites by procuring and distributing emergency shelter kits and essential non-food items. the cerf allocations were expected to ultimately benefit more than 11.2 million people. the cap is led by the hc, who triggers the interagency appeal and collaborates with the iasc country team at the local level and the erc at headquarters. participants in the process include: • iasc. although all team members are encouraged to participate in chap development, some members may make appeals for funding outside of the un and its cap (as is often the case with the red cross). • donors. donors participate in chap development by committing to "good humanitarian donorship principles." • host government(s). the cap is best prepared in consultation with the host government, particularly the ministries the un operational agencies are working with on a day-to-day basis. • affected population(s). whenever possible, it is always advantageous to include the affected populations' perspective into relief and recovery planning. a consolidated appeal (ca) is a fundraising document prepared by several agencies working to outline annual financing requirements for implementing a chap. although governments cannot request funding through the ca, ngos can make a request as long as their proposed project goals are in line with chap priorities. the ca is usually prepared by the hcs in september or october, and then launched globally by the un secretary-general at the donor's conference held each november. the ca lasts as long as is necessary for funding purposes, usually a year or more. the sectors that may be considered by the ca include: • agriculture • coordination and support services the process for filing a ca is as follows: 1. at the onset of the emergency, a situation report is issued (can cover from day 1 to week 2). 2. in the meantime, a flash appeal may be prepared and launched (covers week 2 to month 6). 3. finally, a ca may be issued. if the situation and needs in the field change, a revision to any part of an appeal can be issued at any time. additionally, projects can be added, removed, or modified within the appeal at any time. approximately 80 percent of cap and flash appeal funding comes from a small group of wealthy nations, including canada, the european community humanitarian office (echo) and the european commission, germany, japan, the netherlands, norway, sweden, the united kingdom, and the united states. in high-profile events, private donors may constitute a large percentage of donations, such as occurred in the case of the 2004 tsunami disaster in asia. the chap is a strategic plan developed by agencies working together at the field level that assesses needs in an emergency and coordinates response. it acts as the foundation for a ca, and includes the following information: 1. common analysis of the context for humanitarian assistance 2. needs assessment 3. best, worst, and most likely scenarios 4. identification of roles and responsibilities (who does what and where) 5. clear statement of long-term objectives and goals 6. framework for monitoring strategy and revising as necessary a flash appeal is a special kind of ca, designed for structuring a coordinated humanitarian response for the first three to six months of an emergency. whenever a crisis or natural disaster occurs, the un hc may issue a flash appeal in consultation with all stakeholders involved in the humanitarian response (including the affected government). it is normally issued between the second and fourth weeks of the response and provides a concise overview of urgent lifesaving needs. it may also include early recovery projects if they can be implemented within the appeal's time frame. in 2013, as a part of the inter-agency standing committee (iasc) transformative agenda, the united nations changed the way that the cap was issued. the 2014 appeal, which addresses the 2013 emergencies, was the largest appeal to date, calling for $12.9 billion (more than $4.4 billion greater than the 2013 appeal) to support 52 million people in 17 countries. the increase was primarily due to a $6.5 billion request for the complex humanitarian emergency in syria, as well as another che in the central african republic and typhoon haiyan in the philippines. the changes begin with the document's name, which is now called the "overview of global humanitarian response" rather than the former "overview of consolidated appeals process." the overall goal of the change is to ensure that the cap process is needs-based and funds are adequately monitored. the change is explained in the appeals document as follows: "now, instead of one overweight cap document trying to present all elements of the program cycle, for 2014 the key elements appear in a series of documents produced in sequence: humanitarian needs overview; strategic response plan (comprising the country strategy plus cluster plans); and periodic monitoring bulletins reporting on basic delivery and outputs compared to targets. discussions are ongoing about the possible production of end-of-year reports on achievements versus objectives" (un 2014b). (see exhibit 10.9). since 1992, more than 330 consolidated and flash appeals have been launched, collectively raising more than $57 billion for ngos, the international organization for migration (iom), and un agencies. in addition to the un agencies discussed previously, which tend to be the primary agencies involved in all forms of disaster management, a handful of organizations provide more focused assistance as deemed necessary in most disasters that require international participation. as illustrated in figure 10 .7, which details un assistance to the various countries affected by the december 2004 asian tsunami and earthquake events, a different mix of un assistance is needed in each country, even within the same international disaster scenario. several of these organizations are detailed in the following list. • international labour organization (ilo). the ilo works with the affected population to address issues related to employment, including job creation, skills training, employment services, small business assistance, and other functions. (see exhibit 10.10.) • international organization for migration (iom) . the iom provides rapid humanitarian aid to displaced populations by supplying emergency shelter, transporting relief materials, and assisting in medical evacuations. the organization stabilizes populations through the provision of short-term community and microenterprise development programs. iom also actively supports governments in the reconstruction and rehabilitation of affected communities by being the lead service provider of : haiti cannot afford to become a forgotten crisis. important progress has been made in recent years, but the country is still one of the most exposed to risk from disaster and climate change. multiple disasters combined with high unemployment, increased inequality, and poor access to basic social services have prolonged the vulnerability of an estimated three million haitians to displacement, food insecurity, and fragile living conditions. haiti suffers the world's largest cholera epidemic, which has affected over 600,000 people and killed 8,000. although the humanitarian situation in south sudan has stabilized on several fronts, needs remain high-driven primarily by violence and displacement, persistent food insecurity, and chronic poverty. national capacity to deliver basic services is low, with aid agencies the main providers of health care, clean water, livelihoods support, and other services in many parts of the country. while needs are expected to remain high in 2014-2016, in some areas such as food insecurity, there are opportunities for innovative and more targeted approaches to break recurring cycles of hardship. the strategy for 2014-2016 has three objectives: responding to immediate needs, enhancing communities' resilience against shocks and stresses, and building national capacity to deliver basic services. alongside core programmes to save lives and ease suffering, partners are increasingly integrating actions to reduce the risk of natural disasters, strengthen and diversify livelihoods, and address the long-term needs of vulnerable groups, including refugees and children. the strategy also emphasizes the importance of delivering aid in partnership with line ministries and national ngos to ensure humanitarian relief has a long-term positive impact. the strategy spans three years, to better address deep-rooted challenges and measure the impact of relief actions. requirements: $1.1 billion funding received against requirements: 55% people in need: 4.4 million people to receive help: 3.1 million in yemen, more than half the population needs some form of humanitarian aid. the collapse of basic services in 2011-12, endemic food insecurity, destroyed or damaged livelihoods and under-development, along with displacement resulting from conflict, have combined to plunge the country into a humanitarian emergency which may persist into 2015. inflows of refugees and migrants from the horn of africa and returning yemeni migrants count among the vulnerable. ten and a half million people are food-insecure or severely food-insecure, and 1,080,000 children under five suffer from acute or severe malnutrition. about half the population has no access to adequate water sources or sanitation facilities, and a further 8.6 million have insufficient access to health services. an estimated 250,000 returnees need assistance to rebuild their lives, while 240,000 refugees, mostly from somalia, and tens of thousands of mainly ethiopian migrants are stranded in the country. it is expected that the number of returning yemeni migrants, estimated to be 360,000 people, will double in 2014. the weakness of rule-of-law institutions has been identified as a serious protection risk. according to the latest ilo estimates, 2.8 million out of the 5.6 million workers who have either temporarily or permanently lost their livelihoods were working in the service sector. over one third, or 1.8 million, were in agriculture and around 15 per cent in the industry sector. "service sector includes people working in shops, public markets, restaurants, vendors, tricycle and jeepney drivers, mechanics, clerks, teachers, . . . who, like farmers and fisherfolks, have seen their source of income wiped away," said ilo philippine office director lawrence jeff johnson. "at least 2.4 million affected workers were already in a vulnerable situation before the typhoon struck, often living at or near the poverty line, doing whatever work they could find to survive and provide for their families. these people have lost the little they had to begin with. they have no home, no income, no savings and no one to turn to for help," said director johnson. "as the reconstruction efforts gather pace, the number one priority is to ensure that these workers have access to decent jobs, which include at least minimum wage, social protection, and safe working conditions," johnson said. the department of labor and employment (dole) and the department of social welfare and development (dswd) are rolling out emergency employment programmes to respond to the enormous reconstruction and livelihoods needs. the ilo is working closely with them as well as with local governments, business' and workers' organizations, and international partners. "these programmes comply with philippine regulation and international labour standards, ensuring that people are not exploited while they help to rebuild their communities and local economies," johnson explains. workers under the emergency employment programmes receive the minimum wage prevailing in the area and are employed for a minimum of 15 days. they also have access to social protection benefits. "this is a very first step to jump start the economy and quickly put the affected communities back in the driver's seat in rebuilding their lives. ensuring minimum wage and social protection will help stimulate economic growth and speed the recovery process." johnson said. source: ilo, 2013. unaids works with victims to protect them from the kinds of violence and activity that spreads hiv. in 2001, the un general assembly held a special session on hiv/aids and declared that through unaids: [the un would] develop and begin to implement national strategies that incorporate hiv/aids awareness, prevention, care, and treatment elements into programs or actions that respond to emergency situations, recognizing that populations destabilized by armed conflict, humanitarian emergencies, and natural disasters, including refugees, internally displaced persons, and in particular, women and children, are at increased risk of exposure to hiv infection; and, where appropriate, factor hiv/ aids components into international assistance programs. (un 2005) • united nations population fund (unfpa). unfpa works to promote basic human rights throughout the world, and to increase the possibilities of women and young people to lead healthy and productive lives. their work focuses specifically on reproductive health and safe pregnancies and deliveries. during humanitarian crises, there is often a demand for reproductive health services even though distribution and health care systems have broken down. unfpa works closely with its humanitarian relief partners to support early and effective action to meet the reproductive health needs of refugees, idps, and others caught in crisis situations. supply shortages compound health risks in already dangerous situations and are a major obstacle to reproductive health in emergencies. existing supplies may fall far short of demand when large numbers of people move into a safer location. supplies, equipment, and medicine are organized and stored by unfpa for immediate distribution when an earthquake, flood, violent conflict, or other crisis arises. a rapid-response fund enables unfpa to mount a quick response to emergencies, especially in the initial stages. supplies are packaged in 12 different emergency reproductive health kits, including a "clean birthing kit." once an emergency situation stabilizes, the procurement of reproductive health materials becomes a regular part of a more comprehensive healthcare program. • united nations human settlement programme (un-habitat) . un-habitat is mandated by the un general assembly to "promote socially and environmentally sustainable towns and cities with the goal of providing adequate shelter for all" (un 2014). un-habitat is mandated through the habitat agenda (a global settlement plan adopted in june 1996 by the international community) to take the lead in mitigation, response, and post-disaster rehabilitation capabilities in human settlements. the habitat agenda clearly outlines the link between human settlement development and vulnerability to disasters. in addition, it emphasizes the need for coordination and close partnerships with national and local governments, as well as civil society. finally, the habitat agenda recognizes the strong impact disasters have on women, and affirms the need for women's active involvement in disaster management. these steering principles underpin all normative and operational activities of the un-habitat disaster management programme (dmp). dmp operates under the disaster, post-conflict and safety section (dpcss), urban development branch. it was created to marshal the resources of un-habitat and other international agencies to provide local government, civil society, and the private sector with practical strategies for mitigating and recovering from conflicts and natural disasters in the context of human settlements. specific areas of attention include: • protecting and rehabilitating housing, infrastructure, and public facilities • providing technical and policy support to humanitarian agencies before and after crisis in the context of human settlements • building partnerships and providing complementary expertise in resettlement of displaced persons and refugees • restoring local social structures through settlement development • rehabilitating local government structures and empowering civil society • land and settlements planning and management for disaster prevention un-habitat launched the city resilience profiling programme (crpp) to support local government efforts to build capacity to reduce disaster risk. through their guidance, governments are assisted in the development of comprehensive and integrated urban planning and implementation of a resilient management approach. the city resilience profile is a baseline assessment of a city-system's ability to withstand and recover from potential hazards. examples of cities that have participated in the program include balangoda, sri lanka; barcelona, spain; beirut, lebanon; dagupan, philippines; dar es salaam, tanzania; lokoja, nigeria; portmore, jamaica; talcahuano/concepcion, chile; tehran, iran; and wellington, new zealand. un-habitat plays an important role in disaster recovery, given the impact on housing so many disasters have. the organization has lead agency status within the united nations system for coordinating activities related to human settlement. it is mandated in this role through the habitat agenda. the organization's responsibilities in this regard are to support national governments, local authorities, and civil society in ensuring that risk is not retained in the reconstruction housing that follows the event. housing reconstruction often begins soon after the disaster has occurred, and un-habitat seeks to deploy quickly to ensure that resilient building practices are incorporated into the recovery planning process. • united nations environmental program (unep). unep is the un agency focused on the protection of the environment and wise use of natural spaces. unep has several divisions that address global emergency and disaster management needs. • unep's disasters and conflicts sub-program was created to assess and address the environmental impacts of disasters and conflicts, especially as they relate to human health, livelihoods, and security. since 1999, this program has responded to crises in more than 40 countries. their assistance is provided to other un agencies responding as well as directly to the host country government. the disasters and conflicts sub-program has four overarching objectives: • perform post-crisis environmental assessments; • support post-crisis environmental recovery; • foster environmental cooperation for peacebuilding; and • promote disaster risk reduction. as the focal point for environment within the un crisis response system, unep also works to integrate environmental considerations within humanitarian and peacekeeping operations. coordinated by unep's post-conflict and disaster management branch, the disasters and conflicts sub-program is delivered through several key actors and partners, including the joint unep/ocha environment unit, the environment and security (envsec) initiative, and the apell (awareness and preparedness from emergencies on a local level) programme. apell, which is based out of the unep industry and environment office in paris, supports disaster risk reduction and disaster preparedness. it seeks to minimize the occurrence and harmful effects of technological accidents and emergencies resulting from human activity or as the consequence of natural disasters, particularly in developing countries. understandably, unep plays a major role in climate change activities, including climate change adaptation. the organization supports developing countries in their efforts to identify and address risk specifically related to changing temperature and precipitation that are associated with global climate change patterns, including sea level rise. one of the primary functions of this office is to help governments to integrate climate change adaptation policy throughout all sectors of government, such that it becomes a major policy goal rather than a distinct, stove-piped component of government. finally, unep promotes sustainable land-use management and helps countries identify opportunities to reduce carbon emissions, which are often blamed for the bulk of climate variability. • united nations educational, scientific, and cultural organization (unesco). unesco's goal is to contribute to the peace and security of the world through education, science, and culture. unesco has been involved in disaster management for decades. this organization advocates for the need for a shift in emphasis from relief and emergency response to prevention and increased preparedness and education of potentially affected populations. it strongly supports the design and dissemination of mitigation measures, as well as public education and awareness. unesco works to increase the role of academic and research sectors in creating risk and vulnerability reduction measures, and supports existing and new institutions through financial and material support. unesco proclaims that their function regarding disaster management is: to promote a better understanding of the distribution in time and space of natural hazards and of their intensity, to set up reliable early warning systems, to devise rational land-use plans, to secure the adoption of suitable building design, to protect educational buildings and cultural monuments, to strengthen environmental protection for the prevention of natural disasters, to enhance preparedness and public awareness through education and training communication and information, to foster post-disaster investigation, recovery and rehabilitation, to promote studies on the social perception of risks. (unesco 2004) • in 2010, the un general assembly created un women, which merged four existing un organizations that focused exclusively on gender equality and women's issues. these included the united nations development fund for women (unifem), the international research and training institute for the advancement of women (instraw), the office of the special adviser on gender issues and advancement of women (osagi), and the division for the advancement of women (daw). un women works to ensure that the needs of women are considered in disaster planning and preparedness efforts, as well as in the aftermath of disasters and in the recovery from them, when women face extraordinary vulnerabilities. un women provides financial and technical assistance to innovative programs and strategies to foster women's empowerment and gender equality. (see exhibit 10.11.) • united nations institute for training and research (unitar). unitar was created to provide training and research within the un system with the goal of increasing the effectiveness of all un programs. in recent years, more of these efforts have focused on the four phases of disaster management, addressing many related topics such as climate change, hazardous materials and pollution, land use, and biodiversity. the global platform for disaster reduction was established in 2007 as a forum for information exchange. the platform meets every two years and allows participants to discuss innovations and developments in drr as well as to share existing knowledge and build partnerships among the various stakeholders. the goal in creating the program was to improve drr implementation by fostering better communication and coordination among stakeholders, to serve as a way for un members to voice their concerns and needs, and to share their best practices and lessons learned. the global platform replaces the former interagency task force for disaster reduction (iatf/ dr), which was led by the un under-secretary-general for humanitarian affairs and composed of representatives from 25 un agencies, international organizations, ngos, and other civil society for millions of people in rural viet nam, the impacts of climate change are mounting and sometimes deadly. as weather patterns change, many of viet nam's women in particular are paying a high price. "the weather becomes more extreme and erratic. storms, heavy rains, and floods destroy fields and houses, kill animals and people every year," said ranh nguyen, 35, a farmer and the head of the women's union group in an dung commune, in binh dinh province, central viet nam. there, ranh and her neighbours have joined the viet nam women's union and are working with un women to strengthen the role of women in disaster risk-reduction and disaster-reduction management. some 80 kilometers from the city of binh dinh, an dung commune is always at high risk of flooding, as it only has one road connecting it to other communes,and landslides often occur during the storm season. almost every year, the commune suffers at least one severe flood that damages crops and houses heavily. and women are often the most affected. however, things are starting to change. "thanks to good preparation and detailed mapping that we developed in the meetings before each storm, nobody in the village was killed or injured severely in the last year storm season. crops, fowl, and cattle were saved," explains ranh, now an official member of the committee for flood and storm control in her commune. prior to the project, there were few women on the committees for flood and storm control (cfsc) in the village. through the training of women in disaster management, as well as national lobbying-supported by un women, undp and other stakeholders-the contribution of women has been recognized. a government decree issued in september 2013 now provides an official space for the women's union in decision-making boards of the cfsc at all levels. "after being involved in the project, i am more aware of the situation of climate change and its impacts on us. last year, we participated in the training and exchanged experiences with other women. we prepared better for our families and our village before the storm came," ranh said. she said that she talked to the other members of the communal committee for flood and storm control. as a result, before the flooding began, they had plans ready to evacuate people living in lowland areas and near the river. "the mapping we did together in the training was really helpful. we discussed how to encourage people to harvest earlier, before the storm season started." in the end, she said, no lives were lost. last year, a four-year-old boy was saved from drowning because his mother performed cpr on him. she and another 120 women and girls learned this technique from the rescue and first aid training provided by the project. "i could not swim before and used to be frightened by the flooded river. but now i am no longer afraid of water thanks to the swimming classes. i will teach my children how to swim and tell other people to learn how to swim too," ranh said. this project continues to be implemented in four new provinces including thua thien hue, quang binh, ca mau and dong thap, all of which face a high risk of flooding. this project is financed through core funding to un women and from the government of luxemburg. stakeholders. the global platform is organized by the un office for disaster risk reduction (unisdr; see below). the global platform for disaster risk reduction is considered the most significant gathering of disaster risk reduction and disaster management stakeholders worldwide. every ten years, the world conference on disaster reduction is held. the first was held in 1995. the second world conference, held in 2005 in kobe, japan, led to the launching of the hyogo framework for action (hfa). the 2015 world conference is to be held in sendai, japan, which was significantly impacted by the great east japan earthquake and tsunami in 2011. the focus of the conference is on the follow-up to the hyogo framework for action, termed the post-2015 framework for disaster risk reduction in the lead-up to the conference. the united nations office for disaster risk reduction (unisdr) is the secretariat of the international strategy of disaster reduction and the global hub of the disaster risk reduction community, which includes national governments, ngos, intergovernmental organizations, financial institutions, technical bodies, and others. unisdr serves as the focal point for the implementation of the hyogo framework for action (hfa), the ten-year plan to address global disaster risk that commenced in 2005 and is set to expire in 2015. unisdr was created in 1999, at the end of the international decade for natural disaster reduction. the organization functions as a clearinghouse for disaster reduction information; campaigns to raise hazard awareness; and produces articles, journals, and other publications and promotional materials related to disaster reduction. unisdr maintains an organizational vision that is guided by the three strategic goals of the hfa for which it is tasked to oversee. these include: integrating disaster risk reduction into sustainable development policies and planning; 2. developing and strengthening institutions, mechanisms and capacities to build resilience to hazards; and 3. incorporating risk reduction approaches into emergency preparedness, response, and recovery programs. the organization describes the four key functions that guide its efforts as follows: • we coordinate international efforts in disaster risk reduction and guide, monitor as well as report regularly on progress of the implementation of the hyogo framework for action. we organize a biennial global platform on disaster risk reduction with leaders and decision makers to advance risk reduction policies and support the establishment of regional, national and thematic platforms. • we campaign and advocate to create global awareness of disaster risk reduction benefits and empower people to reduce their vulnerability to hazards. our current campaigns focus on safer schools and hospitals as well as resilient cities. • we encourage for greater investments in risk reduction actions to protect people's lives and assets including climate change adaptation, more education on drr, and increased participation of men and women in the decision making process. • we inform and connect people by providing practical services and tools such as the risk reduction website preventionweb, publications on good practices, country profiles and the global assessment report on disaster risk reduction, which is an authoritative analysis of global disaster risks and trends. (unisdr 2012) unisdr is led by the un special representative of the secretary-general for disaster risk reduction. margareta wahlstrom currently holds this post. the position was created in 2008 to lead and oversee all drr activities mandated by the un general assembly (ga), the economic and social council (ecosoc), and the hyogo framework for action (hfa), as well as policy directions by the secretary-general. other responsibilities include the ongoing and arduous process of facilitating the development of the post-2015 framework for drr that will follow the hfa, overseeing the management of the trust fund for the international strategy for disaster reduction, and carrying out highlevel advocacy and resource mobilization activities for risk reduction and implementation of the hfa. one of the most significant functions of unisdr is monitoring the progress achieved by nations and global regions per the hyogo framework for action. monitoring is an almost ongoing process, with reports on progress produced every two years (as well as interim reports on off years, in some instances). the hfa monitor is an online reporting system that nations and regional organizations use to assess their capabilities and progress according to the indicators outlined in the hfa. the hfa monitor template, found on the hfa monitor website, defines the areas of assessment. the result of this process is a national or regional hfa progress report. not all countries produce the reports, and for those that do, reports are not necessarily submitted for each reporting period. critics note that it is a self-reporting and ranking system, but in the absence of any other system on the scale of the hfa monitor, the information it provides is highly informative and very useful in estimating capacity. the information is also used to produce papers and reports on various thematic issues, such as gender in disaster management, integration of drr and climate change adaptation, early warning, and others. the world bank and unisdr work closely together on a number of key disaster risk reduction issues, notably those related to development and disaster reconstruction, through a unisdr/world bank global facility for disaster reduction and recovery (wb/gfdrr) partnership. other similar drr-and disaster risk management-focused partnerships have been formed with various regional international organizations, including the association of southeast asian nations (asean), organization of the islamic conference (oic), pan american health organization (paho), applied geoscience and technology division of the secretariat of the pacific community (sopac), economic community of west african states (ecowas), and african union (au). unisdr is headquartered in geneva and has representation at the un headquarters in new york city. the organization also has regional offices in africa (nairobi), the americas (panama and brazil), asia/pacific (bangkok, japan, and korea), the pacific (sub-regional office in suva), the arab states (cairo), europe (brussels and bonn), and central asia (sub-regional office in almaty). (see figure 10 .8.) unisdr also works with and advises a number of key thematic platforms on disaster risk reduction issues, including: response (un-spider) the un is the only global international organization of its kind. it is not, however, the only governing organization made up of several national governments. many of the world's regions have pooled their collective resources and services to create large, influential organizations. like the un, these organizations address issues of regional and global importance, many of which focus on or peripherally address disaster management. in times of disaster, both within and outside of their regions of concern, they bring much of the same financial, technical, and equipment resources discussed throughout this book. this section identifies and briefly describes the largest of these organizations. the north atlantic treaty organization (nato) is an alliance of 28 countries from north america and europe formed by a treaty signed on april 4, 1949. its fundamental goal is safeguarding its members' freedom and security using political and military means. over the years, nato has taken on an increasing role in international disaster management and peacekeeping missions. nato maintains a military force made up of member countries' troops. although they work in concert, troops always remain under the control of their home nation's government. nato has helped to end violent conflicts in bosnia, kosovo, and the former yugoslav republic of macedonia. nato's disaster and crisis management activities, which extend beyond its typical military operations, are geared toward protecting populations. as part of the worldwide civil protection drive described in chapter 8, nato began developing measures to protect member nation citizens from nuclear attack as early as the 1950s. as elsewhere, nato member countries soon realized that these capabilities could be used effectively during disasters induced by floods, earthquakes, and technological incidents and during humanitarian disasters. nato's first involvement in disaster operations came in 1953, following devastating floods in northern europe. in 1958, it established detailed procedures for the coordination of assistance between nato member countries in case of disasters. these procedures remained in place and provided the basis for nato's civil emergency planning in subsequent years. in 1998, nato established the euro-atlantic disaster response coordination center to coordinate aid provided by member and partner countries to a disaster-stricken area in a member or partner country. it also established a euro-atlantic disaster response unit, which is a non-standing, multinational mix of national civil and military elements volunteered by member or partner countries for deployment to disaster areas. civil emergency planning has become a key facet of nato involvement in crisis management. in recent years, nato has assisted flood-devastated albania, czech republic, hungary, romania, and ukraine, supported the unhcr in kosovo, sent aid to earthquake-stricken turkey, helped to fight fires in the former yugoslav republic of macedonia and in portugal, supported flood response in pakistan, and supported ukraine and moldova after extreme weather conditions destroyed power transmission capabilities. nato has taken an active role in the response to the 2005 south asia earthquake, as described in exhibit 10.12. nato also regularly conducts civil emergency planning exercises. the european union (eu) originated in may of 1950, when six european countries (belgium, germany, france, italy, luxembourg, and the netherlands) joined together to address common issues related to the coal and steel industries. since that time, the scope of their work has expanded significantly, as has their membership. the eu is now a major regional international organization representing 28 member states and is in the process of admitting several other eastern and southern european countries in a push toward greater inclusion. the eu considers itself a "family of european countries, committed to working together for peace and prosperity" (bbc 2014). like the un, it is not a government, nor does it have any authority over its members; it is an organization established for increased regional cooperation. regional international organizations the devastating october 2005 earthquake in pakistan is estimated to have killed 80,000 people and left up to three million without food or shelter just before the onset of the harsh himalayan winter. on october 11, 2005, in response to a request from pakistan, nato launched an operation to assist in the urgent relief effort. nato airlifted supplies donated by nato member and partner countries as well as the unhcr via two air bridges from germany and turkey; 168 flights delivered almost 3,500 tons of relief supplies. the supplies provided included thousands of tents, stoves, and blankets necessary to protect the survivors from the cold. in addition, nato deployed engineers and medical units from the nato response force to assist in the relief effort. the first teams arrived on october 29, 2005. in just three months of operations, nato achieved the following: • nato's air bridges flew almost 3500 tons of aid to pakistan with 168 flights. these flights carried in nearly 18,000 tents, 505,000 blankets, nearly 17,000 stoves/heaters, more than 31,500 mattresses, 49,800 sleeping bags, tons of medical supplies, and more. • nato's field hospital treated approximately 4,890 patients and conducted 160 major surgeries. mobile medical units treated approximately 3,424 patients in the remote mountain villages; they also contributed significantly to the who immunization program that has helped to prevent the outbreak of disease. • in the cities of arja and bagh, nato engineers repaired nearly 60 kilometers of roads and removed over 41,500 cubic meters of debris, enabling the flow of aid, commerce, and humanitarian assistance to the inhabitants of the valley. nine school and health structures were completed and 13 tent schools erected. the engineers distributed 267 cubic meters of drinking water and upgraded a permanent spring water distribution and storage system to serve up to 8,400 persons per day. • nato engineers also supported the pakistani army in operation winter race, by constructing 110 multipurpose shelters for the population living in the mountains. • nato helicopters transported more than 1,750 tons of relief goods to remote mountain villages and evacuated over 7,650 disaster victims. • nato set up an aviation fuel farm in abbottabad, which carried out some 1,000 refueling missions for civilian and military helicopters. during the mission some 1,000 engineers and supporting staff, as well as 200 medical personnel, worked in pakistan. nato was part of a very large effort aimed at providing disaster relief in pakistan. the pakistani army provided the bulk of the response, with the support of nato, the un, and other international organizations and several individual countries. on october 10, nato received from pakistan a request for assistance in dealing with the aftermath of the 8 october earthquake. the next day, the north atlantic council approved a major air operation to bring supplies from nato and partner countries to pakistan. the airlift began on 13 october and the first tons of supplies arrived in pakistan on 14 october. on 19 october, nato opened a second air bridge from incirlik, turkey, to deliver large quantities of tents, blankets, and stoves donated by the unhcr. on 21 october, in response to a further request from pakistan, nato agreed to deploy engineers and medical personnel from the nato response force to pakistan to further assist in the relief effort. a nato headquarters was deployed to pakistan on 24 october to liaise with pakistani authorities and pave the way for the incoming troops. the first troops, the advance elements of the medical team, began arriving on 29 october, and immediately began treating hundreds of people a day. engineering teams followed and began working in the area around bagh in support of pakistani efforts to repair roads and build shelters and medical facilities. nato engineers also supported the pakistani army in operation winter race, by constructing multipurpose shelters for the population living in the mountains. on 9 november, nato opened a sophisticated 60-bed field hospital, which provided a wide range of care including complex surgical procedures. on the same day, heavy-lift transport helicopters assigned to nato for the operation began flying and delivering supplies to remote mountain villages and evacuating victims. nato also set up an aviation fuel farm in abbottabad, which carried out refueling for civilian and military helicopters, which were essential to the relief effort. on 27 october, additional foreign secretary of pakistan tariq osman hyder addressed a meeting of the euro-atlantic partnership council at nato headquarters in brussels, asking for further assistance. he said that nato could provide continued airlift, funds, logistic and airspace management, mobile fuel tanks, spare parts for helicopters and tactical aircraft, command and control, and winterized tents and sleeping bags. that same day, nato's euro-atlantic disaster response coordination center (eadrcc) received an urgent request from the unhcr for the transport of additional shelter and relief items stored in turkey to pakistan before the winter sets in. nato's relief mission came to an end, on schedule, on 1 february 2006. nato's short-term relief mission was based on the following five elements: 1. coordination of donations from nato and partner countries through the eadrcc in brussels; 2. the air bridge from turkey and germany for the transport of relief goods to pakistan; 3. five helicopters operating in the earthquake-affected area for the transport of supplies to remote mountain villages and evacuation of victims; 4. medical support with a field hospital and mobile medical teams in the area of bagh; 5. engineer support operating in the area around bagh in support of pakistani efforts for the repair of roads and building of shelters, schools, and medical facilities. humanitarian assistance has been a part of the eu mission since 1992, and since that time the organization's work in that area has grown such that today it is the world's most significant humanitarian aid donor. taken together, its members represent a sizeable piece of the global economy, thus enabling them the ability to provide more than 50 percent of all humanitarian aid worldwide. the eu has also structured itself to be an active stakeholder in international disaster management. their work in this regard is not limited to europe and in fact has a global presence. since taking on disaster management responsibilities, the eu has responded through one or more of its various departments to disasters in more than 140 countries. in 2010, the eu restructured its global hazard risk and disaster management capacities. these changes resulted in the merging of two former divisions: one that handled humanitarian assistance and another that centered on civil protection. together these units formed the combined directorate general for humanitarian aid and civil protection (echo). the acronym is a carryover from a former component of the eu's response mechanism called the european community humanitarian office. the move effectively integrated these two functions, which, over time, saw duplicative missions. exhibit 10.13 is drawn from an eu factsheet describing how the eu responded to typhoon haiyan in the philippines in 2013 using this combined function. through its humanitarian aid and civil protection department (echo), the european commission made available us$40.6 million to help the survivors of the typhoon with food assistance, shelter, water and sanitation, health and nutrition, short-term livelihood support, reconstruction of schools, emergency logistics, and coordination of relief efforts. within hours after the disaster struck, the european commission's experts had been deployed to identify priority needs. the commission implemented its assistance primarily through the following partner organizations: assistance supported by echo reached approximately 1.2 victims in the areas affected by the typhoon. the eu civil protection mechanism was activated to ensure coordination of european relief efforts. participating member states supplied personnel and material to support the operation. the eu civil protection mechanism, coordinated by the commission's emergency response and coordination centre (ercc), also supported the transport of civil protection assets to the region with around us$4.9 million. in addition to humanitarian funds, the european commission has released $13.5 million from the eu's development funds to help rebuild people's lives by assisting in recovery and rehabilitation. examples of eu-funded humanitarian projects are described in the following section. • to address food insecurity among the affected population who had little to eat and little to no access to markets, the eu funded the efforts of the world food programme (wfp). wfp provided general distribution of food, including highenergy biscuits during the emergency phase, and then provided supplementary feeding for children and pregnant and lactating women. "food-for-work" and "cash-for-work" initiatives were established. • the eu provided funds to the international committee of the red cross (icrc) and national red cross societies to provide thousands of families with shelter repair kits and to support the livelihoods recovery and wash clusters. the national red cross societies projects supported the delivery of non-food items, including blankets and water storage containers. many families were provided with unconditional cash grants, and communities were given assistance in improving sanitation facilities, restoring primary healthcare services (including medicines), disease prevention, and hygiene awareness. • the eu supported a consortium that includes plan international and oxfam. funding helped to provide relief for the most significantly affected households by enabling livelihoods recovery, distribution of cash-for-work vouchers, and rehabilitation of public service infrastructure, including child-friendly spaces, classrooms, day care centers, and health stations. • to help the approximately 4 million people left homeless by the typhoon, the eu funded the international organization for migration (iom) efforts to improve the well-being and living conditions of those who were displaced, who have returned, or who are planning to go back to their places of origin. special attention was given to persons with disabilities and other special needs. the project provided shelter repair kits to the affected populations and ensured quality management of displacement sites and timely information on communities' return and relocation processes. finally, vulnerable groups targeted by the initiative received health services, psychosocial support, and non-food items such as blankets. based on: ec, 2014. echo enables the eu to respond to most major crises regardless of where they are in the world. at the time of this publication, the eu was involved in the response to ches in syria, south sudan, and the central african republic and was working in several other countries that were no longer entrenched in conflict but nonetheless faced humanitarian needs (e.g., côte d'ivoire). in recent years, the eu annual budget allocation for humanitarian operations has remained at around us$1.35 billion, or about us$3 per person from the combined population of the eu member countries. through this funding, the organization has reached on average about 120 million people each year. echo maintains a staff of more than 300 at its brussels headquarters and more than 400 dispersed throughout 44 field offices in 38 countries worldwide. when a disaster strikes, and presumably upon request, echo staff deploy in order to conduct a needs assessment. if it is determined that assistance is warranted, staff will remain and monitor the situation as it progresses and oversee the implementation of the humanitarian aid projects that echo supports. echo has established relationships with more than 200 other disaster management stakeholders, including 14 un agencies and 194 ngos. echo humanitarian assistance can come in several forms, including food aid; clothing; healthcare supplies; and materials for shelter, water, and sanitation. echo also supports relief work, such as infrastructure repair, removal of mines, psychological support, and education, among many others. echo has a special program, called the "forgotten crisis assessment," that focuses on less salient events. through this program, echo tries to raise the profile of serious incidents it finds are receiving too little attention among the humanitarian community, for the purpose of increasing the funds available to impacted victims. in 2011, echo distributed humanitarian aid worth us$1.48 billion (which amounts to less than 1 percent of the eu budget, yet is, in gross terms, a significant amount in total funding when compared to most other donors). this funding assisted 117 million people in more than 90 countries outside the european union. echo also oversees the eu civil protection mechanism, which comprised 32 states (28 eu member states, plus former yugoslav republic of macedonia, iceland, liechtenstein, and norway). this mechanism enables these nations to coordinate and cooperate in the event of a disaster in one or more eu countries or elsewhere in the world. civil protection agencies from member countries provide inkind assistance, equipment, and teams, or experts that perform damage and needs assessments. echo civil protection relies on the resources of member governments and, if assistance is required in non-eu countries, it typically works in parallel with the humanitarian aid component of echo. for european countries, the coordination and cooperation provided under echo is, in essence, a highly formalized mutual assistance compact that increases the capacity of all nations involved. nations pool their resources and maximize their collective efforts. the key instrument for european civil protection is the civil protection mechanism (cpm), which was established in 2001. the operational heart of cpm is the european commission's monitoring and information centre (mic), which will soon become the european emergency response centre (erc). any country inside or outside eu affected by a disaster and overwhelmed by its magnitude can make an appeal for assistance through the mic/erc. to provide formalized mitigation and preparedness assistance, echo launched its disaster preparedness program, disaster preparedness echo (dipecho), in 1996. dipecho attempts to reduce population vulnerability in disaster-prone regions. between 1996 and 2011, dipecho provided more than $255 million for hundreds of projects worldwide. dipecho-funded projects are implemented by aid agencies working in the region of concern, and support training, capacity building, awareness raising, and early warning projects, as well the organization of relief services. echo disaster preparedness efforts, however, extend beyond dipecho. many of echo's major humanitarian financing decisions, for example, include disaster preparedness or prevention as an objective. even post-disaster emergency responses can seek to reduce future risk. examples of echo risk-reduction activities include livestock shelters built after extreme cold snaps to protect against further herd depletion (peru), training and equipping of community-based fire brigades in forest fire risk zones (indonesia), cholera preparedness and health information (malawi), and antirust measures to prevent water pollution and protect pipes from the effects of volcanic ash (ecuador). the organization of american states (oas) was established in 1948 by 21 nations located in north, central, and south america and the caribbean that wished to strengthen cooperation and advance their common interests in the western hemisphere. through the oas charter these nations committed to a set of common goals. respect for each other's sovereignty has always played a central role in oas affairs. today, all 35 independent nations in the region have ratified the oas charter and serve as members of the organization (though the cuban government was excluded from participation in oas from 1962 to 2009, and has yet to rejoin since the lifting of its ban). the oas is heavily involved in disaster risk reduction and preparedness efforts in the region. the vast majority of such projects are facilitated by the oas office for sustainable development and environment (osde), which supports activities in both individual countries and those that involve multiple countries. the more prominent of these activities focus on the following goals: • supporting the management of trans-boundary water resources • improving information for decision making in biological diversity • establishing land-tenure reform and property rights • supporting the exchange of best practices and technical information in environmental law and enforcement, renewable energy, water management, and biodiversity • improving management systems to reduce the impacts of natural disasters • understanding climate-related vulnerabilities affecting small island states the following is a list of projects that illustrates the range of disaster risk reduction and preparedness activities carried out by oas: mitigation capacity building program. the three-year program assisted countries in the caribbean region to develop comprehensive, national hazard vulnerability reduction policies and associated implementation programs, and develop and implement safer-building training and certificate programs. improvement program with assistance from oas to offer hurricane-resistant home improvement options to low-income families. this program trains local builders in safer construction, offers small loans to families wishing to upgrade their homes, and provides the services of a trained building inspector who approves materials to be purchased and checks minimum standards. in addition to the osde, oas supports disaster risk reduction through its inter-american committee for natural disaster reduction (iacndr). iacndr is the organization's main forum for integrating disaster risk reduction into sustainable development practices. the oas general assembly established the iacndr to strengthen its role in natural disaster reduction and emergency preparedness. the southern african development community (sadc) began in 1980, when a loose alliance of nine southern african states formed (then known as the southern african development coordination conference, or sadcc). the organization's aim was to coordinate development projects to decrease economic dependence on south africa. in 1992, it shifted from a "coordination conference" to a development community known as the sadc. sadc member states are angola, botswana, the democratic republic of congo, lesotho, madagascar, malawi, mauritius, mozambique, namibia, seychelles, south africa, swaziland, united republic of tanzania, zambia, and zimbabwe. sadc's primary mission is to help define regional priorities, facilitate integration, assist in mobilizing resources, and maximize regional development. it approaches problems and national priorities through regional cooperation and action. several sadc programs address the region's safety and security, primarily through risk-reduction mechanisms that include disaster preparedness and mitigation. the following are some examples of sadc disaster-related programs: • food, agriculture, and natural resources directorate • regional early warning unit • regional remote sensing unit the coordination center for natural disaster prevention in central america (cepredenac) was established in 1988 as a coordination center to strengthen the central american region's ability to reduce their population's vulnerability to natural disasters. in may 1995, cepredenac became an official organization to foster regional cooperation among the governments of costa rica, el salvador, guatemala, honduras, nicaragua, and panama. the organization's headquarters are in guatemala city, guatemala. since its founding, the organization has been instrumental in securing region-wide commitment to disaster risk reduction through the passing of several resolutions and the creation of several plans and strategies signed by participating countries. the organization's agenda parallels and coordinates with other specialized regional entities in areas including hydrological resources, agriculture, nutrition, and food security. the cepredenac regional disaster reduction plan (prrd) was created to foster disaster reduction as an integral part of the sustainability of central american societies. its strategic objectives are: • promoting the incorporation of disaster risk reduction in legislation, policies • enhancing and developing greater resilience of the population to disaster risk • promoting the incorporation of disaster risk analysis in the design and implementation of prevention, mitigation, response, recovery, and reconstruction in the countries of the region a participating state may request disaster response assistance once its capabilities have been overwhelmed. cdema solicits and coordinates the assistance offered by other governments, organizations, and individuals, both within and outside the region. this is cdema's primary function. other functions include: • securing, collating, and channeling disaster information to interested governmental organizations and ngos as needed • mitigating disaster consequences affecting participating states • establishing and maintaining sustainable disaster response capabilities among participating states • mobilizing and coordinating disaster relief from governmental organizations and ngos for affected participating states the 16 cdema participating states are structured into four subregions, each of which is headed by an operation unit known as a sub-regional focal point. the functions of each focal point relevant to the recovery effort are to: • acquire and maintain comprehensive emergency management capacity information • test and maintain communications with the coordinating unit and with national disaster management agencies • ensure subregion continuity of operations membership in cdema requires the participating state to establish or maintain a national disaster organization (ndo) or a national relief organization capable of responding swiftly, effectively, and in a coordinated manner to disasters in participating states (typically the government body tasked with domestic emergency management). ndos are headed by the national disaster coordinator (ndc), who is a government official responsible for the day-to-day management of the organization; ndos are the national focal points for cdera's activities in the participating state. the participating states are, in addition, required to: • establish planning groups and define national policies and priorities to address disasters • provide national relief organizations with adequate support, including named emergency coordinators, liaison officers with key ministries, emergency services, utilities, etc. • define the disaster role and functions of government agencies • establish and equip a suitable emergency operations center (eoc) • develop and maintain an appropriate emergency telecommunications system • perform disaster operations planning and associated drills and exercises • review and rationalize disaster-related statutory authorities • develop an emergency shelter policy program involving local participation • develop and implement a comprehensive disaster public awareness program • develop and implement appropriate training programs for disaster management staff in 1989, twenty-four countries in eastern and southern africa established a drought monitoring centre, with its headquarters in nairobi (the dmcn) and a sub-center in harare (dmch), in response to a series of devastating weather-related disasters. in october 2003, the heads of state and governments of the intergovernmental authority on development (igad) held their 10th summit in kampala, uganda, where dmcn was adopted as a specialized igad institution. the name of the institution was changed to igad climate prediction and applications centre (icpac) in order to better reflect its expanded mandates, mission, and objectives within the igad system. a protocol was signed in april 2007, integrating the institution fully into igad. icpac is responsible for seven member countries (djibouti, eritrea, ethiopia, kenya, somalia, sudan, and uganda) and three other countries (burundi, rwanda, and tanzania). the centre's vision is "to become a viable regional centre of excellence in climate prediction and applications for climate risk management, environmental management, and sustainable development," while its mission is "provision of timely climate early warning information and support specific sector applications to enable the region to cope with various risks associated with extreme climate variability and change for poverty alleviation, environment management and sustainable development of the member countries" the objectives of the centre are: 1. to provide timely climate early warning information and support specific sector applications for the mitigation of the impacts of climate variability and change for poverty alleviation, management of environment, and sustainable development; 2. to improve the technical capacity of producers and users of climatic information, in order to enhance the use of climate monitoring and forecasting products in climate risk management and environment management; 3. to develop an improved, proactive, timely, broad-based system of information/product dissemination and feedback, at both sub-regional and national scales through national partners; 4. to expand climate knowledge base and applications within the sub-region in order to facilitate informed decision making on climate risk related issues; and 5. to maintain quality controlled databases and information systems required for risk/vulnerability assessment, mapping and general support to the national/ regional climate risk reduction strategies. (icpac n.d.) the centre has several functions relative to these objectives, which are: • acquisition of climate and remotely sensed data; • develop and archive national and regional climate databanks including calibration of remote sensing records; • process data and develop basic climatological statistics required for baseline risk scenarios and other applications; • monitor, predict, and provide early warning information of the space-time evolutions of weather and climate extremes over the sub-region; • hazards and climate risk mapping of the extreme climate events thresholds; • networking with wmo, the national meteorological and hydrological institutions as well as regional and international centers for data and information exchange; • capacity building in the generation and applications of climate information and products; • applications of climate tools for specific climate sensitive sector risk reduction, environment management , and sustainable development, including integration of indigenous knowledge; • monitor, assess, detect and attribute climate change and associated impacts, vulnerability, adaptation and mitigation options; • develop relevant tools required to address the regional climate challenges through research and applications in all climate sensitive socio-economic sectors including addressing linkages with other natural and man-made disasters; and • networking and exchange of information regarding disasters in the sub-region. (icpac n.d.) the centre offers a number of informational products, including periodic climate and weather bulletins, updates on climate and el niño, and annual climate summaries. to date, the centre has been instrumental in increasing drr in the sub-region through the provision of capacity enhancement, informational products, networking assistance, and more. the league of arab states (las) is a regional igo based in cairo, egypt and encompassing north africa and southwest asia. las was formed in 1945 following the adoption of the alexandria protocol, with a stated goal to "draw closer the relations between member states and co-ordinate collaboration between them, to safeguard their independence and sovereignty, and to consider in a general way the affairs and interests of the arab countries." member states include algeria, bahrain, comoros, djibouti, egypt, iraq, jordan, kuwait, lebanon, libya, mauritania, morocco, oman, state of palestine, qatar, saudi arabia, somalia, sudan, syria, tunisia, united arab emirates, and yemen. in response, and as a follow-up to the first arab summit on socio-economic development, the council of arab ministers responsible for the environment adopted specific actions relating to disaster risk reduction through a decision in may of 2009 to develop an arab strategy for disaster risk reduction. this strategy, entitled the arab strategy for disaster risk reduction 2020, adopted in december of 2010, has a two-fold purpose: 1. to outline a vision, strategic priorities, and core areas of implementation for disaster risk reduction in the arab region, and 2. to enhance institutional and coordination mechanisms and monitoring arrangements to support the implementation of the strategy at the regional, national, and local level through preparation of a programme of action. the arab strategy for disaster risk reduction is designed to complement existing and ongoing efforts in disaster risk reduction by national institutions and regional technical organizations in the las region. implementing partners of the strategy are to focus on multi-sectorial approaches with the purpose of reducing emerging risks across the arab region by 2020, in line with the global priorities outlined by the hyogo framework for action (hfa) and the millennium development goals. the five priorities of the las strategy directly mirror those of the hfa, including the desire to increase nations' capacity to incorporate drr into disaster recovery. specific commitments detailed under these priorities, which pertain to recovery planning actions in the region, include: • ensuring that disaster risk reduction measures are integrated into post-disaster recovery and rehabilitation processes • establishing disaster preparedness plans, contingency plans, and recovery and reconstruction plans at all administrative levels with the participation of women, the aged, children, idps, and people with special needs • ensuring that national/ local financial reserves and contingency mechanisms are in place and well understood by all stakeholders to ensure effective response and recovery when required • addressing national trans-boundary cooperation on disaster response, preparedness and recovery among arab states in the arab region, funding remains the main challenge faced by national and local authorities, civil society organizations, and humanitarian workers implementing disaster risk reduction measures targeting communities at risk. las encourages its members to dedicate at least 1 percent of national development funding and development assistance toward disaster risk reduction measures. specifically, it was recommended that member states assess the possibility of utilizing existing regional funds and mechanisms (including, among other mechanisms, socio-economic development funds and national disaster relief and response budgets) by allocating a dedicated budget for disaster risk reduction and recovery activities at the subregional, national, or local level. the las regional centre for disaster risk reduction (rcdrr) was established in 2009 by a partnership between the kingdom of saudi arabia, the united nations international strategy for disaster reduction (unisdr), and the arab academy for science, technology and maritime transport (aas-tmt), as an intergovernmental organization of the league of arab states targeting the achievement of sustainable development in the arab region. the centre seeks to address risk through knowledge, research, and training of scientific and technical cadres in various disciplines on drr. the main objectives of rcdrr, as per the 2009 rcdrr statutes, are: • integration of drr into regional and national sustainable development policies, strategies, and plans • enhancing regional and national capacities in the field of drr research, education, and training • contributing to the development and harmonization of regional drr methodologies and tools, including database and guidelines • promoting partnership building with a multi-stakeholder approach to accelerate the implementation of the hyogo framework of action the south asian association of regional cooperation (saarc) was officially established in 1985. the objectives of the organization are to: • promote the welfare of the people of south asia and to improve their quality of life • accelerate economic growth, social progress, and cultural development in the region and to provide all individuals the opportunity to live in dignity and to realize their full potential • promote and strengthen selective self-reliance among the countries of south asia • contribute to mutual trust, understanding, and appreciation of one another's problems • promote active collaboration and mutual assistance in the economic, social, cultural, technical, and scientific fields • strengthen cooperation with other developing countries • strengthen cooperation among themselves in international forums on matters of common interest • cooperate with international and regional organizations with similar aims and purposes. the saarc member countries include afghanistan, bangladesh, bhutan, india, maldives, nepal, pakistan, and sri lanka. after • establish and strengthen the regional disaster management system to reduce risks and to improve response and recovery management at all levels • identify and elaborate country and regional priorities for action • share best practices and lessons learnt from disaster risk reduction efforts at national levels • establish a regional system to develop and implement regional programs and projects for early warning • establish a regional system of exchanging information on prevention, preparedness, and management of natural disasters • create a regional response mechanism dedicated to disaster preparedness, emergency relief, and rehabilitation to ensure immediate response • create a regional mechanism to facilitate monitoring and evaluation of achievements toward goals and strategies. the saarc disaster management centre (sdmc) was established in october of 2006 at the facilities of the national institute of disaster management in new delhi to serve as a center of excellence for knowledge, research, and capacity building in disaster management. the centre has the mandate to serve the saarc member countries by providing policy advice and facilitating capacity building services, including strategic learning, research, training, system development, and exchange of information for effective disaster risk reduction and management in south asia. sdmc conducts studies and research, organizes workshops and training programs, publishes its reports and documents, and provides various policy advisory services to the member countries. the secretariat of the pacific community (spc) was founded in australia in 1947 under the canberra agreement to restore order in the region following world war ii. in 1972, the spc applied geoscience and technology division (sopac) was created as a undp regional project, and in 1990 it became an independent igo. in 2011, sopac became a new division under spc, dedicated to promoting sustainable development in its member countries, and its work is carried out through its secretariat based in suva, fiji. sopac members include australia, cook islands, fiji islands, guam, federated states of micronesia, kiribati, marshall islands, new zealand, papua new guinea, samoa, solomon islands, tonga, tuvalu and vanuatu, niue, nauru, and palau. associate members (local administrations of nonself-governing territories) include american samoa, french polynesia, new caledonia, and tokelau. the purpose of sopac is to ensure the earth sciences (inclusive of geology, geophysics, oceanography, and hydrology) are utilized fully in the fulfillment of the spc mission. to fulfill this purpose, the division has three technical work programs: • ocean and islands • water and sanitation • disaster reduction these three programs share common technical support services: the sopac disaster reduction programme (drp) provides technical and policy advice and support to strengthen disaster risk management practices in pacific island countries and territories. the program carries out this responsibility in coordination and collaboration with other technical program areas within sopac and also with a range of regional and international development partners and donors. the overarching policy guidance for drp is the hfa-linked pacific disaster risk reduction and disaster management framework for action 2005-2015 (pacific drr and dm framework for action), which supports and advocates for the building of safer and more resilient communities. the other significant regional policy instruments that help to guide the efforts of the drp are the pacific plan and the pacific islands framework for action on climate change 2006-2015. the sopac disaster risk management policy and planning team (ppt) is responsible for the drm mainstreaming initiative, which sopac spearheads on behalf of the pacific disaster risk management partnership network. in fulfilling this responsibility, the ppt provides the following services to pacific island countries and territories (picts): • leads and coordinates high level advocacy at cabinet/political level to garner support for drm mainstreaming in national, sectorial, local, and community planning and budgetary processes • leads and coordinates the development and implementation of drm national action plans with the support of other members of the pacific drm partnership network • supports the integration of drm and climate change adaptation initiatives at the national level within picts • analyzes budgeted drm investment in annual appropriations of picts • analyzes the economic impact of disaster events • analyzes the cost-benefit of drm measures a major focus of the ppt is to build member country resilience by facilitating the creation of disaster risk management national action plans (naps). the partnership network continued to provide strong support in terms of the realization of drm initiatives linked to nap exercises and also for other risk reduction and disaster management-related activities. in the past several years, this support has shifted to development of joint national action plans (jnaps) that integrate policy on disaster risk reduction and climate change adaptation. several of the countries in the region have established jnaps at the national level. the region is also moving toward a regional-level integrated joint strategy for disaster risk reduction and climate change. at present, regional-level disaster risk reduction and climate change adaptation policies remain separate. sopac led the development of the pacific disaster risk reduction and disaster management framework for action (rfa), signed in 2005, and the secretariat of the pacific community environmental programme (sprep) led the development of the pacific islands framework for action on climate change (pifacc), also signed in 2005. however, these organizations initiated an effort in 2011 to establish a more integrated solution to coincide with the year 2015 expiration of both frameworks. an ongoing process named "the roadmap" is marked by wide stakeholder involvement via a steering committee and broad technical support provided by a technical working group (which includes spc/sopac, sprep, and unisdr). the roadmap process has to date resulted in a draft-integrated strategy entitled the strategy for disaster and climate resilient development in the pacific (srdp). the draft strategy is designed to promote action that is harmonized with existing member state institutional arrangements for climate change adaptation and disaster risk reduction "[to] ensure that efforts are nested within the context of countries' national development strategies and reflected in their budgets, encourage the participation of multiple stakeholder groups, strengthen countries' capacities for risk governance and support the development of well-coordinated innovative funding mechanisms" (spc 2013). drp supports the strengthening of disaster management governance, which has included the development of institutional, policy, and decision-making processes such as disaster management legislative and planning frameworks, and national focal points (ndmos) and guidelines or models of good practice for national application. the emergency management preparedness, response, and coordination capabilities within countries will be critically assessed to determine the level of resources and capacity that is available to protect vulnerable communities. a priority will be to ensure that effective emergency response, communication, and coordination processes are established, and that existing resources are utilized in the most effective way. the drp disaster management team provides the following services to picts: • technical advice and support to review and update national drm governance arrangements and legislation, operational plans and procedures • support for the design and conduct of operational and table-top exercises to test emergency response plans and procedures • support for the conduct of disaster risk management training in collaboration with the pacific drm program of the asia foundation/office of us foreign disaster assistance • design and development of professional training courses in collaboration with taf/ofda and the fiji national university in 2006, sopac established the pacific disaster risk management partnership network to provide a collaborative and cooperative mechanism to support disaster risk management capacity building in the region and help pacific island countries and territories adapt and implement the pacific drr and dm framework for action. the partnership is an "open-ended, voluntary" membership of international, regional, and national government and non-government organizations, with comparative advantages and interests in supporting pacific countries toward mainstreaming drm through addressing their disaster risk reduction and disaster management priorities. the members of the partnership network agree that: • disaster risk reduction and disaster management are sustainable development issues within the broader context of economic growth and good governance; • national governments have a critical role in developing disaster risk reduction and disaster management national programs and plans that reflect the needs of all stakeholders in a whole-ofcountry approach; • a regional effort must be responsive to and support and complement national programs and plans to strengthen resilience to disasters; • as regional partners, we commit to coordinating our activities and to work cooperatively and collaboratively under the guidance of the pacific plan and regional framework for action 2005-2015; and • we can build safer and more resilient nations and communities to disasters if we work in unison and accept this disaster risk management charter as a basis for future action. international financial institutions (ifis) provide loans for development and financial cooperation throughout the world. they exist to ensure financial and market stability and to increase political balance. these institutions are made up of member states arranged on a global or regional basis that work together to provide financial services to national governments through direct loans or projects. in a disaster's aftermath, nations with low capital reserves often request increased or additional emergency loans to fund the expensive task of reconstruction and rehabilitation. without ifis, most developing nations would not have the means to recover. several of the largest ifis are detailed in the following section, including the world bank; one of its subsidiaries, the international monetary fund (imf); the asian development bank; and the inter-american development bank. the world bank was created in 1944 to rebuild europe after world war ii. in 1947, france received the first world bank loan of $250 million for post-war reconstruction. financial reconstruction assistance has been provided regularly since that time in response to countless natural disasters and humanitarian emergencies. today, the world bank is one of the largest sources of development assistance. in the 2009 fiscal year, it provided more than $58.8 billion in loans, breaking all previous lending records for the organization. in fiscal year 2013, the amount of loans had fallen to $52.6 billion, but the bank remains one of the largest development lenders. the world bank is owned collectively by 188 countries and is based in washington, dc. it comprises several institutions referred to as the world bank group (wbg): • international bank for reconstruction and development • international development association the world bank's overall goal is to reduce poverty, specifically to "individually help each developing country onto a path of stable, sustainable, and equitable growth, [focusing on] helping the poorest people and the poorest countries" (wagstaff 2001) . as disasters and ches take a greater and greater toll on the economic stability of many financially struggling countries, the world bank is taking on a more central role in mitigation and reconstruction. developing nations, which are more likely to have weak disaster mitigation or preparedness capacity and therefore little or no affordable access to disaster insurance, often sustain a total financial loss. in the period of rehabilitation that follows the disaster, loans are essential to the success of programs and vital to any level of sustainability or increased disaster resistance. the world bank lends assistance at several points along this cycle. for regular financial assistance, the world bank ensures that borrowed funds are applied to projects that give mitigation a central role during the planning phase. it utilizes its privilege as financial advisor to guide planners, who otherwise might forego mitigation measures in an effort to stretch the loaned capital as far as possible. ensuring that mitigation is addressed increases systems of prediction and risk analysis in projects funded by the world bank. once a disaster occurs, the world bank may be called on for help. because it is not a relief agency, it will not take on any role in the initial response; however, it works to restore damaged and destroyed infrastructure and restart production capabilities. (see exhibit 10.14.) a world bank team may assist with initial impact assessments that estimate financial losses resulting from the disaster and estimated costs of reconstruction, including raised mitigation standards. the world bank also could restructure the country's existing loan portfolio to allow for expanded recovery projects. in addition, world bank projects that have not yet been approved but are in the application process can be redesigned to account for changes caused by the disaster. finally, an emergency recovery loan (erl) can be granted to specifically address recovery and reconstruction issues. erls restore affected economic and social institutions and reconstruct physical assets such as essential infrastructure. it is important to note that erls are not designed for relief activities. they are most appropriate for disasters that adversely impact an economy, are infrequent (recurrent disasters are accommodated by regular lending programs), and create urgent needs. erls are expected to eventually produce economic benefits to the borrowing government; they are usually implemented within three years and are flexible to accommodate the specific needs of each unique scenario. construction performed with erls must use disaster-resistant standards and include appropriate mitigation measures, thus providing overall preparedness for the country affected. once an erl has been granted, the world bank coordinates with the imf, the undp, ngos, and several other international and local agencies to create a strategy that best utilizes these funds within the overall reconstruction effort. the two lending arms of the world bank are the international bank for reconstruction and development and the international development association. international bank for reconstruction and development (ibrd) . established in 1945, the ibrd reduces poverty in middle-income and creditworthy poorer countries. the ibrd attempts to promote sustainable development activities through its loans. it also provides guarantees and other analytical and advisory services. following disasters, countries with strong enough credit can borrow or refinance their existing loans from the ibrd to pay the often staggering costs of reconstruction. international development association (ida). the ida lends to the world's poorest countries, classified as those with a 2010 income of less than $1,135 per person. sixty-four countries currently are eligible to borrow from the ida. it provides interest-free loans and grants for programs aimed at boosting economic growth and improving living conditions. this need is almost always present in the aftermath of disasters, including those caused by violent conflict. in 2006, the global facility for disaster risk reduction, or gfdrr, was created, with the world bank designated as facility manager on behalf of the 41 countries and eight international organizations that make up its membership. gfdrr has a secretariat, based in the washington dc world bank headquarters, which carries out its day-to-day operations. the purpose of gfdrr is to help developing countries address disaster vulnerability and vulnerability to the effects of climate change. its work is primarily driven by the hyogo framework for action, and its programs focus on mainstreaming exhibit 10.14 world bank disaster assistance to bosnia and herzegovina washington, june 30, 2014 the world bank group's board of executive directors today approved a us$100 million credit for the floods emergency recovery project for bosnia and herzegovina (bih), to meet critical needs and restore the functionality of infrastructure essential for public services and economic recovery in affected areas in the aftermath of the worst flooding to hit the country in documented history. the project was prepared in record time in view of the dire situation in the country and will be financed from the international development association's (ida) crisis response window resources. this project will target areas that were hit hardest by the devastating floods. preliminary evidence shows that the largest impact from this disaster was on livelihoods, housing, transport, agriculture, and energy. given the magnitude of the damage caused by flooding and subsequent landslides, the project is designed to support efforts by local and entity governments to quickly re-establish public services to pre-flood levels. the project will also support the government's on-going economic recovery initiatives, in particular in the agriculture sector. in addition to this project, the world bank is working on several other fronts to ensure the provision of a comprehensive package of support for bih as it recovers and rebuilds from the physical and economic devastation. notably, the bank is participating in a systematic recovery needs assessment, led by the bosnia and herzegovina (bih) authorities and supported also by the european union and the united nations. the assessment will provide a basis for developing effective rehabilitation measures for infrastructure and services in the affected areas. the world bank is also considering the restructuring of existing projects in its bih portfolio to meet reconstruction needs. while immediate recovery needs are the top priority of this project, the world bank also stands ready to work with the bih authorities to scale-up flood protection and implement early warning systems. the recently approved drina flood protection project is a good example of the type of work that could be scaled-up, as it addresses the need to prevent future flooding. as emphasized by laura tuck, world bank vice president for europe and central asia, "the floods emergency recovery project will finance critical goods, such as fuel and electricity imports, as well as the reconstruction of local infrastructure. this immediate response, combined with the drina river flood protection project, will support economic recovery in the affected areas, and will help restore bosnia and herzegovina to a growth path following the floods." the world bank portfolio of active projects in bih now includes 14 operations totaling approximately us$578.6 million. areas of support include agriculture, environment, energy efficiency, health, social safety and employment, local infrastructure, and private sector development. release, 2014. disaster risk reduction and climate change adaptation throughout all government sectors in member countries. gfdrr organizes its efforts according to three "business lines," which include: • track i: global and regional partnerships -track i supports unisdr in helping countries to leverage resources to perform pre-disaster investments and activities related to prevention, disaster risk reduction, and disaster preparedness. the key objectives of track i are to: 1) enhance global and regional advocacy, strategic partnerships, and knowledge management for mainstreaming disaster risk reduction; and 2) promote the standardization and harmonization of hazard risk management tools, methodologies, and practices. • track ii: mainstreaming disaster risk reduction in development -track ii provides pre-disaster assistance to developing countries to mainstream and expand disaster risk reduction and climate change adaptation activities. work in this track is performed in conjunction with world bank regional teams, un agencies, and national governments, and is aimed at integrating disaster risk reduction into poverty reduction and development efforts. there are also several sub-programs that include risk assessment, risk reduction, risk financing, and climate change adaptation. • track iii: sustainable recovery -track iii is aimed at early post-disaster recovery in low-income countries through its standby recovery financing facility (srff). track iii is less programmatic than track i and track ii because it is deployed for post-disaster situations, but it does work to build national capacity and facilitate knowledge management with the long term in mind. srff support includes two financing windows: 1) the technical assistance (ta) fund, which supports damage, loss, and needs assessments and develops national capacity for recovery planning and implementation; and 2) the callable fund for accelerated recovery, which provides speedy access to financial resources for disaster recovery and reconstruction. the international monetary fund (imf) was established in 1946 to "promote international monetary cooperation, exchange stability and orderly exchange arrangements; to foster economic growth and high levels of employment; and to provide temporary financial assistance to countries to help ease balance of payments adjustment." it carries out these functions through loans, monitoring, and technical assistance. since 1962, the imf has provided emergency assistance to its 188 member countries after they were struck by natural disasters, and, in a great many cases, when affected by complex emergencies. the assistance provided by the imf is designed to meet the country's immediate foreign-exchange financing needs, which often arise because earnings from exports fall while the need for imports increases (among other causes). imf assistance also helps the affected countries avoid serious depletion of their external reserves. in 1995, the imf began to provide this type of emergency assistance to countries facing post-conflict scenarios in order to enable them to reestablish macroeconomic stability and to provide a foundation for recovery, namely in the form of long-term sustainable growth. this type of assistance is particularly important when a country must cover costs associated with an "urgent balance of payments need, but is unable to develop and implement a comprehensive economic program because its capacity has been damaged by a conflict, but where sufficient capacity for planning and policy implementation nevertheless exists" (imf 2005) . the imf maintains that their support must be part of a comprehensive international effort to address the aftermath of a conflict in order to be effective. its emergency financing is provided to assist the affected country and to gather support from other sources. it is not uncommon for a country to severely exhaust its monetary reserves in response to an emergency situation. in the event of a natural disaster, funding is directed toward local recovery efforts and any needed economic adjustments. the imf lends assistance only if a stable governing body is in place that has the capacity for planning and policy implementation and can ensure the safety of imf resources. after stability has been sufficiently restored, increased financial assistance is offered, which is used to develop the country in its post-emergency status. when a country requests emergency assistance, it must submit a detailed plan for economic reconstruction that will not create trade restrictions or "intensify exchange." if the country is already working under an imf loan, assistance may be in the form of a reorganization of the existing arrangement. it can also request emergency assistance under the rapid financing instrument (rfi). the rapid financing instrument (rfi) is the vehicle that the imf uses to meet disaster-impacted countries' financing needs. the rfi provides funding quickly and with few requirements in instances where it is determined that a disaster or emergency situation has resulted in urgent balance-of-payments needs. emergencies need not be related to a natural or technological hazard-they can also be the result of rapid increases in the price of certain commodities or because of an economic crisis. unlike other imf assistance, there does not need to be a full-fledged financing program in place. prior to the creation of the rfi, the imf used a number of separate programs to address emergency needs, including the emergency natural disaster assistance (enda) program and the emergency post-conflict assistance (epca) program. the 2011 creation of the rfi program combines all emergency needs. rfi financial assistance is provided in the form of outright purchases without the need for a full-fledged program or reviews. however, when a country does request assistance under rfi, they must cooperate with the imf to make every effort to solve their balance-of-payment problems, and must explain the economic policies it proposes to follow to do so. the imf makes the rfi program available to all of its members, though oftentimes very poor countries are more likely to seek assistance under a different program called the rapid credit facility (rcf), which provides similar assistance but has economic-based requirements that many wealthier countries cannot meet. funds access under the rfi program is limited to 50 percent of a nation's quota per year and 100 percent of quota on a cumulative basis. under the rcf program, the access limits are 50 percent of a nation's quota per year and 125 percent of quota on a cumulative basis. the level of access in each case depends on the country's balance-of-payments need. financial assistance provided under the rfi is subject to many of the same financing terms that nations would see in other imf programs, and the funds borrowed are ideally paid back within 39 to 60 months (imf 2011). in certain cases, as decided by the imf and according to specific criteria, recipients of emergency funding may benefit from the imf poverty reduction and growth facility (prgf). the prgf is the imf's low-interest lending facility for low-income countries. prgf-supported programs are underpinned by comprehensive country-owned poverty reduction strategies. under this program, the interest rate on loans is subsidized to 0.5 percent per year, with the interest subsidies financed by grant contributions from bilateral donors. this program has been available for post-conflict emergencies since 2000, but in january 2005, following the south asia tsunami events, the imf executive board agreed to provide a similar subsidization of emergency assistance for natural disasters upon request. the government of a country devastated by disaster often requires technical assistance or policy advice because it has no experience or expertise in this situation. this is especially common in post-conflict situations, where a newly elected or appointed government has been established and officials are rebuilding from the ground up. the imf offers technical assistance in these cases to aid these countries in building their capacity to implement macroeconomic policy. this can include tax and government expenditure capacity; the reorganization of fiscal, monetary, and exchange institutions; and guidance in the use of aid resources. the asian development bank (adb) is a multilateral development financial institution whose primary mission is reducing poverty in asia and the pacific. adb was established in 1966 by 31 countries from both within and outside the region, and has grown to include 67 members as of 2014. forty-eight are from the region and 19 are from other regions. its clients are the 67 member governments, who are also the adb's shareholders. the adb provides emergency rehabilitation loans to its member countries following disasters. adb determined that its assistance in this critical phase of recovery would allow an affected developing country to maintain its development momentum. bank analysts found that, without such assistance, the affected country may reallocate its scarce budgetary resources away from development issues to cover disaster-related expenses, sidetracking development progress. additionally, they found that the production of goods and services would quickly suffer or fail completely if the country could not perform adequate rehabilitation following a disaster. adb assistance in emergencies began in 1987, but was initially extended only to smaller developing countries (e.g., the maldives, papua new guinea, and the smaller pacific island states). loans were limited to $500,000 (increased to $2 million in 1997), with funded projects to be completed within 12 months of disbursement. the funding was designed to address only simple repair and rehabilitation activities as needed in the immediate aftermath of a disaster, with more comprehensive repair being covered by regular bank lending programs. lending was designed to be provided within six weeks of being requested. in 1989, emergency lending was extended to all developing member countries regardless of their size. this change included a fundamental shift in what the emergency loans would cover, from simple repairs to more comprehensive, informed rehabilitation activities. most important, adb wanted to ensure that projects funded by its loans reduced overall risk to the affected nation and its population. other major changes in adb emergency lending policy are included in the following list: • introducing a typology of the causes and effects of disasters • more clearly defining the adb's response during various phases of post-disaster situations • identifying the nature, focus, and coverage of rehabilitation projects • introducing detailed, yet simplified, guidelines for processing rehabilitation projects • targeting rehabilitation loans toward restoring infrastructure and production activities, including capacity building and modernization • mandating that risk analysis and disaster prevention measures be included in all adb projects in disaster-prone developing member countries • closely coordinating disaster responses at all levels (local, national, and international) with those of other external funding agencies, ngos, and community groups • specifying that disaster prevention and mitigation activities were to be promoted along with regional cooperation • including non-natural disasters, for example, wars, civil strife, and environmental degradation (adb 2005) between 1987 and 2013, adb provided $6.4 billion to disaster-affected countries in the form of loans at a rate of approximately one loan per month. the vast majority of the adb emergency loan services during this period were provided in response to natural disaster events, with the remaining dedicated to post-conflict situations. these loans rarely averaged more than 6 percent of the total annual lending by adb and were concentrated primarily in south asia. the project comprises two components: (i) reconstruction and upgrading of damaged roads and bridges in sichuan and shaanxi provinces, and (ii) reconstruction and improvements of damaged schools in shaanxi province. the project will rehabilitate and reconstruct 368 high-priority earthquake-damaged roads in the 19 worst affected counties of sichuan province and 10 subprojects in the four worst affected counties of shaanxi province. the project will rehabilitate and reconstruct 12 highpriority earthquake-damaged education facilities in the three worst affected counties in shaanxi province. these components are designed to be mutually supporting in achieving the overall objective of restoring the affected communities' access to infrastructure to pre-earthquake levels, and ensuring restored infrastructure is in strict compliance with the latest seismic code. based on the government's damage and needs assessment and the request of the prc government, the project identifies specific sectors that require emergency assistance in two of the worst earthquake-affected provinces (i.e., sichuan and shaanxi). the project seeks to (i) build on the immediate relief provided by the government in the earthquake-affected provinces; (ii) contribute to coordinated rehabilitation and reconstruction by different development partners and the government; and (iii) specifically address sustainable recovery priorities by providing indirect livelihood support through public infrastructure rehabilitation and reconstruction, which generates public employment and underpins the restoration of livelihood activities by rehabilitating roads, bridges, and schools. the project design draws on the adb experience in delivering emergency assistance acquired in different developing member countries over the past two decades, and complements relief and other rehabilitation and reconstruction assistance provided by the government, united nations agencies, ngos, bilateral development partners, and the world bank. by meeting the earthquake reconstruction needs of the next three years, the project is consistent with adb's disaster and emergency assistance policy (2004) . the project supports the state overall plan for post-wenchuan earthquake restoration and reconstruction approved by the government on 19 september 2008. the impact of the project is accelerated restoration of education and transport infrastructure in earthquake-affected areas of sichuan and shaanxi provinces. the project will support the government's efforts to (i) restore the livelihoods and economic activities of the affected population; (ii) accelerate poverty alleviation in the earthquake-affected counties, many of which have a high incidence of poverty; and (iii) rehabilitate and reconstruct public and community-based infrastructure that is vulnerable to natural disasters. the outcome of the project is restoration of people's access to transport and education infrastructure to preearthquake levels in 19 counties of sichuan and four counties of shaanxi provinces. the total project cost is estimated at $441.6 million equivalent. a loan of $400 million from adb's ordinary capital resources will be provided under adb's london interbank offered rate (libor)-based lending facility. the loan will have a grace period of 8 years with a maturity period of 32 years, an interest rate determined in accordance with adb's libor-based lending facility, a commitment charge of 0.15% per annum, and such other terms and conditions set forth in the draft loan and project agreements. until june 30, 2012. adb also provides mitigation-related project loans and regional technical assistance (reta) aimed at reducing member countries' overall disaster vulnerability. between august 1987 and december 2013, adb approved $13.1 billion for more than 300 disaster risk management-related projects (in addition to the $6.4 billion provided in disaster-related financing). mitigation and preparedness projects are not considered "emergency" in nature and are therefore funded through the bank's regular lending activities. because mitigation and preparedness activities are most often included as components within larger development projects, adb does not maintain records of its total financial risk reduction-based lending. projects may include resilience-increasing activities such as reforestation, watershed management, coastal protection, agricultural diversification, slope stabilization, and land-use planning, although the project's overall goal is more development oriented. reta and single-country technical assistance activities have included hazard management and disaster preparedness software programs and infrastructure protection assistance. adb has december 31, 2011. as the project is for emergency assistance, implementation will start immediately after approval and be completed within 36 months. sichuan provincial communications department in sichuan province; and hanzhong city government and baoji city government in shaanxi province implementing agencies sichuan highway administration bureau in sichuan province; and county-level highway administration bureaus for roads and bridges, and county-level education bureaus for schools in shaanxi province. the project will bring benefits to the project area by (i) reconstructing and improving road conditions and accessibility in townships and in villages in the sichuan and shaanxi provinces, (ii) reconstructing and improving 12 schools in shaanxi province, and (iii) creating local employment opportunities from project construction and related activities. the project will provide equal benefits to females and males. the economic benefits of the rural roads and bridges include (i) savings in vehicle operating costs as a result of improved traffic and road conditions, (ii) time-savings for rural road users, (iii) savings in road accident costs as a result of fewer accidents, and (iv) economic benefits from generated traffic. the reconstruction and upgrading of rural roads in sichuan and shaanxi provinces will benefit about 5.6 million people, three-quarters of whom are rural and one-third of whom are poor. as reliable transport to markets becomes more readily available, cash crop farming in remote or isolated areas will be stimulated and access to off-farm employment opportunities will be broadened. the project will focus on reconstruction of and improvements to 12 model schools to appropriate design standards, including six junior secondary and six primary schools. this will bring immediate benefits to the schools' 16,600 students (including more than 8000 female students), and long-term benefits to future students drawn from the 460,000 residents of the areas serviced by the schools, about 40% of whom are from rural areas of remote counties. the project will contribute to the government's efforts to rebuild the economy, rehabilitate public infrastructure and utilities, reinstate seismic code compliance, and generate employment. the rehabilitation and reconstruction of damaged schools will enable education services to be restored and will offer long-term benefits for affected persons by supporting opportunities for employment and participation in economic activities. finally, adb assists countries in restarting rehabilitation and overall development in the aftermath of armed conflict. in the past, adb post-conflict intervention focused almost exclusively on infrastructure rehabilitation, an area in which the adb has extensive experience. its focus in this area began to shift in the 1990s to preventing conflicts and helping post-conflict countries move along a solid path of economic and social development. adb is now committed to assisting affected member countries develop mechanisms to effectively manage conflict, including addressing the problems of poor governance and corruption. in 2009, adb established the asia pacific disaster response fund (apdrf) to provide quick funding in the aftermath of a disaster to help governments meet urgent life-saving disaster-response needs. between 2009 and 2013, 19 grants were approved under the fund. apdrf assistance is provided as a grant that may be no larger than us$3 million per event. the size of the grant is determined by: 1. the geographical extent of the disaster's damage; 2. initial estimates of fatalities, injuries, and displaced persons; 3. the country's disaster response capacity; and 4. the date and magnitude of the last disaster to have impacted the country (thereby taking into account the cumulative effect of disasters on the country's ability to respond) (adb 2014). in 2012, adb approved a pilot asian development fund disaster response facility for countries eligible for low-interest loans in the event of a disaster. the pilot program, which runs from 2013 to 2016, is being conducted to strengthen adb's ability to respond to disaster-impacted member countries in a manner that is less ad hoc. the drf will require countries that are eligible to borrow from the asian development fund (adf countries) to contribute a small fraction of their allocations for the benefit of accessing the drf in case of a disaster. the drf will be available to these countries in the case of natural disasters, and will support relief, response, recovery, and reconstruction needs. per the pilot program, the size of the drf will be 3 percent of the total performance-based allocation (pba) received. in case of a disaster, an adf country can get up to 100 percent of its annual pba, or us$3 million per disaster, whichever is higher, from the drf. a blend country, which is a country eligible for both the adf and adb ordinary capital resources, can receive up to 3 percent of its annual pba from the drf if affected by a disaster. established in december 1959, the inter-american development bank (iadb) is the oldest and largest regional multilateral development institution. it was first created to help accelerate economic and social development in latin america and the caribbean. the iadb has been a pioneer in supporting social programs; developing economic, social, educational, and health institutions; promoting regional integration; and providing direct support to the private sector, including microenterprises. the iadb addresses disaster and risk management through its sustainable development department. through the efforts and actions of this department and its disaster risk management policy, the iadb addresses the root causes of the region's high vulnerability to disasters. building on its mandate to promote sustainable development in latin america and the caribbean, the iadb works with countries to integrate risk reduction into their development practice, planning, and investment, and to increase their capacity to manage risk reduction. it also provides funding that directly or indirectly supports disaster mitigation and preparedness. in their "plan of action: facing the challenge of natural disasters in latin america and the caribbean," the iadb outline their six strategic areas of assistance: 1. national systems for disaster prevention and response: building national legal and regulatory frameworks and programs that bring together the planning agencies, local governments, and civil society organizations; developing national strategies for risk reduction; and assessing intersectoral priorities, backed by separate budgets. 2. a culture of prevention: developing and disseminating risk information and empowering citizens and other stakeholders to take risk-reduction measures. 3. reducing the vulnerability of the poor: supporting poor households and communities in reducing their vulnerability to natural hazards and recovering from disasters through reconstruction assistance. 4. involving the private sector: creating conditions for the development of insurance markets, encouraging the use of other risk-spreading financial instruments where appropriate, and designing economic and regulatory incentives for risk reduction behavior. 5. risk information for decision-making: evaluating existing risk assessment methodologies; developing indicators of vulnerability, and stimulating the production and wide dissemination of risk information. 6. fostering leadership and cooperation in the region: stimulate coordinated actions and to mobilize regional resources for investments in risk mitigation. (iadb 2000) the iadb created two mechanisms to allow for rapid loan disbursement in times of disaster: the disaster prevention sector facility and the facility for the immediate response to natural and unexpected disasters (formerly the immediate response facility). in 2001 the iadb established the natural disaster network, represented by each of its borrowing member countries. network members meet annually to discuss topics related to disaster management, such as "national systems for risk management" (2001) the iadb revised its disaster risk management policy in 2008. the new policy is designed to improve the iadb's ability to assist member countries in reaching their development goals by supporting their disaster risk management efforts. (see appendix 10.1 for the full text of the 2008 iadb disaster risk management policy guidelines.) . iadb supports disaster risk reduction through the disaster prevention sector facility, which provides up to $5 million to assist countries in taking an integrated approach to reducing and managing their risk. the iadb also provides loans to help countries cope with financial or economic crises and natural or other disasters through its emergency lending program. in the case of a financial or economic crisis, the iadb requires that the emergency loan fits within an imf-approved and monitored macroeconomic stabilization program. emergency loan disbursement periods are much shorter than other non-disaster loans, ranging up to 18 months in duration. they may be used to support national, provincial, state, and municipal governments and autonomous public institutions. they have a five-year term and a three-year grace period. in the case of natural or other disasters, the emergency lending program is known as the emergency projects, in order to improve project viability. whenever significant risks due to natural hazards are identified in project preparation, appropriate measures will be taken to secure the viability of the project, including the protection of populations and investments affected by bank-financed activities. the bank has nonreimbursable resources that may be used to cover the transaction costs incurred with the implementation of these guidelines. 1.6. these guidelines will also recommend ways to evaluate the benefits and opportunity costs of loan reformulations and give guidance on how to ensure adequate transparency and effective monitoring, auditing, and reporting on the use of redirected funds. in addition, the guidelines describe precautions to be taken to avoid rebuilding or increasing vulnerability during rehabilitation and reconstruction. 1.7. the guidelines are designed to be flexible in their application to the various situations that borrowing member countries and the bank may experience, in the face of natural hazards and disasters affecting their development prospects and performance. 1.8. the present guidelines apply to all natural hazards, including the hydrometeorological hazards-windstorms, floods, and droughts-that are associated with both the existing climate variability and the expected change in long-term climate conditions. of note for risk assessments, climate change is expected to change some countries' disaster risk (their probable losses) by changing the characteristics of the hydrometeorological hazards. 1.8 although uncertainty persists, recent advances in downsizing climate models are allowing disaster managers to better calibrate their risk assessments to understand potential impacts due to climate change at the subnational level. tools for identifying such climate risk at the country and project levels, and measures for mitigating these increased risks to bank investments (climate change adaptation) will be developed under pillar 4 of the bank's sustainable energy and climate change initiative (secci) action plan. purpose and scope 2.1. the purpose of this section is to provide guidance to bank teams on the implementation of directive a-1 of the disaster risk management policy, particularly for countries classified as having high disaster risk, as well as for those sectors that are associated with a high vulnerability to natural disasters and in which the bank has identified opportunities for financing. in accordance with this policy, the bank will encourage countries to include proactive drm in programming activities in those countries, as indicated in directive a-1 of the policy: 2.2. a-1. programming dialog with borrowing member countries. the bank will seek to include the discussion on proactive disaster risk management in the dialog agenda with borrowing member countries. the bank will give due consideration to vulnerability associated with natural hazards and risk management in relation to the priority areas of intervention discussed and agreed with the borrowers for the development of country and regional strategies, and operational programs. the bank will identify countries according to their level of exposure to natural hazards based on existing indicators and bank experience. for countries that are highly exposed to natural hazards, the bank will identify their potential vulnerability as a major development challenge and propose a country level disaster risk assessment. when the assessments identify that potentially important disruptions in the country's social and economic development could be caused by disasters resulting from natural hazards, the bank will encourage the inclusion of disaster risk management activities in the country strategy and operational program agreed with the borrower. these may include policy reforms, specific institutional strengthening and land-use planning activities, measures of financial protection such as through risk transfer, and investment projects conducive to reducing vulnerability at the national, regional, and municipal levels. where the natural hazards may affect more than one country, the bank will encourage a regional approach within the existing programming framework. the bank will promote the use of the disaster prevention sector facility and the disaster prevention fund, described in section v of this policy, and other means it offers to finance the recommended actions resulting from the assessment process. to meet the requirement of the drm policy to identify countries according to their level of risk exposure, a provisional country classification has been developed. the provisional classification will be subject to change, based on expert knowledge, and eventually on the complete data set of risk information derived from the implementation of the bank's indicators for disaster risk and risk management program in its 26 borrowing member countries. the indicators program has been completed in 14 countries to date. as indicated in directive a-1, countries that have been identified as being highly exposed to natural hazards will be encouraged by the bank to include drm as a priority area for bank assistance. in those cases, the bank will propose that a country disaster risk assessment be carried out. the assessment would give an overview of the risks facing a country; identify the sectors and geographical areas that should receive priority attention; and provide initial policy orientation, reviews of relevant institutional capacities, and assistance needs. these assessments may already exist, or may be put together from country and secondary sources. 2.5. the evaluation of the macroeconomic impacts as part of the country disaster risk assessment may allow for the identification of risk reduction needs and the quantification of possible resource gaps between available resources and funding needed for disaster response and recovery. recommendations will be prepared concerning opportunities for the bank to contribute to financial protection against disasters, as appropriate, such as direct funding for risk identification and support for risk transfer in financial markets in order to improve the effectiveness of the country's development efforts in the areas and sectors of bank involvement. 2.6. identification of opportunities for bank financing. in line with the new country development risk framework, a more detailed disaster risk assessment will be recommended when disaster risks faced by certain areas/sectors of bank involvement could significantly jeopardize the achievement of a country's development objectives. these sector-specific or areaspecific assessments would analyze how these risks could affect specific areas/sectors and make recommendations on how best to address the risks identified. for this purpose, loans, technical cooperations, and nonfinancial bank products for proactive drm may be proposed within the country programming activities. 2. implementation of the country strategy: programming dialogue and portfolio management 2.7. when deemed necessary by the bank and if the borrower agrees, drm activities will be included as in the implementation of the country strategy. the bank will give due consideration to the following: in the programming and portfolio reviews, the bank and the borrower may seek to implement risk reduction investments in the priority sectors and geographical areas through disaster prevention and mitigation measures. these investments may be financed with free-standing loans or as part of larger investment programs, policy based loans (pbl), or private sector operations. technical assistance may be considered for carrying out area-or sector-specific risk evaluations, strengthening risk management through policy reforms, organizational design, land-use planning activities, the preparation of new prevention loan programs, and supporting the implementation of financial protection schemes such as through insurance to cover disaster losses. loan portfolio modifications will likely be necessary due to the occurrence of major disasters during the regular programming cycle. borrowers may request new emergency or reconstruction financing and will have access to either new resources, for instance, through the immediate response facility for emergencies caused by disasters (gn-2038-12 and gn-2038-16), or "existing" resources, through loan reformulations (see directive b-1). 2.8. the results of the drm implementation in-country programming will be evaluated using the monitoring system defined in the country strategy document. the bank may recommend activities of a regional nature whenever it is known that a particular disaster could affect several borrowing member countries simultaneously. examples of this situation are the enso (el niño southern oscillation) phenomenon, and the hurricanes and tropical storms in the caribbean and central america. 2.10. the regional activities that possibly involve bank financing will be agreed beforehand with the affected borrowing member countries and may involve coordination with other international entities. the resulting operations to be included in the regional portfolio of the regional strategy document could be funded through bank instruments, such as technical cooperation of the regional public goods program or disaster prevention fund, or loans prepared in parallel, in close cooperation with the countries interested in a regional program. 3.1. the purpose of this section is to provide guidance to project teams on the implementation of the bank's disaster risk management policy directive a-2: risk and project viability. this directive is designed to promote the incorporation of drm in a systematic manner during project preparation and execution. the objective is to reduce risk to levels that are acceptable to the bank and the borrower, as indicated in directive a-2 of the policy: 3.2. identification and reduction of project risk. bank-financed public and private sector projects will include the necessary measures to reduce disaster risk to acceptable levels as determined by the bank on the basis of generally accepted standards and practices. the bank will not finance projects that, according to its analysis, would increase the threat of loss of human life, significant human injuries, severe economic disruption, or significant property damage related to natural hazards. during the project preparation process project teams will identify if the projects have high exposure to natural hazards or show high potential to exacerbate risk. the findings will be reported to the bank through the social and environmental project screening and classification process. project teams should consider the risk of exposure to natural hazards by taking into account the projected distribution in frequency, duration, and intensity of hazard events in the geographic area affecting the project. project teams will carry out a natural hazard risk assessment for projects that are found to be highly exposed to natural hazards or to have a high potential to exacerbate risk. special care should be taken to assess risk for projects that are located in areas that are highly prone to disasters as well as sectors such as housing, energy, water and sanitation, infrastructure, industrial and agricultural development, and critical health and education installations, as applicable. in the analysis of risk and project viability, consideration should be given to both structural and nonstructural mitigation measures. this includes specific attention to the capacity of the relevant national institutions to enforce proper design and construction standards and of the financial provisions for proper maintenance of physical assets commensurate with the foreseen risk. when significant risks due to natural hazard are identified at any time throughout the project preparation process, appropriate measures should be taken to establish the viability of the project, including the protection of populations and investments affected by bank-financed activities. alternative prevention and mitigation measures that decrease vulnerability must be analyzed and included in project design and implementation as applicable. these measures should include safety and contingency planning to protect human health and economic assets. expert opinion and adherence to international standards should be sought, where reasonably necessary. in the case of physical assets, the bank will require that, at the time of project preparation, the borrower establish protocols to carry out periodic safety evaluations (during construction as well as during the operating life of the project) and appropriate maintenance of the project equipment and works, in accordance with generally accepted industry norms under the circumstances. the bank's social and environmental project screening and classification process will evaluate the steps taken by project teams to identify and reduce natural hazard risk. 3.3. under the bank's new risk management development effectiveness framework, a common approach to the management of project risks is proposed. disaster risk is one of several project risks. these guidelines are an input to the bank's approach on project risk management. they apply to bank-financed investment loans and technical cooperation projects in the public and private sector as well as to operations supported by the multilateral investment fund. 3.4. during the assessment, management, and monitoring of disaster risk at the project level, the disaster risk is reviewed at various stages of project preparation and implementation. on this basis, appropriate actions are taken to protect project benefits and outcomes. 3.5. directive a-2 requires that the bank's social and environmental project screening and classification process provide for project teams to identify and reduce disaster risk. the recommended drm steps are as follows: project screening and classification outcome: identifies those projects where the drm policy is applicable and classifies as high, moderate or low risk. document: report of the social and environmental safeguards policy filter (spf) and social and environmental safeguards screening form. document: disaster risk profile in the environment and social strategy. disaster risk assessment (dra), including disaster risk management plan outcome: provides a detailed evaluation of the impacts of the significant natural hazards identified during project classification on project components; and outlines appropriate risk management and mitigation measures. document: dra report, prepared by the borrower (this may be a stand-alone report or it may be incorporated into the environmental impact assessment report). disaster risk management summary outcome: provides information on the specific disaster risks associated with the project and the risk management measures proposed by the borrower. document: drm summary, for inclusion in the environmental and social management report (esmr), prepared by project teams. project implementation, monitoring and evaluation outcome: identifies the approaches which the executing agency applies during project implementation; and which project teams apply during project monitoring and evaluation. 3.6. the bank's social and environmental screening and classification system of projects will be used to filter and classify those projects for which disaster risk is likely to be an issue for project viability and effectiveness. 3.7. there are two possible types of disaster risk scenarios: type 1: the project is likely to be exposed to natural hazards due to its geographic location. type 2: the project itself has a potential to exacerbate hazard risk to human life, property, the environment or the project itself. 3.8. the purpose of this step is to establish, early in the project preparation process, whether natural hazards are likely to pose a threat to the project area during the execution (construction) period and/or the operational life of the project, due to type 1 and type 2 risk scenarios. project classification 3.9. type 1 risk scenario: the level of disaster risk associated with a given project is dependent on the characteristics of the natural hazards as well as on the vulnerability of the sector and project area. the project is classified on the basis of an estimate of the impacts/losses due to the significant hazards associated with type 1 risk scenario. project teams classify their projects in terms of high, moderate, or low disaster risk on the basis of the (i) projected frequency of occurrence and magnitude or intensity of the hazard and (ii) estimated severity of the impacts associated with the hazard, i.e., the magnitude and extent of the likely social, economic, and environmental consequences of the hazard on the various project components and on the general zone of influence of the project. the classification process also provides project teams with a preliminary indication of the hazards likely to be of greatest significance, as well as their likely impacts on project components. and reported as part of the disaster risk profile presented in the environment and social strategy document. the project team will report its findings to the bank unit responsible for social and environmental screening and classification of projects, as part of the bankwide safeguards and risk management procedure. high-risk projects 3.11. the project will typically be classified as high-risk if one or more of the significant natural hazards may occur several times during the execution (construction) period and/ or the operational life of the project and/or the likely severity of social, economic, and/or environmental impacts in the short to medium term are major or extreme. these impacts are of sufficient magnitude to affect project viability and may affect an area broader than the project site. as such hazards may affect project viability, a more detailed investigation of disaster risk, in the form of a dra, is required. moderate-risk projects 3.12. the project will typically be classified as moderate risk if one or more of the prevalent natural hazards are likely to occur at least once during the execution (construction) period and/or the operational life of the project and/or the likely severity of impact in the short to medium term is average. these impacts are typically confined to the project site and can be mitigated at reasonable costs. projects associated with a moderate disaster risk do not typically require a dra. however, a more limited dra may be required, depending on the complexity of the project and where the anticipated vulnerability of a specific project component may compromise the achievement of project outcomes. low-risk projects 3.13. the project will typically be classified as low risk if natural hazards are not likely to occur during construction and/or the operational life of the project and/or associated with a low severity of impact in the short to medium term. those impacts that occur do not lead to a disruption in the normal functioning of the operation and can be corrected as part of project maintenance. the occurrence of the hazard event does not impact on the achievement of project outcomes. a dra is not required. 3.14. type 2 risk scenario: the impacts associated with type 2 risk scenario are addressed under directive b-3 of the bank's environment and safeguards compliance policy (op-703). such impacts are thus considered and included in the categorization of environmental impacts. 3.15. the unit responsible for environmental and social risk mitigation reviews the classification of all operations and may recommend a new classification based on the review of the disaster risk profile presented in the environment and social strategy. the unit and line divisions will need to agree on the final classification of the operations, the level of disaster risk assessment required, and a proposed strategy to address and manage the anticipated impacts. for projects that are identified as high-risk, a dra is required and is prepared by the borrower. the objective of the assessment is to evaluate in greater detail the impacts of the significant natural hazards identified during project classification on project components. the results of the risk assessment will guide the selection of appropriate risk management and mitigation measures. evaluates the frequency, intensity, and severity of previous hazard events that have affected the project area, as well as those predicted to affect the site over the project's operational life. identifies the vulnerability and probable losses of project components, i.e., the nature and magnitude of the probable social, economic, and environmental impacts due to each hazard; this includes both direct and indirect impacts. provides a disaster risk management plan, including proposals for the design of disaster prevention and mitigation measures, including safety and contingency plans to protect human health and economic assets, and their estimated costs; an implementation plan; a monitoring program and indicators for progress; and an evaluation plan. the implementation plan includes protocols to undertake periodic safety evaluations from project implementation up to project completion and maintenance of project equipment and works. project teams include a summary of the dra report in the environmental and social management report, which is reviewed by both the bank unit responsible for environmental and social risk mitigation screening and the sector divisions chiefs will sign off on the esmr and safeguard compliance plan, including the drm activities. the drm summary provides information on the specific disaster risks associated with the project and the risk management measures proposed by the borrower. 3.19. the project's proposed management and mitigation measures should comply with international standards of good practice and relevant national laws and regulations, such as national planning policies, laws and regulations, as well as national building codes and standards. 3.20. project teams will analyze the impact of the disaster risk prevention and mitigation elements in their assessment of project viability, verifying that identified hazard impacts on project components are reduced to acceptable levels. 3.21. the executing agency is responsible for ensuring that all drm activities ( including prevention and mitigation measures) associated with the project are implemented in accordance with the provisions of the loan agreement. this includes periodic safety evaluations and appropriate maintenance during project implementation and through project completion. project teams will monitor implementation to verify that the drm actions in the project risk management plan are carried out effectively; they shall use standard monitoring (project performance monitoring report; ppmr) procedures. purpose and scope 4.1. the loan reformulation addressed by these guidelines provides financing for postdisaster response to the impacts of natural hazard events and physical damage (such as structural collapse and explosions) caused by technological accidents or other types of disasters resulting from human activity. loan reformulation includes the diversion of existing loan resources to specific analysis needs to determine performance indicators, based on the possible revisions and reformulations being considered. analysis of loans used as a source of funding 4.11. the impact of redirecting loan resources from existing loans will be estimated taking into account the intended uses and project objectives of the loan or loans to be used as a source relative to the new proposed use of the funds, thereby creating the conditions for more informed decisions. resource transfers could be done between cost categories within a project (in which case more streamlined approval procedures will apply), or between separate loans as stipulated by bank procedures. 4.12. for choosing existing projects as origin of resources, following factors (in order of priority) would be considered: a. public sector projects. only public sector loans would be considered. loans to the private sector should not be included in the package of loans for possible reformulation as a result of disasters. b. development impact in the reformulated operations. the loans that are having a relatively low economic/financial impact in the country should be considered first as a source for redirecting resources from existing loans toward emergency funding. redirecting resources that are within a loan generally have a smaller effect than those involving several operations. the original development objectives may not be achieved due to the new social or economic situation created by the disaster or it could be considered too expensive to reorient the resources within the old operation. recommendations regarding the redirection of resources will be based on project performance indicators used by the bank. c. level of execution. operations with a low level of physical execution or disbursements and commitments could be chosen for redirection, except for those loans with a very high development impact. the selection should not only be based on a low disbursement rate of the existing loans alone, but also on an analysis of the underlying causes of the poor performance and any remaining opportunities for attaining project goals. d. loans in affected sectors. resource transfers within an affected sector will be preferred due to the greater similarity of their respective objectives compared with those of loans in different sectors. e. loans in affected region(s). in general, existing projects in the disaster area will not be used to provide resources to be transferred to other programs in the same area. however, when damage is so severe that the attainment of the original development objectives is in jeopardy, or the continuation of a certain component of the project as a whole is unjustifiable on account of excessive costs, parts or all of the undisbursed balances may be re-channeled toward emergency or rehabilitation and reconstruction projects in the same area. factors to be considered in projects receiving funding 4.13. the following are the recommended actions to be considered by project teams, while preparing the funding analysis: 4.14 i. technical analysis. for emergencies, the technical analysis will be aimed at re-establishing basic services and critical infrastructure in a time efficient manner. the attainment of fully functioning facilities and productive capacity through rehabilitation and reconstruction will be measured through a detailed technical analysis with the objective of reaching disaster resistance, and fulfilling technical standards across the board and performance criteria required by the bank. 4.15 ii. socioeconomic analysis. for emergency response, the socioeconomic analysis will be limited to the evaluation of the cost-effectiveness of restoring the basic services and critical infrastructure. if information is scarce, the analysis may be done based on comparable data from similar operations elsewhere. any delays in the analysis and processing of the emergency financing may limit the bank to have a meaningful contribution to resolve critical needs that are affecting the population, urgent re-establishment of basic services and critical activities. the analysis for rehabilitation and reconstruction investments will follow standard bank practices. if future project benefits cannot be estimated, cost-effectiveness analysis will be carried out. 4.16 iii. evaluation of institutional capacity and coordination. in order to gain sustainability, existing agencies are preferred to the establishment of new, ad hoc entities. a rapid analysis will be carried out of the institutional capacity, procurement management capability, and financial track record of the existing agencies. based on its results, it will be determined if the resources will be disbursed on an ex post or on a concurrent basis. the administrative and technical responsibilities of all the participating institutions in different sectors and means of coordination need to be clearly defined to facilitate successful execution in a limited time frame. planned strategies and activities need to be coordinated with other international agencies participating in the post-disaster financing. 4.17 i. procurement procedures. the applicable bank policy and rules will be followed for the procurement of goods and services. as an exception, for emergency situations, specific procurement procedures are available, in view of the special nature of these operations and the urgency involved. 4.18 ii. transparency in financing. the financial management and evaluation of procurements, expenses, and the utilization of goods and services to be funded with bank resources for emergency situations will be audited on a concurrent basis, following current bank practices. for rehabilitation and reconstruction investments the review may be on a concurrent or ex post basis depending on risk of lack of transparency estimated by the project teams. loan resources can be used to contract the services of independent public accountants to audit the operation's financial statements as required by the bank. 4.19 iii. monitoring and evaluation. bank resources will be subject to review on a concurrent basis for emergency investments. for rehabilitation and reconstruction, an audit will be required on a concurrent or ex post basis, depending on the risk of lack of transparency as estimated by the project team. data collection will be planned for monitoring and evaluation. only direct project impacts will need to be evaluated. 4.20. vulnerability should not be replicated when designing disaster response financing. in the preparation of reformulations for rehabilitation and reconstruction, a proportion of the resources of the operation should be allocated to prevention and mitigation activities. the percentage of the total cost that will be dedicated to prevention and mitigation should be defined and the viability of these investments assessed by the project team. the project team should also justify any potential deviations from international practices in these allocations for disaster prevention and mitigation. purpose and scope 5.1. the purpose of this section is to provide assistance to project teams on the implementation of directive b-2: reconstruction. specifically guidance is provided on the precautions that country programming process and project teams should take to promote revitalization of development efforts in the aftermath of disasters, while ensuring that rehabilitation and reconstruction projects do not lead to a rebuilding of or an increase in vulnerability. as indicated in directive b-2 of the policy: 5.2. avoiding rebuilding vulnerability. operations that finance rehabilitation and reconstruction after a disaster require special precautions to avoid rebuilding or increasing vulnerability. these include the precautions mentioned in a-2, as well as correcting deficiencies in risk management policies and institutional capacity as reflected in a-1. a significant share of the new investment will be earmarked to reduce vulnerability to future disasters and improve the country's capacity for comprehensive disaster risk management. particular attention must be given to lessons learned from recent hazard events. the bank will not assume that pre-disaster conditions persist in whole or in part in the affected area. disaster risk assessment of the reconstruction project should be carried out taking into account the specifics of the area, the sector, and the infrastructure concerned, as well as the current environmental, social, and economic situation and any changes in the affected area as a result of the disaster. 5.3. reconstruction may follow as a response to the impacts of natural hazard events, and physical damage (such as structural collapse and explosions) resulting from technological accidents or other types of disasters resulting from human activity. 5.4. the guidelines for directive a-2: risk and project viability, as described in section 4 of these guidelines, also apply to rehabilitation and reconstruction projects. for projects identified as high risk, the disaster risk assessment, and design and implementation of risk reduction measures, will incorporate the lessons learned from the disaster event, including the performance of the physical works, the relevant sectors, institutions, and other project components. risk reduction measures will include enhancements in national, regional, and sectoral risk management policies and strengthening of institutional capacity. 5.5. in order to avoid the rebuilding of or an increase in vulnerability, a proportion of the resources of the operation will be allocated to prevention, mitigation, and risk transfer. the percentage of the total cost is at the discretion of the project team, but will be guided by international practices. used with permission from iadb, 2008. reconstruction facility or immediate response facility for emergencies caused by natural and unexpected disasters. the emergency reconstruction facility can use up to $20 million of the iadb's ordinary capital or up to $10 million of the fund for special operations to assist an impacted country the ifis described in this chapter bstdb) • caribbean development bank (cdb) • council of europe development bank (coeb) • development bank of southern africa (dbsa) • european bank for reconstruction and development (ebrd) • islamic development bank (idb) • north american development bank (nadb) proposed loan: peoples republic of china emergency assistance for wenchuan earthquake reconstruction project european commission fao's mandate. fao website facing the challenge of natural disasters in latin america and the caribbean service sector severely affected by typhoon haiyan nato (north atlantic treaty organization), 2010. pakistan earthquake relief operation ocha-85fm3c/$file/ocha_ar2009_hi%20res.pdf?openelement japan diverts rice to tsunami survivors. world food programme (wfp) roadmap towards a strategy for disaster and climate resilient development in the pacific (srdp) by 2015: executive summary un-habitat. secretary-general's envoy for youth overview of global humanitarian response johannesburg plan of implementation. united nations website disaster profiles: third un conference on least developed countries united nations educational, scientific, and cultural organization) unhcr in dubai: first line responder in emergencies. unhcr supply office, dubai. unicef (united nations children's fund) about the unjlc. unjlc website connect and convince to reduce disaster impacts lives saved in viet nam by involving women in disaster planning. press release economics, health, and development: some ethical dilemmas facing the world bank and the international community fast food: wfp's emergency response food aid information system: quantity reporting emergency response framework world bank group to support flood recovery in bosnia and herzegovina through their efforts to mitigate, prepare for, respond to, and recover from natural disasters, multilateral organizations have a major role in international disaster management. all nations are at risk from disasters and, likewise, all nations face the prospect of one day finding themselves requiring help from one or more of these organizations. multilateral organizations direct the collective experience and tools of their member states to benefit all nations in need of assistance-even the wealthiest ones. the progress witnessed by the international disaster management community in recent years can be traced directly to the work of these multilateral organizations, especially focused initiatives such as the international strategy for disaster reduction. provide effective and efficient support to borrowing members in reducing disaster risks and (ii) to facilitate rapid and appropriate assistance by the bank to its borrowers after a disaster. the guidelines are part of the bank's framework for the management of development risk at the country and project levels. there are four possible strategies to manage risks: (i) acceptance, when risks remain below levels deemed tolerable by the parties involved; (ii) prevention and mitigation; (iii) sharing, when risks can be effectively transferred to a third party, for example through insurance; and (iv) rejection ("avoidance"), when the level of risk exceeds the risk level deemed acceptable but cannot be lowered at a reasonable cost. 1.3. the policy directives outline the actions that are to be used both by the iadb staff and by teams of the borrowers, who are responsible for a. country programming-policy directive a-1 b. preparation and execution of new projects-directive a-2 c. loan reformulations for financing disaster response-directive b-1 d. preparation and execution of reconstruction projects-directive b-2 1.4. the guidelines will contribute to the mainstreaming of disaster risk management (drm) into the bank's programming exercises with the borrowers, particularly in high-risk countries.to determine which of the idb's borrowing member countries will require a country risk assessment, a provisional classification of all countries has been prepared. 1.5. the guidelines will be used for the design and implementation of lending programs, technical cooperations, small projects, cofinancing, and preinvestment activities consistent with the identified risk level. they will address ways to manage risk in public and private sector activities within the same project or to another existing project, in order to finance unplanned disaster response. reformulations may thus involve just a single loan or several operations. 4.2. loan reformulation allows for the reallocation of resources from existing loans to other projects under certain circumstances, in the aftermath of disasters, as stipulated in directive b-1 of the policy: 4.3. the bank may approve the reformulation of existing loans in execution in response to disasters if: (i) a state of emergency or disaster has been officially declared by the government; (ii) the impact of the loan reformulation has been estimated taking into account the intended uses and project objectives of the loan or loans to be reformulated relative to the new proposed use of the funds, thereby creating the conditions for more informed decisions on the part of the approving authorities; (iii) adequate transparency and sufficient mechanisms for monitoring, auditing, and reporting the use of the redirected funds are in place, while taking into account the need of a timely response given the nature of the situation; and (iv) a significant share of the redirected funds will be earmarked to reduce the borrower's vulnerability to future disasters and improve the country's capacity for comprehensive disaster risk management. in order to be considered for loan reformulation funding in response to a disaster, the government must have declared a state of emergency or its equivalent, for a region or the country as a whole, according to the laws and regulations of the country. 4.5. the country office should prepare an originating document after the formal declaration of state of emergency by the government, recommending the decisions that should be taken in relation to the projects/programs potentially affected by the disaster. 4.6. the bank may offer technical support to the government in preparing an official request for financing through loan reformulation, on the basis of the originating report. 4.7. once a financing request is received, a project team is appointed, and the approval process of the reformulation operation(s) will follow the established bank procedures on delegation of authority, according to regular bank procedures. once the bank has received an official request from the borrowing country for financing disaster response, the possibility of using fresh idb resources, such as through the immediate response facility (gn-2038-12 and gn-2038-16), is analyzed. if their use is not considered feasible, the impact of the loan reformulation will be estimated by vpc, with support from vps, taking into account the intended uses and project objectives of the loan(s) to be reformulated either: (i) as a provider of funding or (ii) as a recipient of resources. the analysis for operations receiving funding in response to a natural hazard or physical damage from technological activities or other types of disasters resulting from human activity will reflect the nature of the projects, available information, and use of the reallocated resources for an emergency, rehabilitation, and reconstruction. 4.10. the revision of the portfolio in emergency situations should be done jointly with the borrower. those projects whose development objective is unlikely to be achieved should be considered first as candidates for reformulation. the team responsible for the portfolio key: cord-026031-hnf5vayd authors: ford, richard b.; mazzaferro, elisa m. title: emergency care date: 2009-05-21 journal: kirk and bistner's handbook of veterinary procedures and emergency treatment doi: 10.1016/b0-72-160138-3/50002-3 sha: doc_id: 26031 cord_uid: hnf5vayd nan in the event that you suspect peritonitis and have a negative tap with abdominal paracentesis, a diagnostic peritoneal lavage can be performed. to perform abdominal paracentesis, follow this procedure: 1. place the patient in left lateral recumbency and clip a 4-to 6-inch square with the umbilicus in the center. 2. aseptically scrub the clipped area with antimicrobial scrub solution. 3. wearing gloves, insert a 22-or 20-gauge needle or over-the-needle catheter in four quadrants: cranial and to the right, cranial and to the left, caudal and to the right, and caudal and to the left of the umbilicus. as you insert the needle or catheter, gently twist the needle to push any abdominal organs away from the tip of the needle. local anesthesia typically is not required for this procedure, although a light sedative or analgesic may be necessary if severe abdominal pain is present. in some cases, fluid will flow freely from one or more of the needles. if not, gently aspirate with a 3-to 6-ml syringe or aspirate with the patient in a standing position. avoid changing positions with needles in place because iatrogenic puncture of intraabdominal organs may occur. 4. save any fluid collected in sterile red-and lavender-topped tubes for cytologic and biochemical analyses and bacterial culture. monitor hemorrhagic fluid carefully for the presence of clots. normally, hemorrhagic effusions rapidly become defibrinated and do not clot. clot formation can occur in the presence of ongoing active hemorrhage or may be due to the iatrogenic puncture of organs such as the spleen or liver. if abdominal paracentesis is negative, a diagnostic peritoneal lavage can be performed. peritoneal dialysis kits are commercially available but are fairly expensive and often impractical. to perform a diagnostic peritoneal lavage, follow this procedure: 1. clip and aseptically scrub the ventral abdomen as described previously. 2. wearing sterile gloves, cut multiple side ports in a 16-or 18-gauge over-the needle catheter. use care to not cut more than 50% of the circumference of the catheter, or else the catheter will become weakened and potentially can break off in the patient's abdomen. 3. insert the catheter into the peritoneal cavity caudal and to the right of the umbilicus, directing the catheter dorsally and caudally. 4. infuse 10 to 20 ml of sterile lactated ringer's solution or 0.9% saline solution that has been warmed to the patient's body temperature. during the instillation of fluid into the peritoneal cavity, watch closely for signs of respiratory distress because an increase in intraabdominal pressure can impair diaphragmatic excursions and respiratory function. 5. remove the catheter. 6. in ambulatory patients, walk the patient around while massaging the abdomen to distribute the fluid throughout the abdominal cavity. in nonambulatory patients, gently roll the patient from side to side. 7. next, aseptically scrub the patient's ventral abdomen again, and perform an abdominal paracentesis as described previously. save collected fluid for culture and cytologic analyses; however, biochemical analyses may be artifactually decreased because of dilution. remember that you likely will retrieve only a small portion of the fluid that you instilled. during the early stage of repair, granulation tissue, some exudate, and minor epithelialization is observed. place a nonadherent bandage with some antibacterial properties (petroleum or nitrofurazone-impregnated gauze) or absorbent material (foam sponge, hydrogel, or hydrocolloid dressing) in direct contact with the wound to minimize disruption of the granulation tissue bed. next, place an absorbent intermediate layer, followed by a porous outer layer, as previously described. granulation tissue can grow through gauze mesh or adhere to foam sponges and can be ripped away at the time of bandage removal. hemorrhage and disruption of the granulation tissue bed can occur. later in the repair process, granulation tissue can exude sanguineous drainage and have some epithelialization. a late nonadherent bandage is required. the contact layer should be some form of nonadherent dressing, foam sponge, hydrogel, or hydrocolloid substance. the intermediate layer and outer layers should be absorbent material and porous tape, respectively. with nonadherent dressings, wounds with viscous exudates may not be absorbed well. this may be advantageous and enhance epithelialization, provided that complications do not occur. infection, exuberant granulation tissue, or adherence of absorbent materials to the wound may occur and delay the healing process. moist healing is a newer concept of wound management in which wound exudates are allowed to stay in contact with the wound. in the absence of infection a moist wound heals faster and has enzymatic activity as a result of macrophage and polymorphonuclear cell breakdown. enzymatic degradation or "autolytic debridement" of the wound occurs. moist wounds tend to promote neutrophil and macrophage chemotaxis and bacterial phagocytosis better than use of wet-to-dry bandages. a potential complication and disadvantage of moist healing, however, is the development of bacterial colonization, folliculitis, and trauma to wound edges that can occur because of the continuously moist environment. use surfactant-type solutions (constant clens; kendall, mansfield, massachusetts) for initial wound cleansing and debridement. use occlusive dressings for rapid enzymatic debridement with bactericidal properties to aid in wound healing. bandage wet necrotic wounds with a dressing premoistened with hypertonic saline (curasalt [kendall] , 20% saline) to clean and debride the wounds. hypertonic saline functions to desiccate necrotic tissue and bacteria to debride the infected wound. remove and replace the hypertonic saline bandage every 24 to 48 hours. next, place gauze impregnated with antibacterial agents (kerlix amd [kendall] ) over the wound in the bandage layer to act as a barrier to bacterial colonization. if the wound is initially dry or has minimal exudate and is not obviously contaminated or infected, place amorphous gels of water, glycerin, and a polymer (curafil [kendall] ) over the wound to promote moisture and proteolytic healing. discontinue moisture gels such as curafil once the dry wound has become moist. finally, the final stage of moist healing helps to promote the development of a healthy granulation tissue bed. use calcium alginate dressings (curasorb or curasorb zn with zinc [kendall] ) in noninfected wounds with a moderate amount of drainage. alginate gels promote rapid development of a granulation tissue bed and epithelialization. foam dressings also can be applied to exudative wounds after a healthy granulation bed has formed. change foam dressings at least once every 4 to 7 days. for closed wounds without any drainage, such as a laceration that has been repaired surgically, a simple bandage with a nonadherent contact layer (telfa pad [kendall] , for example), intermediate layer of absorbent material, and an outer porous layer (elastikon, vetrap) can 1 be placed to prevent wound contamination during healing. the nonadherent pad will not stick to the wound and cause patient discomfort. because there usually is minimal drainage from the wound, the function of the intermediate layer is more protective than absorptive. any small amount will be absorbed into the intermediate layer of the bandage. it is important in any bandage to place the tape strips or "stirrups" on the patient's limb and then overlap in the bandage, to prevent the bandage from slipping. place the intermediate and tertiary layers loosely around the limb, starting distally and working proximally, with some overlap with each consecutive layer. this method prevents excessive pressure and potential to impair venous drainage. leave the toenails of the third and fourth digits exposed, whenever possible, to allow daily examination of the bandage to determine whether the bandage is impairing venous drainage. if the bandage is too tight and constricting or impeding vascular flow, the toes will become swollen and spread apart. when placed and maintained properly (e.g., the bandage does not get wet), there usually are relatively few complications observed with this type of bandage. in some cases, it is necessary to cover a wound in which a penrose drain has been placed to allow drainage. in many cases, there is a considerable amount of drainage from the drain and underlying soft tissues. the function of the bandage is to help obliterate dead space created by the wound itself, absorb the fluid that drains from the wound and that will contaminate the environment, and prevent external wicking of material from the external environment into the wound. when the bandage is removed, the clinician can examine the amount and type of material that has drained from the wound in order to determine when the drain should be removed. when placing a bandage over a draining wound, the contact layer should be a commercially available nonadherent dressing and several layers of absorbent wide-mesh gauze placed directly over the drain at the distal end of the incision. overlay the layers of gauze with a thick layer of absorbent intermediate dressing to absorb fluid that drains from the wound. if the gauze and intermediate layers are not thick or absorbent enough, there is a potential for the drainage fluid to reach the outer layer of the bandage and provide a source of wicking of bacteria from the external environment into the wound, leading to infection. some wounds such as lacerations have minor bleeding or hemorrhage that require an immediate bandage until definitive care can be provided. to create a pressure bandage, place a nonadherent dressing immediately in contact with the wound, followed by a thick layer of absorbent material, topped by a layer of elastic bandage material such as elastikon or vetrap. unlike the bandage for a closed wound, the top tertiary outer layer should be wrapped with some tension and even pressure around the limb, starting from the distal extremity (toes) and working proximally. the pressure bandage serves to control hemorrhage but should not be left on for long periods. pressure bandages that have been left on for too long can impair nerve function and lead to tissue necrosis and slough. therefore, pressure bandages should be used in the hospital only, so that the patient can be observed closely. if hemorrhage through the bandage occurs, place another bandage over the first until the wound can be repaired definitively. removal of the first bandage will only disrupt any clot that has formed and cause additional hemorrhage to occur. fractures require immediate immobilization to prevent additional patient discomfort and further trauma to the soft tissues of the affected limb. as with all bandages, a contact layer, intermediate layer, and outer layer should be used. place the contact layer in accordance 1 with any type of wound present. the intermediate layer should be thick absorbent material, followed by a top layer of elastic bandage material. an example is to place a telfa pad over a wound in an open distal radius-ulna fracture, followed by a thick layer of cotton gauze cast padding, followed by an elastic layer of kling (johnson & johnson medical, arlington, texas) , pulling each layer tightly over the previous layer with some overlap until the resultant bandage can be "thumped" with the clinician's thumb and forefinger and sound like a ripe watermelon. the bandage should be smooth with consecutive layers of even pressure on the limb, starting distally and working proximally. leave the toenails of the third and fourth digits exposed to monitor for impaired venous drainage that would suggest that the bandage is too tight and needs to be replaced. finally, place a top layer of vetrap or elastikon over the intermediary layer to protect it from becoming contaminated. if the bandage is used with a compound or open fracture, drainage may be impaired and actually lead to enhanced risk of wound infection. bandages placed for initial fracture immobilization are temporary until definitive fracture repair can be performed once the patient's cardiovascular and respiratory status are stable. wounds with exuberant granulation tissue must be handled carefully so as to not disrupt the healing process but to keep an overabundance of tissue from forming that will impair epithelialization. to bandage a wound with exuberant granulation tissue, place a corticosteroid-containing ointment on the wound, followed by a nonadherent contact layer. the corticosteroid will help control the exuberant growth of granulation tissue. next, carefully wrap an absorbent material over the contact layer, followed by careful placement of and overlay of elastic bandage material to place some pressure on the wound. leave the toenails of the third and fourth digits exposed so that circulation can be monitored several times daily. bandages that are too tight must be removed immediately to prevent damage to neuronal tissue and impaired vascularization, tissue necrosis, and slough. because wound drainage may be impaired, there is a risk of infection. gaping wounds or those that have undermined in between layers of subcutaneous tissue and fascia should be bandaged with a pressure bandage to help obliterate dead space and prevent seroma formation. an example of a wound that may require this type of bandage is removal of an infiltrative lipoma on the lateral or ventral thorax. use caution when placing pressure bandages around the thorax or cervical region because bandages placed too tightly may impair adequate ventilation. to place a pressure bandage and obliterate dead space, place a nonadherent contact layer over the wound. usually, a drain is placed in the wound, so place a large amount of wide-mesh gauze at the distal end of the drain to absorb any wound exudate or drainage. place several layers of absorbent material over the site to further absorb any drainage. place a layer of elastic cotton such as kling carefully but firmly over the dead space to cause enough pressure to control drainage. place at least two fingers in between the animal's thorax and the bandage to ensure that the bandage is not too tight. in many cases, the bandage should be placed once the animal has recovered from surgery and is able to stand. if the bandage is placed while the animal is still anesthetized and recumbent, there is a tendency for the bandage to be too tight. finally, the tertiary layer should be an elastic material such as elastikon or vetrap. many wounds require a pressure relief bandage to prevent contact with the external environment. wounds that may require pressure relief for healing include decubitus ulcers, pressure bandage or cast ulcers, impending ulcer areas (such as the ileum or ischium of recumbent or cachexic patients), and surgical repair sites of ulcerated areas. pressure relief bandages can be of two basic varieties: modified doughnut bandage and doughnut-shaped bandage. to create a cup or clamshell splint, follow this procedure (figures 1-7 to 1-11): 1. place a nonadherent contact layer directly over the wound. 2. place stirrups of tape in contact with the skin of the dog, to be placed over the intermediate layer and prevent the bandage from slipping. 3. place a fairly thick layer of absorbent intermediate bandage material over the contact layer such that the bandage is well-padded. pull the tape stirrups and secure them to the intermediate layer. 4. place a length of cast material that has been rolled to the appropriate length, such that the cast material is cupped around the patient's paw, and lies adjacent to the caudal aspect of the limb to the level of the carpus or tarsus. in the case of a clamshell splint, place a layer of cast material on the cranial and caudal aspect of the paw and conform it in place. 5. take the length of cast padding and soak it in warm water after it has been rolled to the appropriate length. wring out the pad, and secure/conform it to the caudal (or cranial and caudal, in the case of a clamshell splint) aspect of the distal limb and paw. 6. secure the cast material in place with a layer of elastic cotton gauze (kling). 7. secure the bandage in place with a snug layer of elastikon or vetrap. short or long splints made of cast material can be incorporated into a soft padded bandage to provide extra support of a limb above and below a fracture site. for a caudal or lateral splint to be effective, it must be incorporated for at least one joint above any fracture site to prevent a fulcrum effect and further disruption or damage to underlying soft tissue structures. a short lateral or caudal splint is used for fractures and luxations of the distal metacarpus, metatarsus, carpus, and tarsus. to place a short lateral or caudal splint, follow this procedure: 1. secure a contact layer as determined by the presence or absence of any wound in the area. 2. place tape stirrups on the distal extremity to be secured later to the intermediate bandage layer and to prevent slipping of the bandage distally. 3. place layers of roll cotton from the toes to the level of the mid tibia/fibula or mid radius/ulna. place the layers with even tension, with some overlap of each consecutive layer, moving distally to proximally on the limb. 4. secure the short caudal or lateral splint and conform it to the distal extremity to the level of the toes and proximally to the level of the mid tibia/fibula or mid radius/ulna. 5. secure the lateral or caudal splint to the limb with another outer layer of elastic cotton (kling). 6. cover the entire bandage and splint with an outer tertiary layer of vetrap or elastikon. make sure that the toenails of the third and fourth digits remain visible to allow daily evaluation of circulation. long lateral or caudal splints are used to immobilize fractures of the tibia/fibula and radius/ulna. the splints are fashioned as directed for short splints but extend proximally to the level of the axilla and inguinal regions to immobilize above the fracture site. â�¢ packed cell volume drops rapidly to less than 20% in the dog and less than 12% to 15% in the cat â�¢ acute loss of more than 30% of blood volume (30 ml/kg in dog, 20 ml/kg in cat) â�¢ clinical signs of lethargy, collapse, hypotension, tachycardia, tachypnea (acute or chronic blood loss) â�¢ ongoing hemorrhage is present â�¢ poor response to crystalloid and colloid infusion â�¢ life-threatening hemorrhage caused by thrombocytopenia or thrombocytopathia â�¢ surgical intervention is necessary in a patient with severe thrombocytopenia or thrombocytopathia plasma support â�¢ life-threatening hemorrhage with decreased coagulation factor activity â�¢ severe inflammation (pancreatitis, systemic inflammatory response syndrome) â�¢ replenish antithrombin (disseminated intravascular coagulation, protein-losing enteropathy or nephropathy) â�¢ surgery is necessary in a patient with decreased coagulation factor activity â�¢ severe hypoproteinemia is present; to partially replenish albumin, globulin, and clotting factors type a cats typically possess weak anti-b antibodies of igg and igm subtypes. transfusion of type b blood into a type a cat will result in milder clinical signs of reaction and a markedly decreased survival half-life of the infused rbcs to just 2 days. because type ab cats possess both moieties on their cell surface, they lack naturally occurring alloantibodies; transfusion of type a blood into a type ab cat can be performed safely if a type ab donor is not available. the life span of an rbc from a type-specific transfusion into a cat is approximately 33 days. . indications for fresh whole blood transfusion include disorders of hemostasis and coagulopathies including disseminated intravascular coagulation, von willebrand's disease, and hemophilia. fresh whole blood and platelet-rich plasma also can be administered in cases of severe thrombocytopenia and thrombocytopathia. stored whole blood and packed rbcs can be administered in patients with anemia. if pcv drops to below 10% or if rapid hemorrhage causes the pcv to drop below 20% in the dog or less than 12% to 1 *indicates that this must be done for each donor being tested. minor crossmatch* 2. obtain a crossmatch segment from blood bank refrigerator for each donor to be crossmatched, or use an edta tube of donor's blood. make sure tubes are labeled prop-erly. 3. collect 2 ml of blood from recipient and place in an edta tube. centrifuge blood for 5 minutes. 4. extract blood from donor tubing. centrifuge blood for 5 minutes. use a separate pipette for each transfer because cross-contamination can occur. 5. pipette plasma off of donor and recipient cells and place in tubes labeled dp and rp, respectively. 6. place 125 âµl of donor and recipient cells in tubes labeled dr and rr, respectively. 7. add 2.5 ml 0.9% sodium chloride solution from wash bottle to each red blood cell (rbc) tube, using some force to cause cells to mix. 8. centrifuge rbc suspension for 2 minutes. 9. discard supernatant and resuspend rbcs with 0.9% sodium chloride from wash bottle. 10 . repeat steps 8 and 9 for a total of three washes. 11. place 2 drops of donor rbc suspension and 2 drops of recipient plasma in tube labeled ma (this is the major crossmatch). 12. place 2 drops of donor plasma and 2 drops recipient rbc suspension in tube labeled mi (this is the minor crossmatch). 13. prepare control tubes by placing 2 drops donor plasma with 2 drops donor rbc suspension (this is the donor control); and place 2 drops recipient plasma with 2 drops recipient rbc suspension (this is the recipient control). 14. incubate major and minor crossmatches and control tubes at room temperature for 15 minutes. 15. centrifuge all tubes for 1 minute. 16. read tubes using an agglutination viewer. 17. check for agglutination and/or hemolysis. 18. score agglutination with the following scoring scale: 4+ one solid clump of cells 3+ several large clumps of cells 2+ medium-sized clumps of cells with a clear background 1+ hemolysis, no clumping of cells neg = negative for hemolysis; negative for clumping of red blood cells fresh whole blood coagulopathy with active hemorrhage (disseminated intravascular coagulation, thrombocytopenia; massive acute hemorrhage; no stored blood available) stored whole blood massive acute or ongoing hemorrhage; hypovolemic shock caused by hemorrhage that is unresponsive to conventional crystalloid and colloid fluid therapy; unavailability of equipment required to prepare blood components packed red blood cells nonregenerative anemia, immune-mediated hemolytic anemia, correction of anemia before surgery, acute or chronic blood loss fresh frozen plasma factor depletion associated with active hemorrhage (congenital: von willebrand's factor, hemophilia a, hemophilia b; acquired: vitamin k antagonist, rodenticide intoxication, dic); acute or chronic hypoproteinemia (burns, wound exudates, body cavity effusion; hepatic, renal, or gastrointestinal loss); colostrum replacement in neonates frozen plasma acute plasma or protein loss; chronic hypoproteinemia; (contains stable colostrum replacement in neonates; hemophilia b and clotting factors) selected clotting factor deficiencies platelet-rich plasma* thrombocytopenia with active hemorrhage (immune-mediated thrombocytopenia, dic); platelet function abnormality (congenital: thrombasthenia in bassett hounds; acquired: nsaids, other drugs) cryoprecipitate congenital factor deficiencies (routine or before surgery): (concentration of factor hemophilia a, hemophilia b, von willebrand's disease, viii, von willebrand's hypofibrinogenemia; acquired factor deficiencies factor, and fibrinogen) *must be purchased because logistically one cannot obtain enough blood simultaneously to provide a significant amount of platelets; platelets infused have a very short (<2 hours) half-life. dic, disseminated intravascular coagulation; nsaids, nonsteroidal antiinflammatory drugs. universal donor (e.g., should be administered whenever possible. because there is no universal donor in the cat and because cats possess naturally occurring alloantibodies, all cat blood should be typed and crossmatched before any transfusion. if fresh whole blood is not available, a hemoglobin-based oxygen carrier (oxyglobin, 2 to 7 ml/kg iv) can be administered until blood products become available. table 1 -4 indicates blood component dose and administration rates. blood products should be warmed slowly to 37â°c before administering them to the patient. blood warmer units are available for use in veterinary medicine to facilitate rapid transfusion without decreasing patient body temperature (thermal angel; enstill medical technologies, inc., dallas, texas). red blood cell and plasma products should be administered in a blood administration set containing a 170-âµm in-line filter. smaller in-line filters (20 âµm) also can be used in cases in which extremely small volumes are to be administered. blood products should be administered over a period of 4 hours, whenever possible, according to guidelines set by the american association of blood banks. the volume of blood components required to achieve a specific increment in the patient's pcv depends largely on whether whole blood or packed rbcs are transfused and whole blood 20 ml/kg will increase max rate: 22 ml/kg/ max: 22 ml/kg/ volume by 10% 24 hours hour packed red 10 ml/kg will increase critically ill blood cells volume by 10% patients (e.g., cardiac failure or renal failure): 3-4 ml/kg/hour fresh frozen 10 ml/kg body mass (repeat 4-10 ml/minute or use rates as for plasma in 2-3 days or in 3-5 days whole blood (infuse within 4-6 hours) or until bleeding stops); monitor act, aptt, and pt before and 1 hour after transfusion cryoprecipitate general: 1 unit/10 kg/12 hours 4-10 ml/minute or use rates as for whole or until bleeding stops blood (infuse within 4-6 hours) hemophilia a: 12-20 units factor viii/kg; 1 unit of cryoprecipitate contains approximately 125 units of factor viii platelet-rich 1 unit/10 kg (1 unit of 2 ml/minute plasma platelet-rich plasma will check platelet count before and 1 hour increase platelet count after transfusion 1 hour after transfusion by 10,000/âµl) whether there is ongoing hemorrhage or rbc destruction. because the pcv of packed rbcs is unusually high (80% for greyhound blood), a smaller total volume is required than whole blood to achieve a comparable increase in the patient's pcv. in general, 10 ml/kg of packed rbcs or 20 ml/kg whole blood will raise the recipient's pcv by 10%. the "rule of ones" states that 1 ml per 1 lb of whole blood will raise the pcv by 1%. if the patient's pcv does not raise by the amount anticipated by the foregoing calculation(s), causes of ongoing hemorrhage or destruction should be considered. the goal of red blood component therapy is to raise the pcv to 25% to 30% in dogs and 15% to 20% in cats. if an animal is hypovolemic and whole blood is administered, the fluid is redistributed into the extravascular compartment within 24 hours of transfusion. this will result in a secondary rise in the pcv 24 hours after the transfusion in addition to the initial rise 1 to 2 hours after the rbc transfusion is complete. the volume of plasma transfused depends largely on the patient's need. in general, plasma transfusion should not exceed more than 22 ml/kg during a 24-hour period for normovolemic animals. thaw plasma at room temperature, or place it in a ziplock freezer bag and run under cool (not warm) water until thawed. then administer the plasma through a blood administration set that contains an in-line blood filter or through a standard driptype administration set with a detachable in-line blood administration filter. the average rate of plasma infusion in a normovolemic patient should not exceed 22 ml/kg/hour. in acute need situations, plasma can be delivered at rates up to 5 to 6 ml/kg/minute. for patients with cardiac insufficiency or other circulatory problems, plasma infusion rates should not exceed 5 ml/kg/hour. plasma or other blood products should not be mixed with or used in the same infusion line as calcium-containing fluids, including lactated ringer's solution, calcium chloride, or calcium gluconate. the safest fluid to mix with any blood product is 0.9% sodium chloride. administer fresh frozen plasma, frozen plasma, and cryoprecipitate at a volume of 10 ml/kg until bleeding is controlled or source of ongoing albumin loss ceases. the goal of plasma transfusion therapy is to raise the albumin to a minimum of 2.0 g/dl or until bleeding stops as in the case of coagulopathies. monitor the patient to ensure that bleeding has stopped, coagulation profiles (act, aptt, and pt) have normalized, hypovolemia has stabilized, and/or total protein is normalizing, which are indications for discontinuing ongoing transfusion therapy. plasma cryoprecipitate can be purchased or manufactured through the partial thawing and then centrifugation of fresh frozen plasma. cryoprecipitate contains concentrated quantities of vwf, factor viii, and fibrinogen and is indicated in severe forms of von willebrand's disease and hemophilia a (factor viii deficiency). platelet-rich plasma must be purchased from a commercial source. one unit of fresh whole blood contains 2000 to 5000 platelets. the viability of the platelets contained in the fresh whole blood is short-lived, just 1 to 2 hours after transfusion into the recipient. because platelet-rich plasma is difficult to obtain, animals with severe thrombocytopenia or thrombocytopathia should be treated with immunomodulating therapies and the administration of fresh frozen plasma. in dogs, blood and plasma transfusions can be administered intravenously or intraosseously. the cephalic, lateral saphenous, medial saphenous, and jugular veins are used most commonly. fill the recipient set so that the blood in the drip chamber covers the filter (normal 170-âµm filter). with small amounts of blood (50 ml) or critically ill patients, use a 40-âµm filter. avoid latex filters for plasma and cryoprecipitate administration. blood can 30 1 emergency care be administered at variable rates, but the routine figure of 4 to 5 ml/minute often is used. normovolemic animals can receive blood at 22 ml/kg/day. dogs in heart failure should receive infusions at no more than 4 ml/kg/hour. volume is given as needed. to calculate the approximate volume of blood needed to raise hematocrit levels, use the following formula for the dog: anticoagulated blood volume (ml) = body mass (kg) ã� 90 ã� pcv desired â�� pcv of recipient pcv of donor in anticoagulant an alternative formula is the following: 2.2 ã� recipient body mass (kg) ã� 30 (dog) ã� pcv desired â�� pcv of recipient pcv of donor in anticoagulant surgical emergencies and shock may require several times this volume within a short period. if greater than 25% of the patient's blood volume is lost, supplementation with colloids, crystalloids, and blood products is indicated for fluid replacement. one volume of whole blood achieves the same increase in plasma as two to three volumes of plasma. if the patient's blood type is unknown and type a-negative whole blood is not available, any dog blood can be administered to a dog in acute need if the dog has never had a transfusion before. if mismatched blood is given, the patient will become sensitized, and after 5 days, destruction of the donor rbcs will begin. in addition, any subsequent mismatched transfusions may cause an immediate reaction (usually mild) and rapid destruction of the transfused rbcs. the clinical signs of a transfusion reaction typically only are seen when type a blood is administered to a type a-negative recipient that has been sensitized previously. incompatible blood transfusions to breeding females can result in isoimmunization and in hemolytic disease in the puppies. the a-negative bitch that receives a transfusion with a-positive and that produces a litter from an a-positive stud can have puppies with neonatal isoerythrolysis. cats with severe anemia in need of a blood transfusion are typically extremely depressed, lethargic, and anorexic. the stress of restraint and handling can push these critically ill patients over the edge and cause them to die. extreme gentleness and care are mandatory in restraint and handling. the critically ill cat should be cradled in a towel or blanket. supplemental flow-by or mask oxygen should be administered, whenever possible, although it may not be clinically helpful until oxygen-carrying capacity is replenished with infusion of rbcs or hemoglobin. blood can be administered by way of cephalic, medial saphenous, or the jugular vein. intramedullary infusion is also possible, if vascular access cannot be accomplished. the average 2-to 4-kg cat can accept 40 to 60 ml of whole blood injected intravenously over a period of 30 to 60 minutes. administer filtered blood at a rate of 5 to 10 ml/kg/hour. the following formula can be used to estimate the volume of blood required for transfusion in a cat: anticoagulated blood volume (ml) = body mass (kg) ã� 70 ã� pcv desired â�� pcv of recipient pcv of donor in anticoagulant the exact overall incidence and clinical significance of transfusion reactions in veterinary medicine are unknown. several studies have been performed that document the incidence of transfusion reactions in dogs and cats. overall, the incidence of transfusion reactions in dogs and cats is 2.5% and 2%, respectively. transfusion reactions can be immune-mediated and non-immune-mediated and can happen immediately or can be delayed until after a transfusion. acute reactions usually occur within minutes to hours of the onset of transfusion but may occur up to 48 hours after the transfusion has been stopped. acute immunologic reactions include hemolysis and acute hypersensitivity including rbcs, platelets, and leukocytes. signs of a delayed immunologic reaction include hemolysis, purpura, immunosuppression, and neonatal isoerythrolysis. acute nonimmunologic reactions include donor cell hemolysis before onset of transfusion, circulatory volume overload, bacterial contamination, citrate toxicity with clinical signs of hypocalcemia, coagulopathies, hyperammonemia, hypothermia, air embolism, acidosis, and pulmonary microembolism. delayed nonimmunologic reactions include the transmission and development of infectious diseases and hemosiderosis. clinical signs of a transfusion reaction typically depend on the amount of blood transfused, the type and amount of antibody involved in the reaction, and whether the recipient has had previous sensitization. monitoring the patient carefully during the transfusion period is essential in recognizing early signs of a transfusion reaction, including those that may become life threatening. a general guideline for patient monitoring is first to start the transfusion slowly during the first 15 minutes. monitor temperature, pulse, and respiration every 15 minutes for the first hour, 1 hour after the end of the transfusion, and every 12 hours minimally thereafter. also obtain a pcv immediately before the transfusion, 1 hour after the transfusion has been stopped, and every 12 hours thereafter. monitor coagulation parameters such as an act and platelet count at least daily in patients requiring transfusion therapy. the most common documented clinical signs of a transfusion reaction include pyrexia, urticaria, salivation/ptyalism, nausea, chills, and vomiting. other clinical signs of a transfusion reaction may include tachycardia, tremors, collapse, dyspnea, weakness, hypotension, collapse, and seizures. severe intravascular hemolytic reactions may occur within minutes of the start of the transfusion, causing hemoglobinemia, hemoglobinuria, disseminated intravascular coagulation, and clinical signs of shock. extravascular hemolytic reactions typically occur later and will result in hyperbilirubinemia and bilirubinuria. pretreatment of patients to help decrease the risk of a transfusion reaction remains controversial, and in most cases, pretreatment with glucocorticoids and antihistamines is ineffective at preventing intravascular hemolysis and other reactions should they occur. the most important component of preventing a transfusion reaction is to screen each recipient carefully and process the donor component therapy carefully before the administration of any blood products. treatment of a transfusion reaction depends on its severity. in all cases, stop the transfusion immediately when clinical signs of a reaction occur. in most cases, discontinuation of the transfusion and administration of drugs to stop the hypersensitivity reaction will be sufficient. once the medications have taken effect, restart the transfusion slowly and monitor the patient carefully for further signs of reaction. in more severe cases in which a patient's cardiovascular or respiratory system become compromised and hypotension, tachycardia, or tachypnea occurs, immediately discontinue the transfusion and administer diphenhydramine (1 mg/kg im), dexamethasone-sodium phosphate (0.25 to 0.5 mg/kg iv), and epinephrine to the patient. the patient should have a urinary catheter and central venous catheter placed for measurement of urine output and central venous pressures. aggressive fluid therapy may be necessary to avoid renal insufficiency or renal damage associated with severe intravascular hemolysis. overhydration with subsequent pulmonary edema generally can be managed with supplemental oxygen administration and intravenous or intramuscular administration of furosemide (2 to 4 mg/kg). plasma products with or without heparin can be administered for disseminated intravascular coagulation. the hbocs can be stored at room temperature and have a relatively long shelf life compared with red blood component products. the hbocs function to carry oxygen through the blood and can diffuse oxygen past areas of poor tissue perfusion. an additional characteristic of hbocs is as a potent colloid, serving to maintain fluid within the vascular space. for this reason, hbocs must be used with caution in euvolemic patients and patients with cardiovascular insufficiency. central venous pressure (cvp) measures the hydrostatic pressure in the anterior vena cava and is influenced by vascular fluid volume, vascular tone, function of the right side of the heart, and changes in intrathoracic pressure during the respiratory cycle. the cvp is not a true measure of blood volume but is used to gauge fluid therapy as a method of determining how effectively the heart can pump the fluid that is being delivered to it. thus the cvp reflects the interaction of the vascular fluid volume, vascular tone, and cardiac function. measure cvp in any patient with acute circulatory failure, large volume fluid diuresis (i.e., toxin or oliguric or anuric renal failure), fluid in-and-out monitoring, and cardiac dysfunction. the placement of central venous catheters and thus cvp measurements is contraindicated in patients with known coagulopathies including hypercoagulable states. to perform cvp monitoring, place a central venous catheter in the right or left jugular vein. in cats and small dogs, however, a long catheter placed in the lateral or medial saphenous vein can be used for trends in cvp monitoring. first, assemble the equipment necessary for jugular catheter (see vascular access techniques for how to place a jugular or saphenous long catheter) and cvp monitoring (box 1-7). after placing the jugular catheter, take a lateral thoracic radiograph to ensure that the tip of the catheter sits just outside of the right atrium for proper cvp measurements (see to establish an intravenous catheter for cvp, follow this procedure: 1. assemble the cvp setup such that the male end of a length of sterile intravenous catheter extension tubing is inserted into the t port of the jugular or medial/lateral saphenous catheter. make sure to flush the length of tubing with sterile saline before connecting it to the patient to avoid iatrogenic air embolism. 2. next, insert the male end of a three-way stopcock into the female end of the extension tubing. 3. attach a 20-ml syringe filled with heparinized sterile 0.9% saline to one of the female ports of the three-way stopcock and either a manometer or a second length of intravenous extension tubing attached to a metric ruler. 4. lay the patient in lateral or sternal recumbancy. 5. turn the stopcock off to the manometer/ruler and on to the patient. infuse a small amount of heparinized saline through the catheter to flush the catheter. 6. next, turn the stopcock off to the patient and on to the manometer. gently flush the manometer or length of extension tubing with heparinized saline from the syringe. use care not to agitate the fluid and create air bubbles within the line or manometer that will artifactually change the cvp measured. 7. next, lower the 0 cm point on the manometer or ruler to the level of the patient's manubrium (if the patient is in lateral recumbancy) or the point of the elbow (if the patient is in sternal recumbancy). 8. turn the stopcock off to the syringe, and allow the fluid column to equilibrate with the patient's intravascular volume. once the fluid column stops falling and the level rises and falls with the patient's heartbeat, measure the number adjacent to the bottom of the meniscus of the fluid column. this is the cvp in centimeters of water (see figure 1 -4). 9. repeat the measurement several times with the patient in the same position to make sure that none of the values has been increased or decreased artifactually in error. alternately, attach the central catheter to a pressure transducer and perform electronic monitoring of cvp. there is no absolute value for normal cvp. the normal cvp for small animal patients is 0 to 5 cm h 2 o. values less than zero are associated with absolute or relative hypovolemia. values of 5 to 10 cm h 2 o are borderline hypervolemia, and values greater than 10 cm h 2 o suggest intravascular volume overload. values greater than 15 cm h 2 o may be correlated with congestive heart failure and the development of pulmonary edema. in individual patients, the trend in change in cvp is more important than absolute values. as a rule of thumb, when using cvp measurements to gauge fluid therapy and avoid vascular and pulmonary overload, the cvp should not increase by more than 5 cm h 2 o in any 24-hour period. if an abrupt increase in cvp is found, repeat the measurement to make sure that the elevated value was not obtained in error. if the value truly has increased dramatically, temporarily discontinue fluid therapy and consider administration of a diuretic. delaforcade am, rozanski ea: central venous pressure and arterial blood pressure measurements, vet clin north am small anim pract 31 (6) the diagnosis of intracellular fluid deficit is difficult and is based more on the presence of hypernatremia or hyperosmolality than on clinical signs. an intracellular fluid deficit is expected when free water loss by insensible losses and vomiting, diarrhea, or urine is not matched by free water intake. consideration of the location of the patient's fluid deficit, history of vomiting and diarrhea, no visible clinical signs of deficit 4% dry mucous membranes, mild skin tenting 5% increased skin tenting, dry mucous membranes, mild tachycardia, normal pulse* 7% increased skin tenting, dry mucous membranes, tachycardia, weak pulse pressure 10% increased skin tenting, dry corneas, dry mucous membranes, 12% elevated or decreased heart rate, poor pulse quality, altered level of consciousness* the respiratory system further contributes to acid-base status by changes in the elimination of carbon dioxide. hyperventilation decreases the blood pco 2 and causes a respiratory alkalosis. hypoventilation increases the blood pco 2 and causes a respiratory acidosis. depending on the altitude, the pco 2 in dogs can range from 32 to 44 mm hg. in cats, normal is 28 to 32 mm hg. venous pco 2 values are 33 to 50 mm hg in dogs and 33 to 45 mm hg in cats. use a systematic approach whenever attempting to interpret a patient's acid-base status. ideally, obtain an arterial blood sample so that you can monitor the patient's oxygenation and ventilation. once an arterial blood sample has been obtained, follow these steps: 1. determine whether the blood sample is arterial or venous by looking at the oxygen saturation (sao 2 ). the sao 2 should be greater than 90% if the sample is truly arterial, although it can be as low as 80% if a patient has severe hypoxemia. 2. consider the patient's ph. if the ph is outside of the normal range, an acid-base disturbance is present. if the ph is within the normal range, an acid-base disturbance may or may not be present. if the ph is low, the patient is acidotic. if the ph is high, the patient is alkalotic. 3. next, look at the base excess or deficit. if the base excess is increased, the patient has higher than normal bicarbonate. if there is a base deficit, the patient may have a low bicarbonate or increase in unmeasured anions (e.g., lactic acid or ketoacids). 4. next, look at the bicarbonate. if the ph is low and the bicarbonate is low, the patient has a metabolic acidosis. if the ph is high and the bicarbonate is elevated, the patient has a metabolic alkalosis. 5. next, look at the paco 2 . if the patient's ph is low and the paco 2 is elevated, the patient has a respiratory acidosis. if the patient's ph is high and the paco 2 is low, the patient has a respiratory alkalosis. 6. finally, if you are interested in the patient's oxygenation, look at the pao 2 . normal pao 2 is greater than 80 mm hg. the metabolic acidosis early in renal failure may be hyperchloremic and later may convert to typical increased anion gap acidosis. 7. next, you must determine whether the disorders present are primary disorders or an expected compensation for disorders in the opposing system. for example, is the patient retaining bicarbonate (metabolic alkalosis) because of carbon dioxide retention (respiratory acidosis)? use the chart in table 1 -6 to evaluate whether the appropriate degree of compensation is occurring. if the adaptive response falls within the expected range, a simple acid-base disorder is present. if the response falls outside of the expected range, a mixed acid-base disorder is likely present. 8. finally, you must determine whether the patient's acid-base disturbance is compatible with the history and physical examination findings. if the acid-base disturbance does not fit with the patient's history and physical examination abnormalities, question the results of the blood gas analyses and possibly repeat them. the most desirable method of assessing the acid-base status of an animal is with a blood gas analyzer. arterial samples are preferred over venous samples, with heparin used as an anticoagulant (table 1-7) . potassium primarily is located in the intracellular fluid compartment. serum potassium is regulated by the actions of the sodium-potassium-adenosinetriphosphatase pump on cellular membranes, including those of the renal tubular epithelium. inorganic metabolic acidosis artifactually can raise serum potassium levels because of redistribution of extracellular potassium in exchange for intracellular hydrogen ion movement in an attempt to correct serum ph. metabolic acidosis potassium is one of the major players in the maintenance of resting membrane potentials of excitable tissue, including neurons and cardiac myocytes. changes in serum potassium can affect cardiac conduction adversely. hyperkalemia lowers the resting membrane potential and makes cardiac cells, particularly those of the atria, more susceptible to depolarization. characteristic signs of severe hyperkalemia that can be observed on an ecg rhythm strip include an absence of p waves, widened qrs complexes, and tall tented or spiked t waves. further increases in serum potassium can be associated with bradycardia, ventricular fibrillation, and cardiac asystole (death). treatment of hyperkalemia consists of administration of insulin (0.25 to 0.5 units/kg, iv regular insulin) and dextrose (1 g dextrose per unit of insulin administered, followed by 2.5% dextrose iv cri to prevent hypoglycemia), calcium (2 to 10 ml of 10% calcium gluconate administered iv slowly to effect), or sodium bicarbonate (1 meq/kg, iv slowly). insulin plus dextrose and bicarbonate therapy help drive the potassium intracellularly, whereas calcium antagonizes the effect of hyperkalemia on the myocardial cells. all of the treatments work within minutes, although the effects are relatively short-lived (20 minutes to 1 hour) unless the cause of the hyperkalemia is identified and treated appropriately (box 1-10). dilution of serum potassium also results from restoring intravascular fluid volume and correcting metabolic acidosis, in most cases. treatment with a fluid that does not contain potassium (preferably 0.9% sodium chloride) is recommended. hypokalemia elevates the resting membrane potential and results in cellular hyperpolarization. hypokalemia may be associated with ventricular dysrhythmias, but the ecg changes are not as characteristic as those observed with hyperkalemia. causes of hypokalemia include renal losses, anorexia, gastrointestinal loss (vomiting, diarrhea), intravenous fluid diuresis, loop diuretics, and postobstructive diuresis (box 1-11). if the serum potassium concentration is known, potassium supplementation in the form of potassium chloride or potassium phosphate can be added to the patient's intravenous fluids. correct serum potassium levels less than 3.0 meq/l or greater than 6.0 meq/l. potassium rates should not exceed 0.5 meq/kg/hour (table 1 -8) . metabolic acidosis from bicarbonate depletion often corrects itself with volume restoration in most small animal patients. patients with moderate to severe metabolic acidosis may benefit from bicarbonate supplementation therapy. the metabolic contribution to acid-base balance is identified by measuring the total carbon dioxide concentration or calculating the bicarbonate concentration. if these measurements are not available, the degree of expected metabolic acidosis can be estimated subjectively by the severity of underlying disease that often contributes to metabolic acidosis: hypovolemic or traumatic shock, septic shock, diabetic ketoacidosis, or oliguric/anuric renal failure. if the metabolic acidosis is estimated to be mild, moderate, or severe, add sodium bicarbonate at 1, 3, and 5 meq/kg body mass, respectively. patients with diabetic ketoacidosis may not require bicarbonate administration once volume replacement and perfusion is restored, and the ketoacids are metabolized to bicarbonate. if the bicarbonate measurement of base deficit is known, the following formula can be used as a gauge for bicarbonate supplementation: base deficit ã� 0.3 = body mass (kg) = meq bicarbonate to administer osmolality osmolality is measured by freezing point depression or a vapor pressure osmometer, or it may be calculated by the following formula: mosm/kg = 2[(na + ) + (k + )] + bun/2.8 + glucose/18 where sodium and potassium are measured in milliequivalents, and bun and glucose are measured in milligrams per deciliter. osmolalities less than 260 mosm/kg or greater 38 1 emergency care than 360 mosm/kg are serious enough to warrant therapy. the difference between the measured osmolality and the calculated osmolality (the osmolal gap) should be less than 10 mosm/kg. if the osmolal gap is greater than 20 mosm/kg, consider the presence of unmeasured anions such as ethylene glycol metabolites. the volume of extracellular fluid is determined by the total body sodium content, whereas the osmolality and sodium concentration are determined by water balance. serum sodium concentration is an indication of the amount of sodium relative to water in the extracellular fluid and provides no direct information about the total body sodium content. unlikely to cause hyperkalemia in presence of normal renal function unless iatrogenic (e.g., continuous infusion of potassium-containing fluids at an excessively rapid rate) acute mineral acidosis (e.g., hydrochloric acid or ammonium chloride) insulin deficiency (e.g., diabetic ketoacidosis) acute tumor lysis syndrome reperfusion of extremities after aortic thromboembolism in cats with cardiomyopathy hyperkalemic periodic paralysis (one case report in a pit bull) mild hyperkalemia after exercise in dogs with induced hypothyroidism infusion of lysine or arginine in total parenteral nutrition solutions nonspecific î²-blockers (e.g., propranolol)* cardiac glycosides (e.g., digoxin)* urethral obstruction ruptured bladder anuric or oliguric renal failure hypoadrenocorticism selected gastrointestinal disease (e.g., trichuriasis, salmonellosis, or perforated duodenal ulcer) late pregnancy in greyhound dogs (mechanism unknown but affected dogs had gastrointestinal fluid loss) chylothorax with repeated pleural fluid drainage hyporeninemic hypoaldosteronism â�  angiotensin-converting enzyme inhibitors (e.g., enalapril)* angiotensin receptor blockers (e.g., losartan)* cyclosporine and tacrolimus* potassium-sparing diuretics (e.g., spironolactone, amiloride, and triamterene)* nonsteroidal antiinflammatory drugs* heparin* trimethoprim* from dibartola sp: fluid, electrolyte and acid-base disorders in small animal practice, st louis, 2005, saunders. *likely to cause hyperkalemia only in conjunction with other contributing factors (e.g., other drugs, decreased renal function, or concurrent administration of potassium supplements). â�  not well documented in veterinary medicine. if refractory hypokalemia is present, supplement magnesium at 0.75 meq/kg/day for 24 hours. alone unlikely to cause hypokalemia unless diet is aberrant administration of potassium-free (e.g., 0.9% sodium chloride or 5% dextrose in water) or potassium-deficient fluids (e.g., lactated ringer's solution over several days) bentonite clay ingestion (e.g., cat litter) alkalemia insulin/glucose-containing fluids catecholamines hypothermia hypokalemic periodic paralysis (burmese cats) albuterol overdosage patients with hyponatremia or hypernatremia may have decreased, normal, or increased total body sodium content (boxes 1-12 and [1] [2] [3] [4] [5] [6] [7] [8] [9] [10] [11] [12] [13] ). an increased serum sodium concentration implies hyperosmolality, whereas a decrease in serum sodium concentration usually, but not always, implies hypoosmolality. the severity of clinical signs of hypernatremia and hyponatremia is related primarily to the rapidity of the onset of the change rather than to the magnitude of the associated plasma hyperosmolality or hypoosmolality. clinical signs of neurologic disturbances include disorientation, ataxia, and seizures, and coma may occur at serum sodium concentrations less than 120 meq/l or greater than 170 meq/l in dogs. therapy of hypernatremia or hyponatremia with fluid containing low or higher concentrations of sodium should proceed with caution, for rapid changes (decreases or increases) of serum sodium and osmolality can cause rapid changes in the intracellular and extracellular fluid flux, leading to intracellular dehydration or edema, even though the serum sodium has not been returned to normal. a rule of thumb is to not raise or lower the serum sodium by more than 15 meq/l during any one 24-hour period. restoration of the serum sodium concentration over a period of 48 to 72 hours is better. in almost all circumstances, an animal will correct its sodium balance with simple fluid restoration. if severe hypernatremia exists that suggests a free water deficit, however, the free water deficit should be calculated from the following formula: hypernatremia can be corrected slowly with 0.45% sodium chloride plus 2.5% dextrose, 5% dextrose in water, or lactated ringer's solution (sodium content: 130 meq/l). correct hyponatremia initially with 0.9% sodium chloride. sodium is balanced predominantly by chloride and bicarbonate. the difference between these concentrations, (na , has been called the anion gap. the normal anion gap is between 12 and 25 meq/l. when the anion gap exceeds 25, consider the possibility of an accumulation of unmeasured anions (e.g., lactate, ketoacids, phosphate, sulfate, ethylene glycol metabolites, and salicylate). abnormalities in the anion gap may be helpful in determining the cause of metabolic acidosis (boxes 1-14 and 1-15). the colloid oncotic pressure of blood is associated primarily with large-molecular-weight colloidal substances in circulation. the major player in maintaining intravascular and interstitial oncotic pressure, the water-retaining property of each fluid compartment, is albumin. albumin contributes roughly 80% to the colloidal oncotic pressure of blood. the majority of albumin is located within the interstitial space. hypoalbuminemia can result from increased loss in the form of protein-losing enteropathy or nephropathy and wound exudates, or it may be due to lack of hepatic albumin synthesis. serum albumin pools are in a constant flux with interstitial albumin. once interstitial albumin pools become depleted from replenishing serum albumin, serum albumin levels can continue to decrease, which can lead to a decrease in colloidal oncotic pressure. serum albumin less than 2.0 g/dl has been associated with inadequate intravascular fluid retention and the development of peripheral edema and third spacing of fluid. oncotic pressure can be restored with the use of artificial or synthetic colloids or natural colloids (see colloids). maintenance fluid requirements have been extrapolated from the formulas used to calculate a patient's daily metabolic energy requirements because it takes 1 ml of water to metabolize 1 kcal of energy (table 1 -9) . the patient's daily metabolic water (fluid) requirements can be calculated by the following formula: administration of an isotonic crystalloid fluid for maintenance requirements often can produce iatrogenic hypokalemia. in most cases, supplemental potassium must be added to prevent hypokalemia resulting from inappetance, kalliuresis, and supplementation with isotonic crystalloid fluids. the most reliable method of determining the degree of fluid deficit is by weighing the animal and calculating acute weight loss. acute weight loss in a patient with volume loss in the form of vomiting, feces, wound exudates, and urine is due to fluid loss and not loss of muscle or fat. lean body mass normally is not gained or lost rapidly enough to cause major changes in body weight. one milliliter of water weighs approximately 1 g. this fact allows calculation of the patient's fluid deficit, if ongoing losses can be measured. when a patient first presents, however, the body weight before a fluid deficit has occurred rarely is known. instead, one must rely on subjective measures of dehydration to estimate the patient's percent dehydration and to calculate the volume of fluid required to rehydrate the patient over the next 24 hours. to calculate the volume deficit, use the following formula: body mass (kg) ã� (% dehydration) ã� 1000 = fluid deficit (ml) the patient's fluid deficit must be added to the daily maintenance fluid requirements and administered over a 24-hour period. ongoing losses can be determined by measuring urine output, weighing the patient at least 2 to 3 times a day, and measuring the volume or weight of vomitus or diarrhea. a crystalloid fluid contains crystals of salts with a composition similar to that of the extracellular fluid space and can be used to maintain daily fluid requirements and replace fluid deficits or ongoing fluid losses (table 110) . metabolic, acid-base, and electrolyte imbalances also can be treated with isotonic fluids with or without supplemental electrolytes and buffers. depending on the patient's clinical condition, choose the specific isotonic crystalloid fluid to replace and maintain the patient's acid-base and electrolyte status ( table 1-11) . crystalloid fluids are readily available, are relatively inexpensive, and can be administered safely in large volumes to patients with no preexisting cardiac or renal disease or cerebral edema. following infusion, approximately 80% of the volume of a crystalloid fluid infused will redistribute to the interstitial fluid compartment. as such, crystalloid fluids alone are ineffective for ongoing intravascular volume depletion when given as a bolus. the crystalloid fluid bolus must be followed by a constant rate infusion, taking into consideration the patient's daily maintenance fluid requirements and ongoing fluid losses. administration of a large volume of crystalloid fluids can cause dilutional anemia and coagulopathies. *30 ã� bw kg + 70 = kcal/day = ml/day. note: this formula will slightly underestimate the requirements for patients that are less than 2 kg and will slightly overestimate the requirements for patients greater than 70 kg. retain fluid in the vascular space, the volume of crystalloid fluid infused (maintenance + deficit + ongoing losses) should be decreased by 25% to 50% to avoid vascular volume overload. two major classes of colloids exist: natural and synthetic. natural colloids (whole blood, packed rbcs, plasma) are discussed elsewhere in this text. concentrated human albumin is a natural purified colloid that recently has become more popular in the treatment of advanced hypoalbuminemia and hypoproteinemia and will be discussed here. synthetic colloids are starch polymers and include dextrans and hetastarch. concentrated human albumin is available as a 5% or 25% solution. the 5% solution has an osmolality similar to that of serum (308 mosm/l), whereas the 25% solution is hyperoncotic (1500 mosm/l). a 25% albumin solution draws fluid from the interstitial space into the intravascular space. concentrated albumin solutions often are used to restore circulating volume when synthetic colloids are not available. albumin not only is important at maintaining the colloidal oncotic pressure of blood but also serves as a valuable free-radical scavenger and carrier of drugs and hormones necessary for normal tissue function and healing. albumin levels less than 2.0 g/dl have been associated with increased morbidity and mortality. concentrated human albumin solutions can be administered as an effective method of restoring interstitial and serum albumin concentrations in situations of acute and chronic hypoalbuminemia. albumin (25%) is available in 50-and 100-ml vials and is more cost-efficient as an albumin replacement than procurement and administration of fresh frozen plasma. recommended albumin infusion rates are 2 to 5 ml/kg over 4 hours, after pretreatment with diphenhydramine. although concentrated human albumin is structurally similar to canine albumin, closely monitor the patient for signs of allergic reaction during and after the infusion. dextran-70 is a synthetic high-molecular-weight polysaccharide (sucrose polymer) with a molecular weight of 70,000 d. particles less than 50,000 d, are cleared rapidly by the kidneys, whereas larger particles are cleared more slowly by the hepatic reticuloendothelial system. dextran-70 can coat platelets and inhibit platelet function and so must be used with caution in patients with known coagulopathies. the total daily dosage should not exceed 40 ml/kg/day. hetastarch (hydroxyethyl starch) is a large-molecular-weight amylopectin polymer, has molecules with a molecular weight that exceeds 100,000 d, and has an average half-life of 24 to 36 hours in circulation. hetastarch can bind with vwf and cause prolongation of the act and aptt; however, it does not cause a coagulopathy. recommended rates of hetastarch infusion are 5-to 10-ml incremental boluses for the treatment of hypotension and 20 to 30 ml/kg/day as a constant rate infusion for maintenance of colloidal oncotic pressure. many are the acceptable ways to administer the fluids prescribed for each patient based on the degree of dehydration, estimation of ongoing losses, ability to tolerate oral fluid, and metabolic, acid-base, and electrolyte derangements. administer the fluids in a manner that is best for the patient and most appropriate for the practice. to determine the rate of intravenous fluid infusion, take the total volume of fluids that have been prescribed and divide the total volume by the total number of hours in a day that intravenous fluids can be delivered safely and monitored. the safest and most accurate way to deliver intravenous fluids, particularly in extremely small animals or those with congestive heart failure, is through an intravenous fluid pump. fluid should not be administered intravenously if the patient cannot be monitored to make sure that the fluids are being delivered at a safe rate and that the fluid line has not become disconnected. supplement fluids over as many hours as possible to allow the patient as much time as possible to redistribute and fully utilize the fluids administered. fluids administered too quickly can cause a diuresis to occur, such that the majority of the fluids administered will be excreted in the urine. if time is limited or if extra time is needed for safe administration of fluids, consider using a combination of intravenously and subcutaneously 46 1 emergency care administered fluids. intravenous is the preferred route of administration of fluids in any patient with dehydration and hypovolemia. as intravascular volume depletion occurs, reflex peripheral vasoconstriction occurs to restore core perfusion. the subcutaneous tissue are not perfused well and therefore fluids administered subcutaneously will not be absorbed well into the interstitial and intravascular spaces. subcutaneously administered fluids can be absorbed slowly and delivered effectively in the management of mild interstitial dehydration and in the treatment of renal insufficiency. subcutaneously administered fluids should never take the place of intravenously administered fluids in a hypovolemic patient or one with severe interstitial dehydration. intramedullary (intraosseous) infusion works well in small patients in which vascular access cannot be established. shock doses of fluids and other substances, including blood products, can be administered under pressure through an intraosseous cannula. because of the inherent discomfort and risk of osteomyelitis with intraosseous infusion, establish vascular access as soon as possible. the safest and most efficient method of intravenous fluid infusion is through a fluid pump. in cases in which a fluid pump is unavailable, infusion by gravity feed is the next option. infusion sets from various manufacturers have calibrated drip chambers such that a specific number of drops will equal 1 ml of fluid. fluid rates can be calculated based on the number of drops that fall into the drip chamber per minute: fluid volume to be infused (ml) = ml/hour number of hours available many pediatric drip sets deliver 60 drops/ml, such that milliliters/hour equals drops/ minute. carefully record fluid orders so that the volume to be administered is recorded as milliliters/hour, milliliters/day, and drops/minute. this will allow personnel to detect major discrepancies and calculation errors more readily. the volume actually delivered should be recorded in the record by nursing personnel. all additives should be listed clearly on the bottle on a piece of adhesive tape or a special label manufactured for this purpose. a strip of adhesive tape also can be attached to the bottle and marked appropriately to provide a quick visualization of the estimate of volume delivered. includes a large-bore flexible orogastric lavage tube, permanent marker or white tape, lubricating jelly, warm water, two large buckets, a roll of 2-inch white tape, and a manual lavage pump. to perform the orogastric lavage, follow this procedure: 1. place all animals under general anesthesia with a cuffed endotracheal tube in place to protect the airway and prevent aspiration of gastric contents into the lungs. 2. place a roll of 2-inch white tape into the animal's mouth, and secure the tape around the muzzle. you will insert the tube through the hole in the center of the roll of tape. 3. next, place the distal end of the tube at the level of the last rib, directly adjacent to the animal's thorax and abdomen. measure the length of the tube from the most distal end to the point where it comes out of the mouth, and label this location on the tube with a permanent marker or piece of white tape. 4. lubricate the distal portion of the tube, and gently insert it through the roll of tape in the animal's mouth. 5. gently push the tube down the esophagus. palpate the tube within the esophagus. two tubes should be palpable, the orogastric tube, and the patient's trachea. push the tube down into the stomach. you can verify location by blowing into the proximal end of the tube and simultaneously auscultating the stomach for borborygmi. 6. insert the manual pump to the proximal end of the tube, and instill the warm water. alternate instilling water with removal of fluid and gastric debris by gravity. repeat the process until the efflux fluid is clear of any debris. 7. save fluid from the gastric efflux fluid for toxicologic analyses. hackett tb: emergency approach to intoxications, clin tech small anim pract 15 (2):82-87, 2000. hypoxia, or inadequate tissue oxygenation, is the primary reason for supplemental oxygen therapy. major causes of hypoxia include hypoventilation, ventilation-perfusion mismatch, physiologic or right-to-left cardiac shunt, diffusion impairment, and decreased fraction of inspired oxygen (table 1-12) . inadequate tissue perfusion caused by low cardiac output or vascular obstruction also can result in circulatory hypoxia. finally, histiocytic hypoxia results from inability of cells to use oxygen that is delivered to them. this form of hypoxia can be observed with various toxin ingestions (bromethalin, cyanide) and in septic shock. a patient's oxygenation status can be monitored invasively by drawing of arterial blood gas samples or noninvasively through pulse oximetry, in most cases (see acid-base physiology and pulse oximetry). inspired air at sea level has a po 2 of 150 mm hg. as the air travels through the upper respiratory system to the level of the alveolus, the po 2 drops to 100 mm hg. tissue oxygen saturation in a normal healthy animal is 95 mm hg. after oxygen has been delivered to the tissues, the oxygen left in the venous system (pvo 2 ) is approximately 40 mm hg. normally, oxygen diffuses across the alveolar capillary membrane and binds reversibly with hemoglobin in rbcs. a small amount of oxygen is carried in an unbound diffusible form in the plasma. when an animal has an adequate amount of hemoglobin and hemoglobin becomes fully saturated while breathing room air, supplemental oxygen administration will only increase the sao 2 a small amount. the unbound form of oxygen dissolved in plasma will increase. if, however, inadequate hemoglobin saturation is obtained by breathing room air, as in a case of pneumonia or pulmonary edema, for example, breathing a higher fraction of inspired oxygen (fio 2 ) will improve bound and unbound hemoglobin levels. the formula for calculating oxygen content of arterial blood is as follows: where cao 2 is the arterial oxygen content, 1.34 is the amount of oxygen that can be carried by hemoglobin (hb), sao 2 is the hemoglobin saturation, and 0.003 ã� pao 2 is the amount of oxygen dissolved (unbound) in plasma. dissolved oxygen actually contributes little to the total amount of oxygen carried in the arterial blood, and the majority depends on the amount or availability of hemoglobin and the ability of the body (ph and respiratory status) to saturate the hemoglobin at the level of the alveoli. oxygen therapy is indicated whenever hypoxia is present. the underlying cause of the hypoxia also must be identified and treated, for chronic, lifelong oxygen therapy is rarely feasible in veterinary patients. if hemoglobin levels are low due to anemia, oxygen supplementation must occur along with rbc transfusions to increase hemoglobin mass. whenever possible, use arterial blood gas analyses or pulse oximetry to gauge a patient's response to oxygen therapy and to determine when an animal can be weaned from supplemental oxygen. the goal of oxygen therapy is to increase the amount of oxygen bound to hemoglobin in arterial blood. oxygen supplementation can be by hood, oxygen cage or tent, nasal or nasopharyngeal catheter, or tracheal tube. in rare cases, administration of oxygen with mechanical ventilation may be indicated. administration of supplemental oxygen to patients with chronic hypoxia is sometimes necessary but also dangerous. with chronic hypoxia the patient develops a chronic respiratory acidosis (elevated paco 2 ) and depends almost entirely on the hypoxic ventilatory drive to breathe. administration of supplemental oxygen increases pao 2 and may inhibit the central respiratory drive, leading to hypoventilation and possibly respiratory arrest. therefore, closely monitor animals with chronic hypoxia that are treated with supplemental oxygen. oxygen hoods can be purchased from commercial sources or can be manufactured in the hospital using a rigid elizabethan collar, tape, and plastic wrap. to make an oxygen hood, place several lengths of plastic wrap over the front of the elizabethan collar and tape them in place. leave the ventral third of the collar open to allow moisture and heat to dissipate and carbon dioxide to be eliminated. place a length of flexible oxygen tubing under the patient's collar into the front of the hood, and run humidified oxygen at a rate of 50 to 100 ml/kg/minute. animals may become overheated with an oxygen hood in place. carefully monitor the patient's temperature so that iatrogenic hyperthermia does not occur. commercially available plexiglass oxygen cages can be purchased from a variety of manufacturers. the best units include a mechanical thermostatically controlled compressor cooling unit, a circulatory fan, nebulizers or humidifiers to moisten the air, and a carbon dioxide absorber. alternately, a pediatric (infant) incubator can be purchased from hospital supply sources, and humidified oxygen can be run into the cage at 2 to 10 l/minute (depending on the size of the cage). high flow rates may be required to eliminate nitrogen and carbon dioxide from the cage. in most cases, the fio 2 inside the cage reaches 40% to 50% using this technique. disadvantages of using an oxygen cage are high consumption/ use of oxygen, rapid decrease in the fio 2 within the cage whenever the cage must be opened for patient treatments, lack of immediate access to the patient, and potential for iatrogenic hyperthermia. one of the most common methods for oxygen supplementation in dogs is nasal or nasopharyngeal oxygen catheters: 1. to place a nasal or nasopharyngeal catheter, obtain a red rubber catheter (8f to 12f, depending on the size of the patient). a. for nasal oxygen supplementation, measure the distal tip of the catheter from the medial canthus of the eye to the tip of the nose. b. for nasopharyngeal oxygen supplementation, measure the catheter from the ramus of the mandible to the tip of the nose. 2. mark the tube length at the tip of the nose with a permanent marker. 3. instill topical anesthetic such as proparacaine (0.5%) or lidocaine (2%) into the nostril before placement. 4. place a stay suture adjacent to (lateral aspect) the nostril while the topical anesthetic is taking effect. 5. lubricate the tip of the tube with sterile lubricant. 6. gently insert the tube into the ventral medial aspect of the nostril to the level made with the permanent marker. if you are inserting the tube into the nasopharynx, push the nasal meatus dorsally while simultaneously pushing the lateral aspect of the nostril medially to direct the tube into the ventral nasal meatus and avoid the cribriform plate. 7. once the tube has been inserted to the appropriate length, hold the tube in place with your fingers adjacent to the nostril, and suture the tube to the stay suture. if the tube is removed, you can cut the suture around the tube and leave the stay suture in place for later use, if necessary. 8. suture or staple the rest of the tube dorsally over the nose and in between the eyes to the top of the head, or laterally along the zygomatic arch. 9. attach the tube to a length of flexible oxygen tubing, and provide humidified oxygen at 50 to 100 ml/kg/minute. 10. secure an elizabethan collar around the patient's head to prevent the patient from scratching at the tube and removing it. the rule of 60s states that if a patient's pao 2 is less than 60 mm hg, or if the paco 2 is 60 mm hg, mechanical ventilation should be considered. for mechanical ventilation, anesthetize the patient and intubate the patient with an endotracheal tube. alternately, a temporary tracheostomy can be performed and the patient can be maintained on a plane of light to heavy sedation and ventilated through the tracheostomy site. this method, a noninvasive means of determining oxygenation is through the use of pulse oximetry. a pulse oximeter uses different wavelengths of light to distinguish characteristic differences in the properties of the different molecules in a fluid or gas mixture, in this case, oxygenated (oxyhemoglobin) and deoxygenated hemoglobin (deoxyhemoglobin) in pulsatile blood. the process is termed pulse oximetry. oxyhemoglobin and deoxyhemoglobin are different molecules that absorb and reflect different wavelengths of light. oxyhemoglobin absorbs light in the infrared spectrum, allowing wavelengths of light in the red spectrum to transmit through it. conversely, deoxyhemoglobin absorbs wavelengths of the red spectrum and allows wavelengths in the infrared spectrum to transmit through the molecule. the spectrophotometer in the pulse oximeter transmits light in the red (660 nanometers) and infrared (920 nanometers) spectra. the different wavelengths of light are transmitted across a pulsatile vascular bed and are detected by a photodetector on the other side. the photodetector processes the amount of light of varying wavelengths that reaches it, then transmits an electrical current to a processor that calculates the difference in the amount of light originally transmitted and the amount of light of similar wavelength that actually reaches the photodetector. the difference in each reflects the amount of light absorbed in the pulsatile blood and can be used to calculate the amount or ratio of oxyhemoglobin to deoxyhemoglobin in circulation, or the functional hemoglobin saturation by the formula: where hbo 2 is oxygenated hemoglobin, and hb is deoxygenated hemoglobin. four molecules of oxygen reversibly bind to hemoglobin for transport to the tissues. carbon monoxide similarly binds to hemoglobin and forms carboxyhemoglobin, a molecule that is detected similarly as oxygenated hemoglobin. thus sao 2 as detected by a pulse oximeter is not reliable if carboxyhemoglobin is present. in most cases, pulse oximetry or sao 2 corresponds reliably to the oxyhemoglobin dissociation curve. oxygen saturation greater than 90% corresponds to a pao 2 greater than 60 mm hg. above this value, large changes in pao 2 are reflected in relatively small changes in sao 2 , making pulse oximetry a relatively insensitive method of determining oxygenation status when pao 2 is normal. because pulse oximetry measures oxygenated versus nonoxygenated hemoglobin in pulsatile blood flow, it is fairly unreliable when severe vasoconstriction, hypothermia, shivering or trembling, or excessive patient movement are present. additionally, increased ambient lighting and the presence of methemoglobin or carboxyhemoglobin also can cause artifactual changes in the sao 2 , and thus the measurement is not reliable or accurate. most pulse oximeters also display a waveform and the patient's heart rate. if the photodetector does not detect a good quality signal, the waveform will not be normal, and the heart rate displayed on the monitor will not correlate with the patient's actual heart rate. the efficiency of ventilation is evaluated using the paco 2 value on an arterial blood gas sample. alternatively, a noninvasive method to determine end-tidal carbon dioxide is through use of a capnograph. the science of capnometry uses a spectrophotometer to measure carbon dioxide levels in exhaled gas. the capnometer is placed in the expiratory limb of an anesthetic circuit. a sample of exhaled gas is aliquoted from the breath, and an infrared light source is passed across the sample. a photodetector on the other side of the sample flow measures the amount or concentration of carbon dioxide in the sample of expired gas. the calculated value is displayed as end-tidal carbon dioxide. this value also can be displayed as a waveform. when placed in graphic form, a waveform known as a capnograph is displayed throughout the ventilatory cycle. normally, at the onset of exhalation, the gas exhaled into the expiratory limb of the tubing comes from the upper airway or physiologic dead space and contains relatively little carbon dioxide. as exhalation continues, a steep uphill slope occurs as more carbon dioxide is exhaled from the bronchial tree. near the end of exhalation, the capnogram reaches a plateau, which most accurately reflects the carbon dioxide level at the level of the alveolus. because carbon dioxide diffuses across the alveolar basement membrane so rapidly, this reflects arterial carbon dioxide levels. if a plateau is not reached and notching of the waveform occurs, check the system for leaks. if the baseline waveform does not reach zero, the patient may be rebreathing carbon dioxide or may be tachypneic, causing physiologic positive end-expiratory pressure. the soda-sorb in the system should be replaced if it has expired. conversely, low end-tidal carbon dioxide may be associated with a decrease in perfusion or blood flow. decreased perfusion can be associated with low end-tidal carbon dioxide values, particularly during cardiopulmonary cerebral resuscitation. end-tidal carbon dioxide levels are one of the most accurate predictors of the efficacy of cardiopulmonary cerebral resuscitation and patient outcome. additionally, the difference between arterial carbon dioxide levels (paco 2 ) and end-tidal carbon dioxide can be used to calculate dead-space ventilation. increases in the difference also occur with poor lung perfusion and pulmonary diffusion impairment. thoracocentesis refers to the aspiration of fluid or air from within the pleural space. thoracocentesis may be diagnostic to determine whether air or fluid is present and to characterize the nature of the fluid obtained. thoracocentesis also can be therapeutic when removing large volumes of air or fluid to allow pulmonary reexpansion and correction of hypoxemia and orthopnea. to perform thoracocentesis, follow this procedure: 1. first, assemble the equipment necessary (box 1-16). 2. next, clip a 10-cm square in the center of the patient's thorax on both sides. 3. aseptically scrub the clipped area. 4. ideally, thoracocentesis should be performed within the seventh to ninth intercostal space. rather than count rib spaces in an emergent situation, visualize the thoracic cage as a box, and the clipped area as a box within the box. you will insert your needle or catheter in the center of the box and then direct the bevel of the needle dorsally or ventrally to penetrate pockets of fluid or air present. 5. attach the needle or catheter hub to the length of intravenous extension tubing. attach the female port of the intravenous extension tubing to the male port of the three-way stopcock. attach the male port of the 60-ml syringe to one of the female ports of the three-way stopcock. the apparatus is now assembled for use. 6. insert the needle through the intercostal space such that the bevel of the needle initially is directed downward. 7. next, push down on the hub of the needle such that the needle becomes parallel with the thoracic wall. by moving the hub of the needle in a clockwise or counterclockwise manner, the bevel of the needle will move within the thoracic cavity to penetrate pockets of air or fluid. in general, air is located dorsally and fluid is located more ventrally, although this does not always occur. 8. aspirate air or fluid. save any fluid obtained for cytologic and biochemical analyses and bacterial culture and susceptibility testing. in cases of pneumothorax, if the thoracocentesis needs to be repeated more than 3 times, consider using a thoracostomy tube. place a thoracostomy tube in cases of pneumothorax whenever negative suction cannot be obtained or repeated accumulation of air requires multiple thoracocentesis procedures. thoracostomy tubes also can be placed to drain rapidly accumulating pleural effusion and for the medical management of pyothorax. before attempting thoracostomy tube placement, make sure that all necessary supplies are assembled (box 1-17; table 1-13) . to place a thoracostomy tube, follow this procedure: 1. lay the patient in lateral recumbency. 2. clip the patient's entire lateral thorax. 3. aseptically scrub the lateral thorax. 4. palpate the tenth intercostal space. 5. have an assistant pull the patient's skin cranially and ventrally toward the point of the elbow. this will facilitate creating a subcutaneous tunnel around the thoracostomy tube. 6. draw up 2 mg/kg 2% lidocaine (1 mg/kg for cats) along with a small amount of sodium bicarbonate to take away some of the sting. 7. insert the needle at the dorsal aspect of the tenth intercostal space and to the seventh intercostal space. inject the lidocaine into the seventh intercostal space at the point where the trocarized thoracic drainage catheter will penetrate into the thoracic cavity. slowly infuse the lidocaine as you withdraw the needle to create an anesthetized tunnel through which to insert the catheter. 8. while the local anesthetic is taking effect, remove the trocar from the catheter and cut the proximal end of the catheter with a mayo scissors to facilitate adaptation with the christmas tree adapter. 9. attach the christmas tree adapter to the three-way stopcock and the three-way stopcock to a length of intravenous extension tubing and the 60-ml syringe so that the apparatus can be attached immediately to the thoracostomy tube after placement. 10. aseptically scrub the lateral thorax a second time and then drape it with sterile huck towels secured with towel clamps. 11. wearing sterile gloves, make a small stab incision at the dorsal aspect of the tenth intercostal space. 12. insert the trocar back into the thoracostomy drainage tube. insert the trocar and tube into the incision. tunnel the tube cranially for approximately 3 intercostal spaces while an assistant simultaneously pulls the skin cranially and ventrally toward the point of the elbow. 13. at the seventh intercostal space, direct the trocar and catheter perpendicular to the thorax. grasp the catheter apparatus at the base adjacent to the thorax to prevent the trocar from going too far into the thorax. 14. place the palm of your dominant hand over the end of the trocar, and push the trocar and catheter into the thoracic cavity, throwing your weight into the placement in a swift motion, not by banging the butt of your hand on the end of the stylette. for small individuals, standing on a stool, or kneeling over the patient on the triage table can create leverage and make this process easier. the tube will enter the thorax with a pop. 15. gently push the catheter off of the stylette, and remove the stylette. 16. immediately attach the christmas tree adapter and have an assistant start to withdraw air or fluid while you secure the tube in place. 17. first, place a horizontal mattress suture around the tube to cinch the skin securely to the tube. use care to not penetrate the tube with your needle and suture. 18. next, place a purse-string suture around the tube at the tube entrance site. leave the ends of the suture long, so that you can create a finger-trap suture to the tube, holding the tube in place. 19. place a large square of antimicrobial-impregnated adhesive tape over the tube for further security and sterility. 20. if antimicrobial adhesive is not available, place a gauze pad 4 ã� 4 inches square over the tube, and then wrap the tube to the thorax with cotton roll gauze and elastikon adhesive tape. 21. draw the location of the tube on the bandage to prevent cutting it with subsequent bandage changes. an alternate technique to use if a trocar thoracic drainage catheter is not available is the following: 1. prepare the lateral thorax and infuse local lidocaine anesthetic as listed before. 2. make a small stab incision with a no. 10 scalpel blade, as listed before. 3. obtain the appropriately sized red rubber catheter and cut multiple side ports in the distal end of the catheter, taking care to not cut more than 50% of the circumference of the diameter of the tube. 4. insert a rigid, long urinary catheter into the red rubber catheter to make the catheter more rigid during insertion into the pleural space. 5. grasp the distal end of the catheter(s) in the teeth of a large carmalt. tunnel a metzenbaum scissors under the skin to the seventh intercostal space and make a puncture through the intercostal space. 6. remove the metzenbaum scissors, and then tunnel the carmalt and red rubber tube under the skin to the hole created in the seventh intercostal space with the metzenbaum scissors. 7. insert the tips of the carmalt and the red rubber catheter through the hole, and then open the teeth of the carmalt. 8. push the red rubber catheter cranially into the pleural cavity. 9. remove the carmalt and the rigid urinary catheter, and immediately attach the suction apparatus. secure the red rubber catheter in place as listed before. placement of a temporary tracheostomy can be lifesaving to relieve upper respiratory tract obstruction, to facilitate removal of airway secretions, to decrease dead space ventilation, to provide a route of inhalant anesthesia during maxillofacial surgery, and to facilitate mechanical ventilation. in an emergent situation in which asphyxiation is imminent and endotracheal intubation is not possible, any cutting instrument placed into the trachea distal to the point of obstruction can be used. to perform a slash tracheostomy, quickly clip the fur and scrub the skin over the third tracheal ring. make a small cut in the trachea with a no. 11 scalpel blade, and insert a firm tube, such as a syringe casing. alternately, insertion of a 22-gauge needle attached to intravenous extension tubing and adapted with a 1-ml syringe case to attach to a humidified oxygen source also temporarily can relieve obstruction until a temporary tracheostomy can be performed. in less emergent situations, place the patient under general anesthesia and intubate the patient. assemble all the equipment necessary before starting the temporary tracheostomy procedure (box 1-18). to perform a tracheostomy, follow this procedure: 1. place the patient in dorsal recumbency. 2. clip the ventral cervical region from the level of the ramus of the mandible caudally to the thoracic inlet and dorsally to midline. 3. aseptically scrub the clipped area, and then drape with sterile huck towels secured with towel clamps. 4. make a 3-cm ventral midline skin incision over the third to sixth tracheal rings, perpendicular to the trachea. 5. bluntly dissect through the sternohyoid muscles to the level of the trachea. 6. carefully pick up the fascia overlying the trachea and cut it away with a metzenbaum scissors. 7. place two stay sutures through/around adjacent tracheal rings. 8. incise in between trachea rings with a no. 11 scalpel blade. take care to not cut more than 50% of the circumference of the trachea. 9. using the stay sutures, pull the edges of the tracheal incision apart, and insert the tracheostomy tube. the shiley tube contains an internal obturator to facilitate placement into the tracheal lumen. remove the obturator, and then insert the inner cannula, which can be removed for cleaning as needed. 10. once the tube is in place, secure the tube around the neck with a length of sterile umbilical tape. postoperative care of the tracheostomy tube is as important as the procedure itself. because the tracheostomy tube essentially bypasses the protective effects of the upper respiratory system, one of the most important aspects of tracheostomy tube care and maintenance is to maintain sterility at all times. any oxygen source should be humidified with sterile water or saline to prevent drying of the respiratory mucosa. if supplemental oxygen is not required, instill 2 to 3 ml of sterile saline every 1 to 2 hours to moisten the mucosa. wearing sterile gloves, remove the internal tube and place it in a sterile bowl filled with sterile hydrogen peroxide and to be cleaned every 4 hours (or more frequently as necessary). if a shiley tube is not available, apply suction to the internal lumen of the tracheostomy tube every 1 to 2 hours (or more frequently as needed) with a sterile 12f red rubber catheter attached to a vacuum pump to remove any mucus or other debris that potentially could plug the tube. unless the patient demonstrates clinical signs of fever or infection, the prophylactic use of antibiotics is discouraged because of the risk of causing a resistant infection. after the temporary tracheostomy is no longer necessary, remove the tube and sutures, and leave the wound to heal by second intention. primary closure of the wounds could predispose the patient to subcutaneous emphysema and infection. baker gd: trans-tracheal oxygen therapy in dogs with severe respiratory compromise due to tick (i. holocyclus) toxicity, aust vet pract 34 (2) urohydropulsion is a therapeutic procedure for removal of uroliths from the urethra of the male dog. the technique works best if the animal is heavily sedated or is placed under general anesthesia (figure 1-12) . to perform urohydropulsion, follow this procedure: 1. place the animal in lateral recumbency. 2. clip the fur from the distal portion of the prepuce. 3. aseptically scrub the prepuce and flush the prepuce with 12 to 20 ml of antimicrobial flush solution. 4. have an assistant who is wearing gloves retract the penis from the prepuce. 5. while wearing sterile gloves, lubricate the tip of a rigid urinary catheter as for urethral catheterization. 6. gently insert the tip of the catheter into the urethra until you meet the resistance of the obstruction. 7. pinch the tip of the penis around the catheter. 8. have an assistant insert a gloved lubricated finger into the patient's rectum and press ventrally on the floor of the rectum to obstruct the pelvic urethra. 9. attach a 60-ml syringe filled with sterile saline into proximal tip of the catheter. 10. quickly inject fluid into the catheter and alternate compression and relaxation on the pelvic urethra such that the urethra dilates and suddenly releases the pressure, causing dislodgement of the stone. small stones may be ejected from the tip of the urethra, whereas larger stones may be retropulsed back into the urinary bladder to be removed surgically at a later time. the type of catheter that you choose for vascular access depends largely on the size and species of the patient, the fragility of the vessels to be catheterized, the proposed length of time that the catheter will be in place, the type and viscosity of the fluid or drug to be administered, the rate of fluid flow desired, and whether multiple repeated blood samples will be required (table 1-14) . a variety of over-the-needle, through-the-needle, and over-the-wire catheters are available for placement in a variety of vessels, including the jugular, cephalic, accessory cephalic, medial saphenous, lateral saphenous, dorsal pedal artery, and femoral artery. one of the most important aspects of proper catheter placement and maintenance is to maintain cleanliness at all times. the patient's urine, feces, saliva, and vomit are common sources of contamination of the catheter site. before placing a peripheral or central catheter in any patient, consider the patient's physical status including whether vomiting, diarrhea, excessive urination, or seizures. in a patient with an oral mass that is drooling excessively or a patient that is vomiting, peripheral cephalic catheterization may not be the most appropriate, to prevent contamination. conversely, in a patient with excessive urination or diarrhea, a lateral or medial saphenous catheter is likely to become contaminated quickly. whenever one places or handles a catheter or intravenous infusion line, the person should wash the hands carefully and wear gloves to prevent contamination of the intravenous catheter and fluid lines. one of the most common sources of catheter contamination in veterinary hospitals is through caretakers' hands. in emergent situations, placement of a catheter may be necessary under less than ideal circumstances. remove those catheters as soon as the patient is more stable, and place a second catheter using aseptic techniques. in general, once the location of the catheter has been decided, set up all equipment necessary for catheter placement before starting to handle and restrain the patient. lists the equipment needed for most types of catheter placement. after setting up all of the supplies needed, clip the fur over the site of catheter placement. make sure to clip all excess fur and long feathers away from the catheter site, to prevent contamination. for catheter placement in limbs, clip the fur circumferentially around the site of catheter placement to facilitate adherence of the tape to the limb and to facilitate catheter removal with minimal discomfort at a later date. next, aseptically scrub the catheter site with an antimicrobial scrub solution such as hibiclens. the site is now ready for catheter insertion. consider using a central venous catheter whenever multiple repeated blood samples will need to be collected from a patient during the hospital stay. central venous catheters also can be used for cvp measurement, administration of hyperoncotic solutions such as parenteral nutrition, and administration of crystalloid and colloid fluids, anesthesia, and other injectable drugs (figures 1-13 and 1-14) . to place a jugular central venous catheter, place the patient in lateral recumbancy and extend the head and neck such that the jugular furrow is straight. clip the fur from the ramus of the mandible caudally to the thoracic inlet and dorsally and ventrally to midline. wipe the clipped area with gauze 4 ã� 4-inch squares to remove any loose fur and other debris. aseptically scrub the clipped area with an antimicrobial cleanser. venocaths (abbott laboratories) are a through-the-needle catheter that is contained within a sterile sleeve for placement. alternately, other over-the-wire central venous catheters can be placed by the seldinger technique. sterility must be maintained at all times, regardless of the type of catheter placed. wearing sterile gloves, drape the site of catheter placement with sterile drapes, and occlude the jugular vein at the level of the thoracic inlet. pull the clear ring and wings of emergency diagnostic and therapeutic procedures 59 1 figure 1 -13: lateral thoracic radiograph of a central venous catheter. note that the tip of the catheter is inserted in its proper location, just outside of the right atrium. the catheter cover down toward the catheter itself to expose the needle. remove the guard off of the needle. lift the skin over the proposed site of catheter insertion and insert the needle under the skin, with the bevel of the needle facing up. next, reocclude the vessel and pull the skin tight over the vessel to prevent movement of the vessel as you attempt to insert the needle. in some cases, it may be difficult actually to see the vessel in obese patients. if you cannot visualize or palpate the needle, gently bounce the needle over the vessel with the bevel up. the vessel will bounce in place slightly, allowing a brief moment of visualization to facilitate catheter placement. once the vessel has been isolated and visualized, insert the needle into the vessel at a 15-to 30-degree angle. watch closely for a flash of blood in the catheter. when blood is observed, insert the needle a small distance farther, and then push the catheter and stylette into the vessel for the entire length, until the catheter and stylette can be secured in the catheter hub. if the catheter cannot be inserted fully into the vessel for its entire length, the tip of the needle may not be within the entire lumen, the catheter may be directed perivascularly, and the catheter may be caught at the thoracic flexure and may be moving into one of the tributaries that feeds the forelimb. extend the patient's head and neck, and lift the forelimb up to help facilitate placement. do not force the catheter in because the catheter potentially can form a knot and will need to be removed surgically. remove the needle from the vessel, and have an assistant place several 4 ã� 4-inch gauze squares over the site of catheter placement with some pressure to control hemorrhage. secure the catheter hub into the needle guard, and remove the stylette from the catheter. immediately insert a 3-to 6-ml syringe of heparinized saline and flush the catheter and draw back. if you are in the correct place, you will be able to draw blood from the catheter. to secure the catheter in place, tear a length of 1-inch white tape that will wrap around the patient's neck. pull a small length of the catheter out of the jugular vein to make a semicircle. the semicircle should be approximately 1 /2 inch in diameter. let the length of catheter lie on the skin, and then place 4 ã� 4-inch gauze squares impregnated with antimicrobial ointment over the site of catheter insertion. secure the proximal end of white tape around the white and blue pieces of the catheter, and wrap the tape around the patient's neck so that the tape adheres to the skin and fur. repeat the process by securing the gauze to the skin with two additional lengths of white tape, starting to secure the gauze in place by first wrapping the tape dorsally over the patient's neck, rather than under the patient's neck. in between each piece of tape and bandage layer, make sure that the catheter flushes and draws back freely, or else occlusion can occur. gently wrap layers of cotton roll gauze, kling, and elastikon or vetrap over the catheter. secure a male adapter or t port that has been flushed with heparinized saline, and then label the catheter with the size and length of catheter, date of catheter placement, and initials of the person who placed the catheter. the catheter is ready for use. monitor the catheter site daily for erythema, drainage, vessel thickening, or pain upon infusion. if any of these signs occur, or if the patient develops a fever of unknown origin, remove the catheter, culture the catheter tip aseptically, and replace the catheter in a different location. as long as the catheter is functional without complications, the catheter can remain in place. central catheters also can be placed via the seldinger or over-the-wire technique. a number of companies manufacture kits that contain the supplies necessary for over-the-wire catheter placement. each kit minimally should contain an over-the-needle catheter to place into the vessel, a long wire to insert through the original catheter placed, a vascular dilator to dilate the hole in the vessel created by the first catheter, and a long catheter to place into the vessel over the wire. additional accessories can include a paper drape, sterile gauze, a scalpel blade, local anesthetic, 22-gauge needles, and 3-or 6-ml syringes. restrain the patient and prepare the jugular furrow aseptically as for the percutaneous through-the-needle catheter placement. the person placing the catheter should wear sterile gloves throughout the process to maintain sterility. pick up the skin over the site of catheter placement, and insert a small bleb of local anesthetic through the skin. the local anesthetic should not be injected into the underlying vessel (figure 1-15) . make a small nick into the skin through the local anesthetic with a no. 10 or no. 11 scalpel blade. use care to avoid lacerating the underlying vessel. next, occlude the jugular vein as previously described, and insert the over-the-needle catheter into the vessel. watch for a flash of blood in the catheter hub. remove the stylette from the catheter. next, insert the long wire into the catheter and into the vessel (figures 1-16 and 1-17) . never let go of the wire. remove the catheter, and place the vascular dilator over the wire and into the vessel (figure 1-18) . gently twist to place the dilator into the vessel a short distance, creating a larger hole in the vessel. the vessel will bleed more after creating a larger hole. remove the vascular dilator, and leave the wire in place within the vessel. insert the long catheter over the wire into the vessel (figure 1-19) . push the catheter into the vessel to the catheter hub (figure 1-20) . slowly thread the wire through a proximal port in the catheter. once the catheter is in place, remove the wire, and suture the catheter in place to the skin with nonabsorbable suture. cover the catheter site with sterile gauze and antimicrobial ointment, cotton roll bandaging material, gauze, and kling or vetrap. flush the catheter with heparinized saline solution, and then use the catheter for infusion of parenteral nutrition, blood products, crystalloid and colloid fluids, medications, and frequent blood sample collection. examine the catheter site daily for evidence of infection or thrombophlebitis. the catheter can remain in place as long as it functions and no complications occur. place the patient in sternal recumbency as for cephalic venipuncture. clip the antebrachium circumferentially, and wipe the area clean of any loose fur and debris (figure 1-21) . aseptically scrub the clipped area, and have an assistant occlude the cephalic vein at the crook of the elbow. the person placing the catheter should grasp the distal carpus with the nondominant hand and insert the over-the-needle catheter into the vessel at a 15-to 30-degree angle ( figure 1-22) . watch for a flash of blood in the catheter hub, and then gently push the catheter off of the stylette (figure 1-23) . have the assistant occlude the vessel over the catheter to prevent backflow. flush the catheter with heparinized saline solution. make sure that the skin and catheter hub are clean and dry to ensure that the tape adheres to the catheter hub and skin. secure a length of 1 /2-inch white tape tightly around the catheter and then around the limb. make sure that the catheter hub does not "spin" in the tape, or else the catheter will fall out. next, secure a second length of 1-inch adhesive tape under the catheter and around the limb and catheter hub (figure 1-24 ). this piece of tape helps to stabilize the catheter in place. finally, place a flushed t port or male adapter in the catheter hub and secure to the limb with white tape. make sure that the tape is adhered to the skin securely, but not so tightly as to impede venous outflow (figure 1-25) . the catheter site can be covered with a cotton ball impregnated with antimicrobial ointment and layers of bandage material. label all catheters with the date of placement, the type and gauge of catheter inserted, and the initials of the person who placed the catheter. the femoral artery can be catheterized for placement of an indwelling arterial catheter. indwelling arterial catheters can be used for continuous invasive arterial blood pressure monitoring and for procurement of arterial blood samples. place the patient in lateral recumbancy, and tape the down leg in an extended position. clip the fur over the femoral artery and aseptically scrub the clipped area. palpate the femoral artery as it courses distally on the medial surface of the femur and anterior to the pectineus muscle. make a small nick incision over the proposed site of catheter placement using the bevel of an 18-gauge needle. place a long over-the-needle catheter through the nick in the skin and direct it toward the palpable pulse. place the tip of the catheter so that the needle tip rests in the subcutaneous tissue between the artery and the palpating index finger. advance the needle steeply at a 30-degree angle to secure the superficial wall of the vessel and then the deep wall of the vessel. the spontaneous flow of blood in the catheter hub ensures that the catheter is 1 figure 1 -25: catheter is taped in place with a t-port. situated in the lumen of the artery. feed the catheter off of the stylette, and cover the hub with a catheter cap. flush the catheter with sterile heparinized saline solution, and then secure it in place. some persons simply tape the catheter in place with pieces of 1 /2-and 1-inch adhesive tape. others use a "butterfly" piece of tape around the catheter hub and suture or glue the tape to the adjacent skin for added security. the dorsal pedal artery commonly is used for catheter placement. to place a dorsal pedal arterial catheter, place the patient in lateral recumbency. clip the fur over the dorsal pedal artery, and then aseptically scrub the clipped area. tape the distal limb so that the leg is twisted slightly medially for better exposure of the vessel, or the person placing the arterial catheter can manipulate the limb into the appropriate position. palpate the dorsal pedal pulse as it courses dorsally over the tarsus. place an over-the-needle catheter percutaneously at a 15-to 30-degree angle, threading the tip of the needle carefully toward the pulse. advance the needle in short, blunt movements, and watch the catheter hub closely for a flash of pulsating blood that signifies penetration into the lumen of the artery. then thread the catheter off of the stylette, and cover the catheter hub with a catheter cap. secure the catheter in place with lengths of 1 /2-and 1-inch adhesive tape as with any other intravenous catheter, and then flush it with heparinized saline solution every 2 to 4 hours. any vessel that can be catheterized percutaneously also can be catheterized with surgical cutdown. restrain the patient and clip and aseptically scrub the limb or jugular vein as for a percutaneous catheterization procedure. block the area for catheter placement with a local anesthetic before cutting the skin over the vessel with a no. 11 scalpel blade. while wearing sterile gloves, pick up the skin and incise the skin over the vessel. direct the sharp edge of the blade upward to avoid lacerating the underlying vessel. using blunt dissection, push the underlying subcutaneous fat and perivascular fascia away from the vessel with a mosquito hemostat. make sure that all tissue is removed from the vessel. using the mosquito hemostat, place two stay sutures of absorbable suture under the vessel. elevate the vessel until it is parallel with the incision, and gently insert the catheter and stylette into the vessel. secure the stay sutures loosely around the catheter. suture the skin over the catheter site with nonabsorbable suture, and then tape and bandage the catheter in place as for percutaneous placement. remove catheters placed surgically as soon as possible and exchange them for a percutaneously placed catheter to avoid infection and thrombophlebitis. the most important aspect of catheter maintenance is to maintain cleanliness and sterility at all times. an indwelling catheter can remain in place for as long as it is functional and no complications occur. change the bandage whenever it becomes wet or soiled to prevent wicking of bacteria and debris from the environment into the vessel. check the bandages and catheter sites at least once a day for signs of thrombophlebitis: erythema, vessel hardening or ropiness, pain upon injection or infusion, and discharge. also closely examine the tissue around and proximal and distal to the catheter. swelling of the paw can signify that the catheter tape and bandage are too tight and are occluding venous outflow. swelling above the catheter site is characteristic of perivascular leakage of fluid and may signify that the catheter is no longer within the lumen of the vessel. remove the catheter if it is no longer functional, if there is pain or resistance upon infusion, if there is unexplained fever or leukocytosis, or if there is evidence of cellulitis, thrombophlebitis, or catheter-related bacteremia or septicemia. aseptically culture the tip of the indwelling catheter for bacteria. animals should wear elizabethan collars or other forms of restraint if they lick or chew at the catheter or bandage. catheter patency may be maintained with constant fluid infusion or by intermittent flushing with heparinized saline (1000 units of unfractionated heparin per 250 to 500 ml of saline) every 6 hours. flush arterial catheters more frequently (every 2 hours). disconnect intravenous connections only when absolutely necessary. wear gloves whenever handling the catheter or connections. label all fluid lines and elevate them off of the floor to prevent contamination. date each fluid line and replace it once every 24 to 36 hours. if an intravenous catheter cannot be placed because of small patient size, hypovolemia, hypothermia, or severe hypotension, needles can be placed into the marrow cavity of the femur, humerus, and tibia for intraosseous infusion of fluids, drugs, and blood products. this technique is particularly useful in small kittens and puppies and in exotic species. contraindications to intraosseous infusion is in avian species (which have air in their bones), fractures, and sepsis, because osteomyelitis can develop. an intraosseous catheter is relatively easy to place and maintain but can cause patient discomfort and so should be changed to an intravenous catheter as soon as vascular access becomes possible. to place an intraosseous catheter, clip and aseptically scrub the fur over the proposed site of catheter placement. the easiest place for intraosseous placement is in the intertrochanteric fossa of the femur. inject a small amount of a local anesthetic through the skin and into the periosteum where the trocar or needle will be inserted. place the patient in lateral recumbency, and grasp the leg in between your fingers, with the stifle braced against the palm of your hand. push the stifle toward the abdomen (medially) to abduct the proximal femur away from the body. this will shift the sciatic nerve out of the way of catheter placement. insert the tip of the needle through the skin and into the intertrochanteric fossa. gently push with a simultaneous twisting motion, pushing the needle parallel with the shaft of the femur, toward your palm. you may feel a pop or decreased resistance as the needle enters the marrow cavity. gently flush the needle with heparinized saline. if the needle is plugged with bone debris, remove the needle and replace it with a fresh needle of the same type and size in the hole that you have created. a spinal needle with an internal stylette also can be placed. the stylette will prevent the needle from becoming clogged with bone debris during insertion. secure the hub of the needle with a butterfly length of white adhesive tape and then suture it to the skin to keep the catheter in place. the catheter is now ready for use. the patient should wear an elizabethan collar to prevent disruption or removal of the catheter. the intraosseous catheter can be maintained as any peripheral catheter, with frequent flushing and daily evaluation of the catheter site. the definition of pain has been debated philosophically over the ages and has changed as knowledge has increased. pain is defined as an unpleasant sensory or emotional experience associated with actual or perceived tissue damage. until recognition of a noxious stimulus occurs in the cerebral cortex, no response or adaptation results. rational management of pain requires an understanding of the underlying mechanisms involved in pain and an appreciation of how analgesic agents interact to disrupt pain mechanisms. multiple factors and causes produce pain in human beings and domestic animal species. the causes of pain, psychological and physical, may derive from many different mechanisms within emergency medicine, among them trauma, infectious disease, neglect, environmental stress, surgery, and acute decompensation of chronic medical conditions. the two major classes of pain are acute and chronic pain. box 1-20 gives specific categories and causes of pain. the pain sensing and response system can be divided into the following categories: nociceptors, which detect and filter the intensity of the noxious stimuli; primary afferent nerves, which transmit impulses to the central nervous system (cns); ascending tracts, which are part of the dorsal horn and the spinal cord that conveys stimuli to higher centers in the brain; higher centers, which are involved in pain discrimination, some memory, and motor control; and modulating or descending systems, which are a means of processing, memorizing, and modifying incoming impulses. current analgesic therapies may inhibit afferent nociceptive transmission within the brain and spinal cord; directly interrupt neural impulse conduction through the dorsal horn, primary afferent nerves, or dorsal root ganglion; or prevent the nociceptor sensitization that accompanies initial pain and inflammation. the physiologic aspects of pain are believed to be produced by the transmission, transduction, and integration of initial nerve endings, peripheral neuronal input, and ascending afferent nerves via the thalamus to the cerebral cortex. ascending afferent nerves to the limbic system are believed to be responsible for the emotional aspects of pain. there are several classification schemes for different types of pain. acute pain, such as that which results from trauma, surgery, or infectious agents, is abrupt in onset, relatively short in duration, and may be alleviated easily by analgesics. in contrast, chronic pain is a long-standing physical disorder or emotional distress that is slow in onset and difficult to treat. both types of pain can be classified further based on site of origin. somatic pain arises from superficial skin, subcutaneous tissue, body wall, or appendages. visceral pain arises from abdominal or thoracic viscera and primarily is associated with serosal irritation. analgesia, then, is the loss of pain without the loss of consciousness. this is in contrast to anesthesia, which is the loss of sensation in the whole body or a part of the body with the loss of consciousness or at least depression of the cns. untreated pain causes immediate changes in the neurohormonal axis, which in turn causes restlessness, agitation, increased heart and respiratory rates, fever, and blood pressure fluctuations, all of which are detrimental to the healing of the animal. a catabolic state is created as a result of increased secretion of catabolic hormones and decreased secretion of anabolic hormones. the net effect the majority of neurohormonal changes produce is an increase in the secretion of catabolic hormones. hyperglycemia is produced and may persist because of production of glucagon and relative lack of insulin. lipolytic activity is stimulated by cortisol, catecholamines, and growth hormone. cardiorespiratory effects of pain include increased cardiac output, vasoconstriction, hypoxemia, and hyperventilation. protein catabolism is a common occurrence and major concern regarding healing. pain associated with inflammation causes increase in tissue and blood levels of prostaglandins and cytokines, both of which promote protein catabolism indirectly by increasing the energy expenditure of the body. powerful evidence indicates that local anesthetic, sympathetic agonist, and opioid neural blockade may produce a modification of the responses to these physiologic changes. variable reduction in plasma cortisol, growth hormone, antidiuretic hormone, î²-endorphin, aldosterone, epinephrine, norepinephrine, and renin is based on the anesthetic technique and the drugs selected. prophylactic administration of analgesics blunts the response before it occurs; analgesics administered following perception or pain are not as effective, and higher doses are generally necessary to achieve an equivalent level of analgesia. effective pain control can be achieved only when the signs of pain can be assessed effectively, reliably, and regularly. the experience of pain is unique to each individual, which makes pain assessment difficult, especially in traumatized and critical patients. most attempts to assess clinical pain use behavioral observations and interactive variables in addition to assessment of physiologic responses such as heart rate and respiratory rate, blood pressure, and temperature. but many factors can influence the processing and outward projection of pain, including altered environments, species differences, withinspecies variations (age, breed, sex), and the type, severity, and chronicity of pain. within-species differences (age, breed, and sex) further complicate the pain assessment. most notable is that different breeds of dogs act differently when confronted with pain or fear. labrador retrievers tend to be stoic, whereas greyhounds and teacup breeds tend to react with a heightened state of arousal around even the simplest of procedures (e.g., subcutaneous injections and nail trims). the individual character and temperament of the animal further influences its response. pediatric and neonatal animals seem to have a lower threshold for pain and anxiety than older animals. in any species, the duration and type of pain make it more (acute) or less (chronic) likely to be expressed or exhibited outwardly. unfamiliarity with normal behaviors typical of a particular species or breed makes recognition of their painful behaviors and responses impossible. the definition and recognition of pain in an individual animal is challenging. because of all the differences discussed, there is no straight line from insult, albeit actual or perceived, to degree of pain experienced. nor is there a formula for treating "x" type of pain with "y" type of analgesic. a goal of analgesia is to treat all animals with analgesic drugs and modalities as preemptively as possible and using a multimodal approach. use analgesic treatment as a tool for diagnosis of pain in the event that recognition of these phenomena is difficult for the patient. in other words, with countless drugs and treatment modalities available, analgesic administration should never be withheld in an animal, even if pain is questionable. it is important to remember that no behavior or physiologic variable in and of itself is pathognomonic for pain. interactive and unprovoked (noninteractive) behavior assessments and trending of physiologic data are useful to determine the pain in an individual animal. this is known as pain scoring. baseline observations, especially those observations from someone who has known the animal well, can be helpful to serial behavior and pain assessments. pain scoring systems have been developed and are reviewed elsewhere; the purposes of these systems are to evaluate and to help guide diagnostic and analgesic treatments (table 1 -15) . regardless of the scale or method used to assess pain, the caregiver must recognize the limitations of the scale. if in doubt of whether pain is present or not, analgesic therapy should be used as a diagnostic tool. classic behaviors associated with pain in dogs and cats include abnormal postures, gaits, movements, and behaviors (boxes 1-21 and . stoicism is the apparent apathy and pain: assessment, prevention, and management 71 indifference in the presence of pain and is perhaps the no. 1 sign of ineffective pain relief or persistent pain in many animals, because so many display apathy and classically normal physiologic parameters even in the face of severe distress, overt suffering, or blatant trauma and illness. the absence of normal behaviors is also a clinical sign of pain, even when abnormal behaviors are not observed. acute pain results in many of the aforementioned behavioral and physiologic signs, but chronic pain in small animals is an entirely different and distinct entity. chronic pain is often present in the absence of obvious tissue pathology and changes in physical demeanor. again, the severity of the pain may not correlate with the severity of any pathologic condition that may or may not be present. chronic pain, especially if insidious in onset (cancer, dental, or degenerative pain), may well go unnoticed in dogs and cats, even by family members or intermittent caregivers. inappetance, lack of activity, panting in a species classically designed to be nose breathers, decreased interest in surroundings, different activity patterns, and abnormal postures are just a few signs of chronic pain in cats and dogs. cats are a species that in particular are exemplary in their abilities to hide chronic pain. they will exhibit marked familial withdrawal, finding secluded areas where they may remain for days to weeks when they experience acute and chronic pain. when deciding on a pain management protocol for a patient, always perform a thorough physical examination and include a pain score assessment before injury and pain has occurred, whenever possible. form a problem list to guide your choice of anesthesia and analgesia. for example, using a nonsteroidal antiinflammatory drug (nsaid) in an animal with renal failure would not be wise. remember to account for current medications that the patient may be taking that may augment or interfere with the analgesic or anesthetic drugs. use multimodal techniques and regional therapy and drugs to target pain at different sites before it occurs. once a strategy is decided upon, frequently reassess the patient and tailor the protocol to meet each patient's response and needs. drug therapy (in particular, opioids with or without î± 2 -agonists) is a cornerstone for acute pain treatment and surgical preemptive pain prevention. however, local anesthetics delivered epidurally, via perineural or plexus injection, intraarticular or trigger point injection, are also effective analgesics for acute and chronic forms of pain and inflammation. the nsaids that classically have been reserved for treatment of more chronic or persistent pain states now are being used regularly for treatment of acute and perioperative pain once blood pressure, coagulation, and gastrointestinal parameters have been normalized. an opioid is any natural or synthetic drug that is derived from the poppy, which interacts with opiate receptors identified on cell membranes. the drugs from this class constitute the most effective means of controlling acute, perioperative, and chronic pain in human and veterinary medicine (table 1 -16) . their physiologic effects result from the interaction with one or more of at least five endogenous opioid receptors (âµ, ï�, î´, îµ, and îº). âµ-receptor agonists are noted for their ability to produce profound analgesia with mild sedation. these drugs diminish "wind-up," the hyperexcitable state resulting from an afferent volley of nociceptive impulses. they elevate the pain threshold and are used preemptively to prevent acute pain. as a class, opioids cause cns depression with their intense analgesia. dose-related respiratory depression reflects diminished response to carbon dioxide levels. cardiac depression is secondary only to bradycardia and is more likely with certain opioids such as morphine and oxymorphone. narcotics produce few if any clinically significant cardiovascular effects in dogs and cats; they are considered cardiac soothing or sparing. because opioids increase intracranial and intraocular pressure, use them more cautiously in patients with severe cranial trauma and or ocular lesions. opioids directly stimulate the chemoreceptor trigger zone and may cause nausea and vomiting. most opioids depress the cough reflex via a central mechanism; this may be helpful in patients recovering from endotracheal intubation irritation. a key characteristic of opioids that makes them desirable for use in emergency and critical care situations is their reversibility. antagonists block or reverse the effect of agonists by combining with receptors and producing minimal or no effects. administer all reversal agents, such as naloxone and naltrexone, slowly if given intravenously and to effect. î± î± 2 -agonists as a class of drugs, î± 2 -agonists warrant special attention because most members of the group possess potent analgesic power at doses that are capable of causing sedation, cns depression, cardiovascular depression, and even general anesthetic states. originally developed for antihypertensive use, î± 2 -agonists quickly have attained sedative analgesic status in veterinary medicine (table 1 -17) . like the opioids, î± 2 -agonists produce their effects by aggravating î±-adrenergic receptors in the cns and periphery. 1 emergency care among them cyclooxygenase-1 (cox-1), the major constitutive enzyme primarily involved in normal physiologic functions, and cox-2, the enzyme responsible for most of the hyperalgesia and pain responses experienced after tissue injury or trauma. some nsaids inhibit cyclooxygenase and lipoxygenase activity. most of the currently available oral and parenteral nsaids for small animal medicine and surgery target the cyclooxygenase pathways predominantly, although one (tepoxalin) is thought to inhibit both pathways. inhibition of cox-1 and cox-2 can inhibit the protective effects and impair platelet aggregation and lead to gastrointestinal ulceration. there are definite contraindications and relative contraindications for the use of nsaids. nonsteroidal antiinflammatory drugs should not be administered to patients with renal or hepatic insufficiency, dehydration, hypotension or conditions that are associated with low circulating volume (congestive heart failure, unregulated anesthesia, shock), or evidence of ulcerative gastrointestinal disease. trauma patients should be stabilized completely regarding vascular volume, tone, and pressure before the use of nsaids. patients receiving concurrent administration of other nsaids or corticosteroids, or those considered to be cushingoid, should be evaluated carefully for an adequate "washout" period (time of clearance of drug from the system) before use of an nsaid or before switching nsaids. patients with coagulopathies, particularly those that are caused by platelet number or function defects or those caused by factor deficiencies, and patients with severe, uncontrolled asthma or other bronchial disease are probably not the patients in which to use nsaids. other advice is that nsaids not be administered to pregnant patients or to females attempting to become pregnant because cox-2 induction is necessary for ovulation and subsequent implantation of the embryo. the administration of nsaids should be considered only in the well-hydrated, normotensive dog or cat with normal renal or hepatic function, with no hemostatic abnormalities, and no concurrent steroid administration. nonsteroidal antiinflammatory drugs can be used in many settings of acute and chronic pain and inflammation. among these are the use in well-stabilized musculoskeletal trauma and surgical pain, osteoarthritis management, meningitis, mastitis, animal bite and other wound healing, mammary or transitional cell carcinoma, epithelial (dental, oral, urethral) inflammation, ophthalmologic procedures, and dermatologic or otic disease. whereas opioids seem to have an immediate analgesic effect when administered, most nsaids will take up to 30 minutes for their effect to be recognized. as such, most perioperative or acute nsaids use is part of a balanced pain management scheme, one that uses narcotics and local anesthetic techniques. nonsteroidal antiinflammatory drugs are devoid of many of the side effects of narcotic administration; namely, decreased gastrointestinal motility, altered sensorium, nausea/vomition, and sedation. nonsteroidal antiinflammatory drugs are also devoid of many of the side effects of steroid administration; namely, suppression of the pituitary adrenal axis. the toxic effects of salicylates in cats are well documented. cats are susceptible because of slow clearance and dose-dependent elimination because of deficient glucuronidation in this species. because of this, the dose and the dosing interval of most commonly used nsaids need to be altered in order for these drugs to be used. cats that have been given canine doses of nsaids (twice daily or even once daily repetitively) may show hyperthermia, hemorrhagic or ulcerative gastritis, kidney and liver injury, hyperthermia, respiratory alkalosis, and metabolic acidosis. acute and chronic toxicities of nsaids have been reported in cats, especially after repeat once daily dosing. ketoprofen, flunixin, aspirin, carprofen, and meloxicam have been administered safely to cats, although like most antibiotics and other medications, they are not approved and licensed for use in cats. an important note, though, is that dosing intervals ranging from 48 to 96 hours have been used, and antithrombotic effects often can be achieved at much lower doses than those required to treat fevers and inflammation. i recommend the use of no loading doses, minimum 48-hour dosing intervals, and assurance of adequate circulating blood volume, blood pressure, and renal function. because many of the nsaids are used off-label in cats, it is imperative that the clinician carefully calculate the dose, modify the dosing interval, and communicate this information to the client before dispensing the drug. even drugs that come in liquid form (meloxicam), if administered to cats via box-labeled directions used for dogs, will be given in near toxic doses. to worsen the misunderstanding about dosages for cats, drops from manufacturer's bottles often are calibrated drops; when these same liquids are transferred into pharmacy syringes for drop administration, the calibration of course is lost, and the animal potentially is overdosed. a more accurate method of dispensing and administering oral nsaids in cats is to calculate the dose in milligrams and determine the exact number of milliliters to administer, rather than use the drop method. ketamine classically was considered a dissociative anesthetic, but it also has potent activity as an n-methyl-d-aspartate (nmda) receptor antagonist. this receptor located in the cns mediates windup and central sensitization (a pathway from acute to chronic pain). blockade of this receptor with microdoses of ketamine results in the ability to provide body surface, somatic, and skin analgesia with potentially lower doses of opioids and î±-agonists. loading doses of 0.5 to 2 mg/kg are used intravenously with continuous rate infusions of 2 to 20 âµg/kg/minute. in and of itself, this drug possesses little to no analgesic ability and indeed in high doses alone often can aggravate, sensitize, or excite the animal in subacute or acute pain. amantadine is another nmda blocker that has been used for its antiviral and parkinson's stabilizing effects. amantadine has been used for neuropathic pain in human beings but is only available in an oral form. suggested starting doses for cats and dogs range from 3 to 10 mg/kg po daily. when the drug is given orally and intravenously, patients are unlikely to develop behavioral or cardiorespiratory effects with ketamine or amantadine. tramadol is an analgesic that possesses weak opioid âµ-agonist activity and norepinephrine and serotonin reuptake inhibition. tramadol is useful for mild to moderate pain in small animals. although the parent compound has very weak opioid activity, the metabolites have excellent binding affinity for the âµ-receptor. tramadol has been used for perisurgical pain control when given orally in cats and dogs at a dose of 1 to 10 mg/kg po sid to bid. cats appear to require only once daily dosing. regardless of its affinity for the opioid receptors, the true mechanism of action of tramadol in companion animals remains largely unknown. gabapentin is a synthetic analog of î³-aminobutyric acid (gaba). originally introduced as an antiepileptic drug, the mechanism of action of gabapentin remains somewhat unclear in veterinary medicine. the drug is among a number of commonly used antiepileptic medications used to treat central pain in human beings. the rationale for use is the ability of the drugs to suppress discharge in pathologically altered neurons. gabapentin does this through calcium channel modulation without binding to glutamate receptors. chronic, burning, neuropathic, and lancinating pain in small animals responds well to 1 to 10 mg/kg po daily. local anesthetic agents are the major class used as a peripheral-acting analgesic ( table 1 -19) . local anesthetics block the transmission of pain impulses at the peripheral nerve nociceptor regions. local anesthetics may be used to block peripheral nerves or inhibit nerve "zones" using regional techniques. although all local anesthetics are capable of providing pain relief, agents with a longer duration of action are preferred for pain management purposes. bupivacaine is an example of a long-acting local anesthetic drug that is used along with lidocaine for long-acting pain relief. a single dose of bupivacaine injected at a local site will provide local anesthesia and analgesia for 6 to 10 hours. when lidocaine is administered as an intravenous constant rate infusion (50 to 75 âµg/kg/minute in dogs, 1 to 10 âµg/kg/minute in cats) is effective in the treatment of chronic neuropathic pain and periosteal and peritoneal pain (e.g., pancreatitis). mexiletine, an oral sodium channel blocker, can be used as an alternative to injectable lidocaine for provision of background analgesia. many drugs (table 1 -20) are used in combination with opioids, î± 2 -agonists, and ketamine to provide anxiolysis and sedation. injection of local anesthetic solution into the connective tissue surrounding a particular nerve produces loss of sensation (sensory blockade) and/or paralysis (motor nerve blockade) in the region supplied by the nerve. local anesthetics also may be administered epidurally, intrathoracically, intraperitoneally, and intraarticularly. lidocaine and bupivacaine are the most commonly administered local anesthetics. lidocaine provides for quick, short-acting sensory and motor impairment. bupivacaine provides for later-onset, longerlasting desensitization without motor impairment. combinations of the two agents diluted with saline are used frequently to provide for quick-onset analgesia that lasts between 4 and 6 hours in most patients. adding narcotic and/or î± 2 agent often maximizes the analgesia and increases the pain-free interval to 8 to 18 hours. epinephrine and preservative-free solutions are recommended. precision placement of anesthetic close to nerves, roots, or plexuses is improved with the use of a stimulating nerve locator. cats seem to be more sensitive to the effects of local anesthetics; as such the lower ends of most dosing ranges are used for blockades in this species. unlike most instances of general anesthesia, during which the animal is rendered unconscious and nerve transmission is decreased by virtue of cns depression, local and regional techniques block the initiation of noxious signals, thereby effectively preventing pain from entering the cns. this is an effective means of not only preventing initial pain but also reducing the changes that take place in the dorsal horn of the spinal cord, spinothalamic tracts, limbic and reticular activating centers, and cortex. frequently, the neurohormonal response that is stimulated in pain and stress is blunted as well. overall, the patient has fewer local and systemic adverse effects of pain, disease processes are minimized, chronic pain states are unlikely, and outcome is improved. regional techniques are best used as part of an analgesic regimen that consists of their continuous administration, narcotics, î±-agonists, anxiolytics, and good nursing. lidocaine can be added to sterile lubricant in a one-to-one concentration to provide decreased sensation for urinary catheterization, nasal catheter insertion, minor road burn analgesia, and pyotraumatic dermatitis analgesia. proparacaine is a topical anesthetic useful for corneal or scleral injuries. local anesthetics can be used to infiltrate areas of damage or surgery by using long-term continuous drainage catheters and small, portable infusion pumps. this is an effective means of providing days of analgesia for massive surgical or traumatic soft tissue injury. even without the catheter, incisional or regional soft tissue blocking using a combination of 1 to 2 mg/kg lidocaine and 0.5 to 2 mg/kg bupivacaine diluted with equal volume of saline and 1:9 with sodium bicarbonate is effective for infiltrating large areas of injury. administration of local anesthetic drugs around the infraorbital, maxillary, ophthalmic mental, and alveolar nerves can provide excellent analgesia for dental, orofacial, and ophthalmic trauma and surgical procedures. each nerve may be desensitized by injecting 0.1 to 0.3 ml of a 2% lidocaine hydrochloride solution and 0.1 to 0.3 ml of 0.5% bupivacaine solution using a 1.2-to 2.5-cm, 22-to 25-gauge needle. precise placement perineurally versus intraneurally (neuroma formation common) is enhanced by using catheters in the foramen versus needle administration. always perform aspiration before administration to rule out intravascular injection of agents. this block is used to provide analgesia for thoracic, lower cervical, cranial abdominal, and diaphragmatic pain. following aseptic preparation, place a small through-the-needle (20-to 22-gauge) catheter in the thoracic cavity between the seventh and ninth intercostal space on the midlateral aspect of the thorax. aseptically mix a 0.5 to 1 mg/kg lidocaine and a 0.2 to 0.5 mg/kg bupivacaine dose with volume of saline equal to the volume of bupivacaine, and slowly inject it over a period of 2 to 5 minutes following aspiration to ensure that no intravascular injection occurs. depending on where the lesion is, position the patient to allow the intrapleural infusion to "coat" the area. most effective is positioning the patient in dorsal recumbency for several minutes following the block to make sure local anesthetic occupies the paravertebral gutters and hence the spinal nerve roots. the block should be repeated every 3 hours in dogs and every 8 to 12 hours in cats. secure the catheter to the skin surface for repetitive administration. administration of local anesthetic around the brachial plexus provides excellent analgesia for forelimb surgery, particularly that distal to the shoulder, and amputations. nerve locator-guided techniques are much more accurate and successful than blind placement of local anesthetic; however, even the latter is useful. to administer a brachial plexus blockade, follow this procedure: 1. aseptically prepare a small area of skin over the point of the shoulder. 2. insert a 22-gauge, 1 1 /2-to 3-inch spinal needle medial to the shoulder joint, axial to the lesser tubercle, and advance it caudally, medial to the body of the scapula, and toward the costochondral junction of the first rib. aspirate first before injection to make sure that intravenous injection does not occur. 3. inject one third of the volume of local anesthetic mix, and then slowly withdraw the needle and fan dorsally and ventrally while infusing the remaining fluid. 4. local anesthetic doses are similar to those for intrapleural blockade. epidural analgesia refers to the injection of an opioid, a phencyclidine, an î±-agonist, or an nsaid into the epidural space. epidural anesthesia refers to the injection of a local anesthetic. in most patients a combination of the two is used. epidural analgesia and anesthesia are used for a variety of acute and chronic surgical pain or traumatically induced pain in the pelvis, tail, perineum, hind limbs, abdomen, and thorax (table 1 -21) . procedures in which epidural analgesia and anesthesia are useful include forelimb and hind limb amputation, tail or perineal procedures, cesarean sections, diaphragmatic hernia repair, pancreatitis, peritonitis, and intervertebral disk disease. epidural blocks performed using opioids or bupivacaine will not result in hind limb paresis or decreased urinary or anal tone (incontinence), unlike lidocaine or mepivicaine epidural blocks. morphine is one of the most useful opioids for administration in the epidural space because of its slow systemic absorption. epidural catheters used for the instillation of drugs through constant rate infusion or intermittent injection can be placed in dogs and cats. routinely placed at the lumbosacral junction, these catheters are used with cocktails including preservative-free morphine, bupivacaine, medetomidine, and ketamine. extremely effective for preventing windup pain in the peritoneal cavity or caudal half of the body, the catheters may be maintained if placed aseptically for 7 to 14 days. to provide epidural analgesia or anesthesia, follow this procedure: 1. position the animal in lateral or sternal recumbency. 2. clip and aseptically scrub over the lumbosacral site. 3. palpate the craniodorsal-most extent of the wings of the ileum bilaterally and draw an imaginary line through them to envision the spine of l7 located immediately behind the imaginary line. 4. advance a 20-to 22-gauge, 1 1 /2-to 3-inch spinal or epidural needle through the skin just caudal to the spine of l7. 5. the needle will lose resistance as it is introduced into the epidural space. drop saline into the hub of the needle, and the saline will be pulled into the epidural space as the needle enters. discrete intercostal nerve blocks can provide effective analgesia for traumatic or postsurgical pain. identify the area of the injury, and infiltrate three segments on either side of the injury with analgesic. to perform an intercostal nerve block, follow this procedure: 1. clip and aseptically scrub the dorsal and ventral third of the chest wall. 2. palpate the intercostal space as far dorsally as possible. 3. use a 25-gauge, 0.625-inch needle at the caudolateral aspect of the affected rib segments and those cranial and caudal. 4. direct the tip of the needle caudally such that the tip of the needle "drops" off of the caudal rib. (this places the needle tip in proximity to the neuromuscular bundle that contains the intercostal nerve that runs in a groove on the caudomedial surface of the rib.) 5. aspirate to confirm that the drug will not go intravenously. 6. inject while slowly withdrawing the needle. inject 0.5 to 1.0 ml at each site, depending on the size of the animal. gaynor js, an acute condition in the abdomen is defined as the sudden onset of abdominal discomfort or pain caused by a variety of conditions involving intraabdominal organs. many animals have the primary complaint of lethargy, anorexia, ptyalism, vomiting, retching, diarrhea, hematochezia, crying out, moaning, or abnormal postures. abnormal postures can include generalized rigidity, walking tenderly or as if "on eggshells," or a prayer position in which the front limbs are lowered to the ground while the hind end remains standing. in some cases, it may be difficult initially to distinguish between true abdominal pain or referred pain from intervertebral disk disease. rapid progression and decompensation of the patient's cardiovascular status can lead to stupor, coma, and death in the most extreme cases, making rapid assessment, treatment, and definitive care extremely challenging. often the patient's signalment and history can increase the index of suspicion for a particular disease process. a thorough history often is overlooked or postponed in the initial stages of resuscitation of the patient with acute abdominal pain. often, asking the same question in a variety of methods can elicit an answer from the client that may lead to the source of the problem and the reason for acute abdominal pain. important questions to ask the client include the following: â�¢ what is your chief complaint or reason that you brought your animal in on emergency? â�¢ when did the signs first start, or when was your animal last normal? â�¢ do you think that the signs have been the same, better, or getting worse? â�¢ does your animal have any ongoing or past medical problems? â�¢ have similar signs occurred in the past? â�¢ does your animal have access to any known toxins, or does he or she run loose unattended? as with any other emergency, the clinician must follow the abcs of therapy, treating the most life-threatening problems first. first, perform a perfunctory physical examination. examination of the abdomen ideally should be performed last, in case inciting a painful stimulus precludes you from evaluating other organ systems more thoroughly. briefly observe the patient from a distance. are there any abnormal postures? is there respiratory distress? is the animal ambulatory, and if so, do you observe any gait abnormalities? do you observe any ptyalism or attempts to vomit? auscultate the patient's thorax for crackles that may signify aspiration pneumonia resulting from vomiting. examine the patient's mucous membrane color and capillary refill time, heart rate, heart rhythm, and pulse quality. many patients in pain have tachycardia that may or may not be accompanied by dysrhythmias. if a patient's heart rate is inappropriately bradycardic, consider hypoadrenocorticism, whipworm infestation, or urinary obstruction or trauma as a cause of hyperkalemia. assess the patient's hydration status by evaluating skin turgor, mucous membrane dryness, and whether the eyes appear sunken in their orbits. a brief neurologic examination should consist of whether the patient is actively having a seizure, or whether mental dullness, stupor, coma, or nystagmus are present. posture and spinal reflexes can assist in making a diagnosis of intervertebral disk disease versus abdominal pain. perform a rectal examination to evaluate for the presence of hematochezia or melena. finally, examination of the abdomen should proceed first with superficial and then deeper palpation. visually inspect the abdomen for the presence of external masses, bruising, or penetrating injuries. reddish discoloration of the periumbilical area often is associated with the presence of intraabdominal hemorrhage. it may be necessary to shave the fur to inspect the skin and underlying structures visually for bruising and ecchymoses. auscultate the abdomen for the presence or absence of borborygmi to characterize gut sounds. next, perform percussion and ballottement to evaluate for the presence of a gas-distended viscus or peritoneal effusion. finally, perform first superficial and then deep palpation of all quadrants of the abdomen, noting abnormal enlargement, masses, or whether focal pain is elicited in any one area. once the physical examination has been performed, implement initial therapy in the form of analgesia, fluid resuscitation, and antibiotics. treatment for any patient with an acute condition in the abdomen and shock is to treat the underlying cause, maintain tissue oxygen delivery, and prevent end-organ damage and failure. a more complete description of shock and oxygen delivery is given in the section on shock. 1 emergency care the administration of analgesic agents to any patient with acute abdominal pain is one of the most important therapies in the initial stages of case management. many patients with acute abdominal pain are clinically dehydrated or are in hypovolemic shock because of hemorrhage. careful titration of intravenous crystalloid and colloid fluids including blood products is necessary based on the patient's perfusion parameters including heart rate, capillary refill time, blood pressure, urine output, and pcv. fluid therapy also should be based on the most likely differential diagnoses, with specific fluid types administered according to the primary disease process. in dogs, a shock volume of fluids is calculated based on the total blood volume of 90 ml/kg/hour. in cats, shock fluid rate is based on plasma volume of 44 ml/kg/hour. in most cases, any crystalloid fluid can be administered at an initial volume of one fourth of a calculated shock dose and then titrated according to whether the patient's cardiovascular status responds favorably or not. in cases of an acute condition in the abdomen from known or suspected hypoadrenocorticism, severe whipworm infestation, or urinary tract obstruction or rupture, 0.9% sodium chloride fluid without added potassium is the fluid of choice. when hemorrhage is present, the administration of whole blood or packed rbcs may be indicated if the patient has clinical signs of anemia and shows clinical signs of lethargy, tachypnea, and weakness. fresh frozen plasma is indicated in cases of hemorrhage resulting from vitamin k antagonist rodenticide intoxication or hepatic failure or in cases of suspected disseminated intravascular coagulation (dic). a more thorough description of fluid therapy is given under the sections on shock and fluid therapy. the empiric use of broad-spectrum antibiotics is warranted in cases of suspected sepsis or peritonitis as a cause of acute abdominal pain. ampicillin sulbactam (22 mg/kg iv q6-8h) and enrofloxacin (10 mg/kg once daily) are the combination treatment of choice to cover gram-negative, gram-positive, aerobic, and anaerobic infections. alternative therapies include a second-generation cephalosporin such as cefotetan (30 mg/kg iv tid) or cefoxitin (22 mg/kg iv tid) or added anaerobic coverage with metronidazole (10 to 20 mg/kg iv tid). tissue oxygen delivery depends on a number of factors, including arterial oxygen content and cardiac output. if an animal has had vomiting and subsequent aspiration pneumonitis, treatment of hypoxemia with supplemental oxygen in the form of nasal, nasopharyngeal, hood, or transtracheal oxygen administration is important (see oxygen supplementation under emergency diagnostic and therapeutic procedures). perform a complete blood count in all cases of acute abdominal pain to determine if lifethreatening infection or coagulopathy including dic is present. in cases of sepsis, infection, or severe nonseptic inflammation, the white blood cell count may be normal, elevated, or low. examine a peripheral blood smear for the presence of toxic neutrophils, eosinophils, atypical lymphocytes, nucleated rbcs, platelet estimate, anisocytosis, and blood parasites. a falling pcv in the face of rbc transfusion suggests ongoing hemorrhage. perform a biochemistry panel to evaluate organ system function. azotemia with elevated bun and creatinine may be associated with prerenal dehydration, impaired renal function, or postrenal obstruction or leakage. the bun also can be elevated when gastrointestinal hemorrhage is present. serum amylase may be elevated with decreased renal function or in cases of pancreatitis. a normal serum amylase, however, does not rule out pancreatitis as a source of abdominal pain. serum lipase may be elevated with gastrointestinal inflammation or pancreatitis. like amylase, a normal serum lipase does not rule out pancreatitis. total bilirubin, alkaline phosphatase, and alanine transaminase may be elevated with primary cholestatic or hepatocellular diseases or may be due to extrahepatic causes including sepsis. obtain a urinalysis via cystocentesis whenever possible, except in cases of suspected pyometra or transitional cell carcinoma. azotemia in the presence of a nonconcentrated (isosthenuric or hyposthenuric) urine suggests primary renal disease. secondary causes of apparent renal azotemia and lack of concentrating ability also occur in cases of hypoadrenocorticism and gram-negative sepsis. renal tubular casts may be present in cases of acute renal ischemia or toxic insult to the kidneys. bacteriuria and pyuria may be present with infection and inflammation. when a urinalysis is obtained via free catch or urethral catheterization, the presence of bacteriuria or pyuria also may be associated with pyometra, vaginitis, or prostatitis/prostatic abscess. serum lactate is a biochemical indicator of decreased organ perfusion, decreased oxygen delivery or extraction, and end-organ anaerobic glycolysis. elevated serum lactate greater than 6 mmol/l has been associated with increased morbidity and need for gastric resection in cases of gdv and increased patient morbidity and mortality in other disease processes. rising serum lactate in the face of adequate fluid resuscitation is a negative prognostic sign. obtain abdominal radiographs as one of the first diagnostic tests when deciding whether to pursue medical or surgical management. the presence of gdv, linear foreign body, pneumoperitoneum, pyometra, or splenic torsion warrants immediate surgical intervention. if a loss of abdominal detail occurs because of peritoneal effusion, perform additional diagnostic tests including abdominal paracentesis (abdominocentesis) and abdominal ultrasound to determine the cause of the peritoneal effusion. abdominal ultrasonography is often useful in place of or in addition to abdominal radiographs. the sensitivity of abdominal ultrasonography is largely operator dependent. indications for immediate surgical intervention include loss of blood flow to an organ, linear bunching or placation of the intestinal tract, intussusception, pancreatic phlegmon or abscess, a fluid-filled uterus suggestive of pyometra, gastrointestinal obstruction, intraluminal gastrointestinal foreign body, dilated bile duct, or gallbladder mucocele, or gas within the wall of the stomach or gallbladder (emphysematous cholecystitis). the presence of peritoneal fluid alone does not warrant immediate surgical intervention without cytologic and biochemical evaluation of the fluid present. see also abdominal paracentesis and diagnostic peritoneal lavage. abdominal paracentesis (abdominocentesis) often is the deciding factor in whether to perform immediate surgery. abdominocentesis is a sensitive technique for detecting peritoneal effusion when more than 6 ml/kg of fluid is present within the abdominal cavity. abdominal effusion collected should be saved for bacterial culture and evaluated biochemically and cytologically based on your index of suspicion of the primary disease process. if creatinine, urea nitrogen (bun) or potassium is elevated compared with that of serum, uroabdomen is present. elevated abdominal fluid lipase or amylase compared with serum supports a diagnosis of pancreatitis. elevated lactate compared with serum lactate or an abdominal fluid glucose less than 50 mg/dl is highly sensitive and specific for bacterial/ septic peritonitis. the presence of bile pigment or bacteria is supportive of bile and septic peritonitis, respectively. free fibers in abdominal fluid along with clinical signs of abdominal pain strongly support gastrointestinal perforation, and immediate surgical exploration is required. text continued on p. 93 the following are clinical conditions, patient signalment, common history, physical examination, and characteristic findings of various diagnostic tests. a blank column next to a condition indicates no specific signalment, history, physical examination, or diagnostic test characteristic for a particular disease process. lack of contiguity of body wall surgical ( medical unless perforation present present c-shaped abnormal gas pattern with plication on radiographs surgical (immediate) dilation of bowel cranial to foreign object, radiopaque object in surgical (immediate) stomach or intestines, hypochloremic metabolic acidosis on bloodwork if pyloric outflow obstruction is present elevated or decreased wbc; foreign material, wbcs and medical unless perforation bacteria on abdominal fluid, elevated lactate and decreased present glucose on abdominal fluid target shaped soft tissue density on abdominal u/s, soft tissue surgical (immediate): density with gas dilation cranially on abdominal radiographs medical management of primary cause colonic distension with hard feces on radiographs medical increased or decreased wbc, septic abdominal effusion surgical (immediate) elevated t bili, alt, alk phos, and wbc hypoechoic hepatic medical after biopsy parenchyma on ultasound hepatomegaly elevated t bili, alt, alk phos, and wbc hyperechoic foci in surgical (immediate) gallbladder or sludge on u/s, free gas in wall of gall bladder abdominal effusion, bile pigment in effusion surgical (immediate) elevated t bili, alk phos, alt surgical (immediate) elevated or decreased wbc, elevated t bili, alk phos and surgical (immediate) alt, free gas in hepatic parenchyma on rads, hypoechoic mass with hyperechoic material in hepatic parenchyma on u/s heteroechoic liver with hyperechoic center on ultrasound surgical (immediate) mixed echogenic mass on ultrasound, soft tissue mass surgical (immediate or density on radiographs, elevated alk phos, alt, delayed) t bili, hypoglycemia pain-cont'd elevated t bili, alk phos, alt, amylase and/or lipase, elevated medical in most cases or decreased wbc, hypocalcemia, focal loss of detail in right unless abscess or cranial quadrant on radiographs hypo-to hyperechoic phlegmon is present pancreas with hyperechoic peri-pancreatic fat on ultrasound, abdominal and/or pleural effusion on radiographs and ultrasound pancreatic soft tissue mass effect on radiographs and surgical if mass identified, ultrasound, elevated amylase and lipase, hypoglycemia, otherwise medical elevated serum insulin management of hypoglycemia splenomegaly on radiographs, hyperechoic spleen with no surgical (immediate) blood flow on ultrasound soft tissue mass effect and loss of abdominal detail on surgical (immediate) radiographs, cavitated mass with abdominal effusion on u/s hyperechoic spleen with no blood flow on abdominal u/s, surgical (immediate) abdominal effusion, thrombocytopenia loss of abdominal detail on radiographs, peritoneal effusion medical unless refractory on u/s, hemoabdomen on abdominocentesis hypotension diagnosis based primarily on clinical signs medical fracture of the os penis on radiographs largely medical unless urethral tear diagnosis based primarily on clinical signs medical, although prepuce may need to be incised to allow replacement of penis into sheath prostatomegaly on radiographs and ultrasound hypoechoic medical prostate on u/s, pyuria and bacteriuria and u/a prostatomegaly on radiographs and ultrasound hypo-to surgical (delayed) hyperechoic prostate on u/s, bacteriuria and pyuria on u/a prostatomegaly on radiographs and ultrasound, prostatic medical/surgical mineralization on radiographs and ultrasound hypoechoic kidneys on u/s, pyuria on u/a, elevated wbc, medical azotemia pyuria, bacteriuria on u/a medical pyelectasia in abdominal u/s, azotemia surgical (immediate) renomegaly on radiographs, azotemia renal mass on u/s, renomegaly on radiographs surgical (immediate) renal mass on u/s, azotemia, lack of renal blood flow surgical (delayed) on u/s calculi in renal pelvis on radiographs and ultrasound, azotemia medical unless both kidneys affected ureteral calculi on radiographs and ultrasound, hydronephrosis, medical unless both azotemia kidneys affected ureteral calculi on radiographs and ultrasound, hydronephrosis, surgical (delayed until fluid or soft tissue density on u/s, azotemia electrolyte stabilization) diagnosis largely based on physical examination medical unless cannot pass findings urethral catheter azotemia, no peritoneal effusion, lack of urine output or surgical (delayed until outflow with ureteral catheterization, double contrast electrolyte stabilization) cystourethrogram indicated transitional cellular casts on u/a, hematuria, mass effect or surgical and medical thickened irregular urethra on ultrasound or management cystourethrogram hypoechoic swollen testicle on testicular ultrasound surgical (immediate) fluid or gas-filled tubular structure on abdominal ultrasound or surgical (immediate) abdominal radiographs soft tissue tubular structure on radiographs, fluid-filled uterus surgical ( in the event of a negative abdominocentesis, but peritoneal effusion or bile or gastrointestinal perforation are suspected, perform a diagnostic peritoneal lavage. peritoneal dialysis kits are commercially available but are often expensive and impractical (see p. 6). animals that have acute abdominal pain can be divided into three broad categories, depending on the primary cause of pain and the initial definitive treatment (table 1-24) . some diseases warrant a nonsurgical, medical approach to case management. other conditions require immediate surgery following rapid stabilization. other conditions initially can be managed medically until the patient is hemodynamically more stable and then may or may not require surgical intervention at a later time. specific management of each disease entity is listed under its own subheading. box 1-23 lists specific indications for exploratory laparotomy. the best means to explore the abdominal cavity accurately and thoroughly is to open the abdomen on midline from the level of the xyphoid process caudally to the pubis for full exposure and then to evaluate all organs in every quadrant in a systematic manner. address specific problems such as gastric or splenic torsion, enteroplication, and foreign body removal, and then copiously lavage the abdomen with warmed sterile saline solution. suction the saline solution thoroughly from the peritoneal cavity so as to not impair macrophage function. in cases of septic peritonitis, the abdomen may be left open, or a drain may be placed for further suction and lavage. the routine use of antibiotics in irrigation solutions is contraindicated because the antibiotics can irritate the peritoneum and delay healing. when the abdominal cavity is left open, secure sterile laparotomy towels and water-impermeable dressings over the abdominal wound with umbilical tape, and then change these daily or as strike-through occurs. open abdomen cases are often effusive and require meticulous evaluation and management of electrolyte imbalances and hypoalbuminemia. the abdomen can be closed and/or the abdominal drain removed when the volume of the effusion decreases, when bacteria are no longer present, and when the neutrophils become more healthy in appearance. bischoff mg: radiographic techniques and interpretation of the acute abdomen, clin tech small anim pract 18 (1) anaphylactic shock occurs as an immediate hypersensitivity reaction to a variety of inciting stimuli (box 1-24). in animals, the most naturally occurring anaphylactic reaction results from wasp or bee stings. most other reactions occur as a result of an abnormal sensitivity to items used in making medical diagnoses or treatment. during an anaphylactic reaction, activation of c5a and the complement system results in vascular smooth muscle dilation and the release of a cascade of inflammatory mediators, including histamine, slow-reacting substance of anaphylaxis, serotonin, heparin, acetylcholine, and bradykinin. clinical signs associated with anaphylaxis differ between dogs and cats. in dogs, clinical signs may include restlessness, vomiting, diarrhea, hematochezia, circulatory collapse, coma, and death. in cats, clinical signs often are associated with respiratory system abnormalities. clinical signs may include ptyalism, pruritus, vomiting, incoordination, bronchoconstriction, pulmonary edema and hemorrhage, laryngeal edema, collapse, and death. the most important steps to remember in any emergency is to follow the abcs of airway, breathing, and circulation. first, establish an airway through endotracheal intubation or emergency tracheostomy, if necessary. concurrently, an assistant should establish vascular or intraosseous access to administer drugs and fluids (box 1-25). the patient should be hospitalized until complete resolution of clinical signs. after initial stabilization and treatment, it is important to maintain vascular access and continue intravenous fluid therapy until the patient is no longer hypotensive, and vomiting and diarrhea have resolved. in cases of fulminant pulmonary hemorrhage and edema, administer supplemental oxygen until the patient is no longer hypoxemic or orthopneic on room air. normalize and maintain blood pressure using positive inotropes (dobutamine, 3-10 âµg/kg/ minute cri) or pressors (dopamine, 3 to 10 âµg/kg/minute iv cri; see shock). if bloodtinged vomitus or diarrhea has been observed, administer antibiotics to decrease the risk of bacterial translocation and sepsis (cefoxitin, 22 mg/kg iv tid; metronidazole, 10 mg/kg iv tid). also consider using gastroprotectant drugs (famotidine, 0.5 to 1.0 mg/kg iv; ranitidine, 0.5 to 2.0 mg/kg po, iv, im bid; sucralfate, 0.25 to 1.0 g po tid; omeprazole, 0.7 to 1.0 mg/kg po sid). a second and less serious form of allergic reaction is manifested as angioneurotic edema and urticaria. in most cases, clinical signs develop within 20 minutes of an inciting allergen. although this type of reaction causes patient discomfort, it rarely poses a life-threatening problem. most animals have mild to severe swelling of the maxilla and periorbital regions. the facial edema also may be accompanied by mild to severe generalized urticaria. some animals may paw at their face, rub at their eyes, or have vomiting or diarrhea. the treatment for angioneurotic edema involves suppressing the immune response by administration of short-acting glucocorticoid drugs and blocking the actions of histamine by the synergistic use of histamine 1 and histamine 2 receptor blockers (box 1-26). in some cases, the inciting cause is a known recent vaccination or insect sting. many times, however, the inciting cause is not known and is likely an exposure to a stinging insect or arachnid. differential diagnoses for acute facial swelling and/or urticaria include acetaminophen toxicity (cats), anterior caval syndrome, lymphadenitis, vasculitis, hypoalbuminemia, and contact dermatitis. observe animals that have presented for angioneurotic edema for a minimum of 20 to 30 minutes after injection of the short-acting glucocorticoids and antihistamines. monitor blood pressure to make sure that the patient does not have concurrent anaphylaxis and hypotension. after partial or complete resolution of clinical signs, the animal can be discharged to its owner for observation. in dogs, mild vomiting or diarrhea may occur within 1 to 2 days after this type of reaction. wherever possible, exposure to the inciting allergen should be avoided. â�¢ administer short-acting glucocorticoid: complications observed while a patient is under anesthesia can be divided into two broad categories: (1) those related to equipment malfunction or human error and (2) the patient's physiologic response to the cardiorespiratory effects of the anesthetic drugs. careful observation of the patient and familiarity with anesthetic equipment, drug protocols, and monitoring equipment is necessary for the safest anesthesia to occur. despite this, however, anesthetic-related complications are frequent and need to be recognized and treated appropriately. many anesthetic drugs have a dose-dependent depressive effect on the respiratory system and cause a decrease in respiratory rate and tidal volume, leading to hypoventilation. respiratory rate alone is not a reliable indicator of the patient's oxygenation and ventilatory status. the respiratory tidal volume can be measured with a wright's respirometer. perform pulse oximetry and capnography as noninvasive measures of the patient's oxygenation and ventilation. ventilation can be impaired as a result of anesthetic drugs, patient position, pneumothorax, pleural effusion (chylothorax, hemothorax, pyothorax), equipment malfunction, rebreathing of carbon dioxide, thoracic wall injury, or alveolar fluid (pulmonary edema, hemorrhage, or pneumonia). problems such as a diaphragmatic hernia, gdv, or gravid uterus can impede diaphragmatic excursions once the patient is placed on its back and can lead to impaired ventilation. the work of breathing also may be increased because of increased resistance of the anesthesia circuit and increased dead space ventilation. this is particularly important in small toy breeds. clinical signs of inadequate ventilation and respiratory complications include abnormal respiratory pattern, sudden changes in heart rate, cardiac dysrhythmias, cyanosis, and cardiopulmonary arrest. end-tidal carbon dioxide, or capnography, gives a graphic display of adequacy of ventilation. rapid decreases in end-tidal carbon dioxide can be caused by disconnection or obstruction of the patient's endotracheal tube or poor perfusion, namely, cardiopulmonary arrest (see capnometry [end-tidal carbon dioxide monitoring]). postoperatively, hypoventilation can occur because of the residual effects of the anesthetic drugs, hypothermia, overventilation during intraoperative support, surgical techniques that compromise ventilation (thoracotomy, cervical disk surgery, atlantooccipital stabilization), postoperative bandaging of the abdomen or thorax, ventilatory muscle fatigue, or injury to the cns. cardiac output is a function of heart rate and stroke volume. factors that influence stroke volume include vascular and cardiac preload, cardiac afterload, and cardiac contractility. the patient's cardiac output can be affected adversely by the negative inotropic and chronotropic and vasodilatory effects of anesthetic drugs, all leading to hypotension. 96 1 emergency care bradycardia, tachycardia, cardiac dysrhythmias, and vascular dilation can lead to hypotension and inadequate organ perfusion. table 1 -25 lists the normal heart rate and blood pressure in dogs and cats. bradycardia is defined as a heart rate below normal values. many anesthetic drugs can cause bradycardia. causes of bradycardia include the use of narcotics or î± 2 -agonist drugs, deep plane of anesthesia, increased vagal tone, hypothermia, and hypoxia. table 1 -26 lists the causes of bradycardia and the necessary immediate action or treatment. tachycardia is defined as a heart rate above normal values. common causes of tachycardia include vasodilation, drugs, inadequate anesthetic depth and perceived pain, hypercapnia, hypoxemia, hypotension, shock, or hyperthermia. table 1 -27 lists the causes and immediate action or treatment for tachycardia. hypotension is defined as physiologically low blood pressure (mean arterial pressure less than 65 mm hg). a mean arterial blood pressure less than 60 mm hg can result in inadequate tissue perfusion and oxygen delivery. the coronary arteries are perfused during diastole. inadequate diastolic blood pressure, less than 40 mm hg, can cause decreased coronary artery perfusion and myocardial hypoxemia that can predispose the heart to dysrhythmias. causes of perianesthetic hypotension include peripheral vasodilation by anesthetic drugs, bradycardia or tachyarrhythmias, hypothermia, inadequate cardiac preload from vasodilation or hemorrhage, decreased venous return from patient position or surgical manipulation of viscera, and decreased cardiac contractility. electrocardiogram monitoring is useful for the early detection of cardiac dysrhythmias during the perianesthetic period. clinical signs of cardiac dysrhythmias include irregular pulse rate or pressure, abnormal or irregular heart sounds, pallor, cyanosis, hypotension, and an abnormal ecg tracing. remember that the single best method of detecting cardiac 98 1 emergency care vagolytic drugs atropine allow time for the drug to wear off. glycopyrrolate allow time for the drug to wear off. sympathomimetic drugs epinephrine allow time for the drug to wear off; administer a î²-blocker; turn off infusion. isoproterenol administer a î²-blocker. turn off infusion; administer a î²-blocker. allow time for drug to wear off. inadequate anesthetic depth increase anesthetic depth. hypercapnia increase ventilation (assisted ventilation). hypoxemia increase gas flow and oxygenation. hypotension decrease anesthetic depth; administer an intravenous crystalloid or colloid bolus, positive inotrope drug, positive chronotrope drug, or pressor. hyperthermia apply ambient or active cooling measures; administer dantrolene sodium if malignant hyperthermia is suspected. hypothermia provide ambient rewarming. hypocalcemia * administer calcium chloride (10 mg/kg iv) or calcium gluconate (23 mg/kg). decrease vaporizer setting/anesthetic depth. reverse with opioids or a 2 -agonists. vasodilation administer an intravenous crystalloid bolus (10 ml/kg). administer an intravenous colloid bolus (5 ml/kg). administer a pressor (epinephrine, phenylephrine dysrhythmias is with your fingertips (palpate a pulse or apex heartbeat) and ears (auscultate the heart). confirm the dysrhythmia by auscultating the heart rate and rhythm, identify the p waves and the qrs complexes, and evaluate the relationship between the p waves and qrs complexes. is there a p wave for every qrs, and a qrs for every p wave? during anesthesia, fluid, acid-base, and electrolyte imbalances can predispose the patient to dysrhythmias. sympathetic and parasympathetic stimulation, including the time of intubation, can predispose the patient to dysrhythmias. if the patient's plane of anesthesia is too light, perception of pain can cause catecholamine release, sensitizing the myocardium to ectopic beats. atrioventricular blockade can be induced with the administration of î± 2 -agonist medications, including xylazine and medetomidine. thiobarbiturates (thiopental) can induce ventricular ectopy and bigeminy. although these dysrhythmias may not be harmful in the awake patient, anesthetized patients are at a particular risk of dysrhythmia-induced hypotension. carefully monitor and treat all dysrhythmias (see cardiac dysrhythmias). box 1-27 lists steps to take to prevent perianesthetic dysrhythmias. awakening during anesthesia can occur and can be caused by equipment failure and simply, although no one likes to admit it, human error. table 1 -29 lists causes of arousal during anesthesia and appropriate immediate actions. awaken patient, and administer dantrolene arousal (e.g., malignant hyperthermia) sodium. â�¢ stabilize acid-base and electrolyte balance before anesthetic induction, whenever possible. â�¢ rehydrate patient before anesthetic induction. â�¢ select anesthetic agents appropriate for the particular patient. â�¢ be aware of the effects of the drugs on the myocardium. â�¢ ensure adequate anesthetic depth and oxygenation before anesthetic induction. â�¢ ensure ventilatory support during anesthesia. â�¢ monitor heart rate, rhythm, blood pressure, pulse oximetry, and capnometry during anesthesia. â�¢ ensure adequate anesthetic depth before surgical stimulation. â�¢ avoid surgical manipulation to the heart or great vessels, whenever possible. â�¢ avoid changes in perianesthetic depth. â�¢ avoid hypothermia. delayed recovery can be caused by a number of factors, including excessive anesthetic depth, hypothermia, residual action of narcotics or tranquilizers, delayed metabolism of anesthetic drugs, hypoglycemia, hypocalcemia, hemorrhage, and breed or animal predisposition. careful monitoring of the patient's blood pressure, acid-base and electrolyte status, anesthetic depth, pcv, and vascular volume intraoperatively and taking care with supportive measures to prevent abnormalities can hasten anesthetic recovery and avoid postoperative complications. gaynor the presentation of a patient with a bleeding disorder often is a diagnostic challenge for the veterinary practitioner (boxes 1-28 and 1-29). in general, abnormal bleeding can be caused by five major categories: (1) vascular trauma, (2) circulating inhibitors of coagulation heparin fibrin degradation products development of spontaneous deep hematomas, unusually prolonged bleeding after traumatic injury, bleeding at multiple sites throughout the body involving multiple organ systems, delayed onset of severe hemorrhage after bleeding, and an inability on the practitioner's part to find an organic cause of bleeding. the signalment, history, clinical signs, and results of coagulation often can aid in making a rapid diagnosis of the primary cause of the disorder and in the selection of appropriate case management. when taking a history, ask the following important questions: â�¢ what is the nature of the bleeding? â�¢ what sites are affected? â�¢ how long has the bleeding been going on? â�¢ has your animal had any previous or similar episodes? â�¢ is there any possibility of any toxin exposure? â�¢ if so, when and how much did your animal consume? â�¢ is there any possibility of trauma? â�¢ does your animal run loose outdoors unattended? â�¢ have you ever traveled, and if so, where? â�¢ has your animal been on any medications recently or currently? â�¢ has your animal been vaccinated recently? â�¢ have any known relatives of your animal had any bleeding disorders? â�¢ are there any other abnormal signs that you have seen? abnormalities found on physical examination may aid in determining whether the hemorrhage is localized or generalized (i.e., bleeding from a venipuncture site versus bleeding diathesis). note whether the clinical signs are associated with a platelet problem and superficial hemorrhage or whether deep bleeding can be associated with abnormalities of the coagulation cascade. also, make an attempt to identify any concurrent illness that can predispose the patient to a bleeding disorder (i.e., pancreatitis, snakebite, sepsis, immunemediated hemolytic anemia, or severe trauma and crush or burn injury). abnormalities associated with coagulopathies include petechiae and ecchymoses, epistaxis, gingival bleeding, hematuria, hemarthrosis, melena, and hemorrhagic cavity (pleural and peritoneal or retroperitoneal) effusions. disseminated intravascular coagulation is a complex syndrome that results from the inappropriate activation of the clotting cascade, leading to disruption of the normal balance between thrombosis and fibrinolysis. the formation of diffuse microthrombi with concurrent consumption of platelets and activated clotting factors leads to end-organ thrombosis with various degrees of clinical hemorrhage. in animals, dic always results from some other pathologic process, including various forms of neoplasia, crush and heat-induced injury, sepsis, inflammation, and immune-mediated disorders (box 1-30). the pathophysiologic mechanisms involved in dic include vascular endothelial damage, activation and consumption of platelets, release of tissue procoagulants, and consumption of endogenous anticoagulants. because dic always results from some other disease process, diagnosis of dic is based on a number of criteria when evaluating various coagulation tests, peripheral blood smears, platelet count, and end products of thrombosis and fibrinolysis. there is no one definitive criterion for the diagnosis of dic (box 1-31). thrombocytopenia occurs as platelets are consumed during thrombosis. it is important to remember that trends in decline in platelet numbers are just as important as thrombocytopenia when making the diagnosis. in some cases the platelet count still may be within the normal reference range but has significantly decreased in the last 24 hours. early in dic the procoagulant cascade dominates, with hypercoagulability. activated clotting time, aptt, and pt may be rapid and shorter than normal. in most cases, we do not recognize the hypercoagulable state in our critically ill patients. later in dic, as platelets and activated clotting factors become consumed, the act, aptt, and pt become prolonged. antithrombin, a natural anticoagulant, also becomes consumed, and antithrombin levels decline. antithrombin levels can be measured at commercial laboratories and in some large veterinary institutions. the end products of thrombosis and subsequent fibrinolysis also can be measured. fibrinogen levels may decline, although this test is not sensitive or specific for dic. fibrin degradation (split) products also become elevated. fibrin degradation products are normally cleared by the liver, and these also become elevated in cases of hepatic failure because of lack of clearance. more recently, cageside d-dimer tests have become available to measure the breakdown product of cross-linked fibrin as a more sensitive and specific monitor of dic. management of dic first involves treating the primary underlying cause. by the time dic becomes evident, rapid and aggressive treatment is necessary. if you are suspicious of dic in any patient with a disease known to incite dic, then ideally, you should begin treatment before the hemostatic abnormalities start to occur for the best possible prognosis. treatment involves replacement of clotting factors and antithrombin and prevention of further clot formation. to replenish clotting factors and antithrombin, administer fresh whole blood or fresh frozen plasma. heparin requires antithrombin as a cofactor to inactivate thrombin and other activated coagulation factors. administer heparin (50 to 100 units/kg sq q6-8h of unfractionated heparin; or fractionated enoxaparin [lovenox], 1 mg/kg sq bid). aspirin (5 mg/kg po bid in dogs; every third day in cats) also can be administered to prevent platelet adhesion. management of dic also involves the rule of twenty monitoring and case management to maintain end-organ perfusion and oxygen delivery (see the rule of 20). hemophilia a is a sex-liked recessive trait that is carried by females and manifested in males. female hemophiliacs can occur when a hemophiliac male is bred with a carrier female. hemophilia a has been reported in cats and a number of dog breeds, including miniature schnauzer, saint bernard, miniature poodle, shetland sheepdog, english and irish setters, labrador retriever, german shepherd, collie, weimaraner, greyhound, chihuahua, english bulldog, samoyed, and vizsla. mild to moderate internal or external bleeding can occur. clinical signs of umbilical cord bleeding can become apparent in some animals shortly after weaning. gingival hemorrhage, hemarthrosis, gastrointestinal hemorrhage, and hematomas may occur. clotting profiles in animals with factor viii deficiency include prolonged aptt and act. the pt and buccal mucosa bleeding time are normal. affected animals have low factor viii activity but normal to high levels of factor viii-related antigen. carrier females can be detected by low (30% to 60% of normal) factor viii activity and normal to elevated levels of factor vii-related antigen. von willebrand's disease is a deficiency or defect in von willebrand's protein. a number of variants of the disease have been described: von willebrand's disease type i is associated with a defect in factor viir/protein concentration, and von willebrand's disease type ii is associated with a defect in viiir:vwf. type i von willebrand's disease is most common in veterinary medicine. von willebrand's disease has been identified in more than 29 breeds of dogs, with an incidence that varies from 10% to 60% depending on the breed of origin. affected breeds include doberman pinchers, german shepherd dogs, scottish terriers and standard manchester terriers, golden retrievers, chesapeake bay retrievers, miniature schnauzers, and pembroke welsh corgis. two forms of genetic expression occur: (1) autosomal recessive disease in which homozygous von willebrand's disease individuals have a bleeding disorder, whereas heterozygous individuals carry the trait but are clinically normal. the second variant of genetic expression involves an autosomal dominant disease with incomplete expression such that heterozygous individuals are affected carriers and homozygous individuals are severely affected. von willebrand's disease has high morbidity, but fortunately a low mortality. dogs with 30% or less than normal vwf tend to hemorrhage. platelet counts are normal, but bleeding times can be prolonged. the aptt can be slightly prolonged when factor viii is less than 50% of normal. routine screening tests are nondiagnostic for this disease, although in a predisposed breed with a normal platelet count, a prolonged buccal mucosa bleeding time strongly supports a diagnosis of von willebrand's disease. documentation of clinical bleeding with low or undetectable levels of factor viii antigen or platelet-related activities of vwf support a diagnosis of von willebrand's disease. recessive animals have zero vwf:antigen (a subunit of factor iii); heterozygotes have 15% to 60% of normal. in the incompletely dominant form, levels of vwf antigen are reduced (less than 7% to 60%). clinical signs in affected animals include epistaxis, hematuria, diarrhea with melena, penile bleeding, lameness, hemarthrosis, hematoma formation, and excessive bleeding with routine procedures such as nail trimming, ear cropping, tail docking, surgical procedures (spay, neuter), and lacerations. estrous and postpartum bleeding may be prolonged. a dna test to detect carriers of the vwf gene is available through vetgen (ann arbor, michigan) and michigan state university. patients with von willebrand's disease should avoid drugs known to affect platelet function adversely (sulfonamide, ampicillin, chloramphenicol, antihistamines, theophylline, phenothiazine tranquilizers, heparin, and estrogen). hemophilia b is an x-linked recessive trait that occurs with less frequency that hemophilia a. the disease has been reported in scottish terriers, shetland and old english sheepdogs, saint bernards, cocker spaniels, alaskan malamutes, labrador retrievers, bichon frises, airdale terriers, and british shorthair cats. carrier females have low (40% to 60% of normal) factor ix activity. clinical signs are more severe than for hemophilia a. congenital deficiencies of factor vii have been reported as an autosomal, incompletely dominant characteristic in beagles. heterozygotes have 50% factor vii deficiency. bleeding tends to be mild. the pt is prolonged in affected individuals. factor x deficiency has been documented in cocker spaniels and resembles fading-puppy syndrome in newborn dogs. internal or umbilical bleeding can occur, and affected dogs typically die. bleeding may be mild in adult dogs. in severe cases, factor x levels are reduced to 20% of normal; in mild cases, factor x levels are 20% to 70% of normal. factor xii deficiency has been documented as an inherited autosomal recessive trait in domestic cats. heterozygotes can be detected because they have a partial deficiency (50% of normal) of factor xii. homozygote cats have less than 2% factor xii activity. deficiency of hageman factor usually does not result in bleeding or other disorders. factor xi deficiency is an autosomal disease that has been documented in kerry blue terriers, great pyrenees, and english springer spaniels. in affected individuals, protracted bleeding may be observed. homozygotes have low factor xi activity (< 20% of normal), and heterozygotes have 40% to 60% of normal. the management of congenital defects of hemostasis typically involves replenishing the clotting factor that is present. usually, this can be accomplished in the form of fresh frozen plasma transfusion (20 ml/kg). if anemia is present because of severe hemorrhage, fresh whole blood or packed rbcs also can be administered. recent research has investigated the use of recombinant gene therapy in the treatment of specific factor deficiencies in dogs; however, the therapy is not yet available for use in clinical practice. in cases of von willebrand's disease, administration of fresh frozen plasma (10 to 20 ml/kg) or cryoprecipitate (1 unit/10 kg body mass) provides vwf, factor viii, and fibrinogen. doses can be repeated until hemorrhage ceases. 1-desamino-8-d-arginine vasopressin (ddavp) also can be administered (1 âµg/kg sc or iv diluted in 0.9% saline given over 10 to 20 minutes) to the donor and patient to increase the release of stored vwf from endothelial cells. a fresh whole blood transfusion can be obtained from the donor and immediately administered to the patient, or spun down and the fresh plasma administered if rbcs are not needed. administer a dose of ddavp to any affected dog before initiating any elective surgical procedures. a supply of fresh frozen plasma and rbcs should be on hand, should uncontrolled hemorrhage occur. platelets are essential to normal blood coagulation. after a vessel is damaged, release of vasoactive amines causes vasoconstriction and sluggish flow of blood in an attempt to squelch hemorrhage. platelets become activated by platelet activating factor, and attach to the damaged vascular endothelium. normal platelet adhesion depends on mediators such as calcium, fibrinogen, vwf:antigen, and a portion of factor viii. after adhesion, the platelets undergo primary aggregation and release a variety of chemical mediators including adenosine diphosphate, prostaglandins, serotonin, epinephrine, thromboplastin, and thromboxane a that promote secondary aggregation and contraction. platelet abnormalities can include decreased platelet production (thrombocytopenia), decreased platelet function (thrombocytopathia), increased platelet destruction, increased platelet consumption, and platelet sequestration. thrombocytopathia refers to platelet function abnormalities. alterations in platelet function can affect platelet adhesion, aggregation, or release of vasoactive substances that help form a stable clot (box 1-32). in von willebrand's disease there is a deficiency in vwf:antigen that results in altered platelet adhesion. vascular purpuras are reported and have been seen in collagen abnormalities such as ehlers-danlos syndrome, which can be inherited as an autosomal dominant trait with complete penetrance and has been recognized in german shepherd dogs, dachshunds, saint bernards, and labrador retrievers. thrombasthenic thrombopathia is a hereditary autosomal dominant abnormality that has been described in otterhounds, foxhounds and scottish terriers. in this condition, platelets do not aggregate normally in response to adenosine diphosphate and thrombin stimulation. evaluation of platelet function is based on a total platelet count, buccal mucosa bleeding time, and thromboelastography. platelet function defects (thrombocytopenia and thrombocytopathia) can affect both sexes. clinical signs can resemble von willebrand's disease. in most cases, buccal mucosa bleeding time will be prolonged, but platelet count and clotting tests will be normal. platelet count can be decreased because of problems with production, increased consumption, sequestration, or destruction. causes of accelerated platelet destruction are typically immune-mediated autoantibodies, drug antibodies, infection, and isoimmune destruction. consumption and sequestration usually are caused by dic, vasculitis, microangiopathic hemolytic anemia, severe vascular injury, hemolytic uremic syndrome, and gram-negative septicemia. primary thrombocytopenia with no known cause has been called idiopathic thrombocytic purpura. in approximately 80% of the cases, thrombocytopenia is associated with immune-mediated destruction caused by immune-mediated hemolytic anemia, systemic lupus erythematosus, rheumatoid arthritis, dic, and diseases that affect the bone marrow. in systemic lupus erythematosus, 20% to 30% of the affected dogs have concurrent idiopathic thrombocytic purpura. when immune-mediated hemolytic anemia and idiopathic thrombocytic purpura are present in the same patient, the disease is called evans syndrome. pf-3 is a non-complement-fixing antibody that is produced in the spleen and affects peripheral and bone marrow platelets and megakaryocytes. antibodies directed against platelets are usually of the igg subtype in animals. antiplatelet antibodies can be measured by a pf-3 release test. platelet counts with immune-mediated destruction typically are less than 50,000 platelets/âµl. infectious causes of thrombocytopenia include ehrlichia canis, anaplasma phagocytophilum (formerly, ehrlichia equi), and rickettsia rickettsii (rocky mountain spotted fever). primary immune-mediated thrombocytopenia has an unknown cause and most frequently is seen in middle-to older-aged female dogs. breed predispositions include cocker spaniels, german shepherd dogs, poodles (toy, miniature, standard), and old english sheepdogs. thrombocytopenia usually is manifested as petechiae, ecchymoses of skin and mucous membranes, hyphema, gingival and conjunctival bleeding, hematuria, melena, and epistaxis. to make a diagnosis of idiopathic thrombocytic purpura, measure the severity of thrombocytopenia (< 50,000 platelets/âµl), analyze the peripheral blood smear for evidence of platelet fragmentation or microthrombocytosis, normal to increased numbers of megakaryocytes in the bone marrow, detection of antiplatelet antibody, increased platelet counts after starting glucocorticoid therapy, and elimination of other causes of thrombocytopenia. if tick-borne illnesses are suspected, antibody titers for e. canis, a. phagocytophilum (formerly e. equi), and r. rickettsii should be performed. treatment of immune-mediated thrombocytopenia involves suppression of the immune system to stop the immune-mediated destruction and to stimulate platelet release from the bone marrow. traditionally, the gold standard to suppress the immune system is to use glucocorticoids (prednisone or prednisolone, 2 to 4 mg/kg po bid divided, or dexamethasone, 0.1 to 0.3 mg/kg iv or po q12h). more recently human serum immunoglobulin (igg) also has been used (0.2 to 0.5 g/kg iv in saline over 8 hours; pretreat with 1 mg/kg diphenhydramine 15 minutes before starting infusion). vincristine (0.5 mg/m 2 iv once) can stimulate the release of platelets from the bone marrow if megakaryocytic precursors are present; however, the platelets released may be immature and potentially nonfunctional. treatment with fresh whole blood or packed rbcs is appropriate if anemia is present; however, unless specific platelet-rich plasma has been purchased from a blood bank, fresh whole blood contains relatively few platelets, which are shortlived (2 hours) and will not effectively raise the platelet count at all. finally, long-term therapy is usually in the form of azathioprine (2 mg/kg po once daily, tapered to 1 mg/kg daily to every other day after 1 week) and cyclosporine (10 to 25 mg/kg po divided). if a tickborne illness is suspected, administer doxycycline (5 to 10 mg/kg po bid) for 4 weeks or if titers come back negative. thrombocytopenia also can occur in the cat. causes for thrombocytopenia in cats include infections (29%), neoplasia (20%), cardiac disease (7%), primary immune-mediated disease (2%), and unknown causes (20%). in one study of cats with feline leukemia and myeloproliferative disease, 44% of cases had thrombocytopenia. warfarin and coumarin derivatives are the major class of rodenticides used in the united states. vitamin k antagonist rodenticides inhibit the epoxidase reaction and deplete active vitamin k, causing a depletion of vitamin k-dependent coagulation factors (ii, vii, ix, x) within 24 hours to 1 week of ingestion, depending on the ingested dose. affected animals can spontaneously hemorrhage anywhere in the body. clinical signs can include hemoptysis, respiratory difficulty, cough, gingival bleeding, epistaxis, hematuria, hyphema, conjunctival bleeding, petechiae and ecchymoses, cavity hemorrhage (pleural, peritoneal, retroperitoneal) with acute weakness, lethargy or collapse, hemarthrosis with lameness, deep muscle bleeds, and intracranial or spinal cord hemorrhage. diagnosis of vitamin k antagonism includes prolonged pt. a pivka (protein induced by vitamin k absence or antagonism) test also can be performed, if possible. treatment of vitamin k antagonist rodenticide intoxication and other causes of vitamin k deficiency involves supplementation with vitamin k 1 (phytonadione, 5 mg/kg sq once with 25-gauge needle in multiple sites, and then 2.5 mg/kg po bid to tid for 30 days). never administer injections of vitamin k intramuscularly, because of the risk of causing deep muscle hematomas, or intravenously, because of the risk of anaphylaxis. the pt should be rechecked 2 days after the last vitamin k capsule is administered, for some of the secondgeneration warfarin derivates are fat-soluble, and treatment may be required for an additional 2 weeks. act, activated clotting time; aptt, activated partial thromboplastin time; bmbt, buccal mucosa bleeding time; fdp, fibrin degradation products; n, normal; pt, prothrombin time. thermal burns are fortunately a relatively infrequent occurrence in veterinary patients. box 1-33 lists various causes of malicious and accidental burns. the location of the burn is also important in assessing its severity and potential to lose function. burns on the perineum, feet, face, and ears are considered to be the most severe because of loss of function and severe pain. often the severity of thermal injury is difficult to assess in animals because hair coat potentially can mask clinical signs and because the thermal injury can continue after the animal has been removed from the heat source. the skin cools slowly and warms slowly, considerations that become important when initiating therapy for burns. the severity of thermal injury is associated with the temperature to which the animal is exposed, the duration of contact, and the ability of the tissue to dissipate heat. the tissue closest to the heat source undergoes necrosis and has decreased blood flow. the severity of thermal burn injury is associated directly with the temperature to which the animal is exposed, the percentage of total body surface area affected, the thickness of injured tissue, and whether underlying complications with other body systems occur. prognosis largely depends on the total body surface area affected (table 1-31) . superficial partial thickness, or first-degree, burns offer the most favorable prognosis. the affected epidermis initially appears erythematous and then quickly desquamates within 3 to 6 days. in most cases, fur grows back without leaving a scar. deep partial thickness, or second-degree, burns involve the epidermis and dermis and are associated with subcutaneous edema, inflammation, and pain. deep partial thickness burns heal from deeper adnexal tissues and from the wound edges and are associated with an increased chance of scarring and depigmentation. the most severe type is known as full thickness, or third-degree, burns, in which thermal injury destroys the entire thickness of the skin and forms an eschar. thrombosis of superficial and deeper skin vasculature and gangrene occurs. treatment involves sequential wound debridement. healing occurs by second intention and reepithelialization or by wound reconstruction. in most cases, scarring is extensive in affected areas. burns greater than 20% of total body surface area will have systemic effects, including impaired cardiovascular function, pulmonary dysfunction, and impaired immune function. burned tissue, with capillary damage, has increased permeability. the release of inflammatory cytokines, oxygen-derived free radical species, prostaglandins, leukotrienes, 108 1 emergency care histamine, serotonin, and kinins results in increased vascular permeability and leakage of plasma proteins into the interstitium and extravascular space. at the time of presentation, first examine the patient and ascertain whether airway obstruction, impaired ventilatory function, circulatory shock, or pain are present. if necessary, establish an airway with endotracheal intubation or emergency tracheostomy. next, cool the burned area(s) with topical cool water. use care to avoid overcooling and iatrogenic hypothermia. the best approach is to cool only one portion of the patient's body at a time, then dry, and repeat the process for all affected areas to avoid overcooling and iatrogenic hypothermia. establish vascular access and administer appropriate and judicious analgesic drugs and intravenous fluid therapy. whenever possible, avoid placing a catheter through an area of burned or damaged skin. in the early stages of burn injury, shock doses of intravenous crystalloid fluids usually are not required. later, however, as severe tissue exudation occurs, protein and fluid losses can become extensive, requiring aggressive crystalloid and colloid support to treat hypovolemia and hypoproteinemia. flush the eyes with sterile saline and examine behind the third eyelids for any particulate matter. stain the corneas to make sure that superficial corneal burns are not present. treat superficial corneal burns with triple antibiotic ophthalmic ointment. next, assess the total body surface area affected, as this will gauge prognosis. depending on the extent of the damage, decide whether the burn is superficial and local therapy is indicated or whether more severe injuries exist that may involve systemic therapy or possibly euthanasia. in most cases the diagnoses of thermal burns are based on a clinical history of being in a house fire, clothes dryer, or under a heating lamp. too frequently, however, thermal burns become apparent days after an elective surgical procedure in which the patient was placed on a faulty heating pad rather than a circulating warm water or warm air blanket. superficial burns appear as singed fur with desquamating, easily epilated hair. this condition also can resemble a superficial or deeper dermatophytosis if history is unknown. other differential diagnoses include immune-mediated vasculitis or erythema multiforme. unless the superficial dermis is blistered, it may be difficult to distinguish between a thermal burn, chemical burn, or electrical burn if the trauma went unnoticed. management of burn injury largely depends on the depth of injury and the total body surface area affected. partial thickness burns and those affecting less than 15% of the total body surface area will require support in the form of antibiotic ointment and systemic analgesic drugs. burns affecting greater than 15% of total body surface area or deep thickness burns require more aggressive therapy. central venous catheters can be placed to administer crystalloid and colloid fluids, parenteral nutrition if necessary, antibiotics, and analgesic drugs. monitor perfusion parameters closely, including heart rate, blood pressure, capillary refill time, and urine output. respiratory function can be impaired because of concurrent smoke inhalation, thermal damage to the upper airways and alveoli, and carboxyhemoglobin or methemoglobin intoxication. respiratory function also can be impaired because of burn injury to the skin around the thoracic cage. thoracic radiographs may reveal patchy interstitial to alveolar infiltrates associated with pulmonary edema, pneumonia, and atelectasis. bronchoscopy often reveals edema, inflammation, particulate matter, and ulceration of the tracheobronchial tree. in some cases, upper airway inflammation is so severe that an emergency tracheostomy must be performed to treat airway obstruction. administer supplemental humidified oxygen at 50 to 100 ml/kg/minute via endotracheal tube, tracheostomy, nasal or intratracheal tube, or hood oxygen if respiratory function and hypoxemia are present. perform blood work including a hematocrit, albumin, bun, creatinine, and glucose at the time of presentation. monitor serum electrolytes, albumin, and colloid oncotic pressure closely because derangements can be severe as burns become exudative. the goal of fluid therapy in the burn patient is to establish and maintain intravascular and interstitial fluid volume, normalize electrolyte and acid-base status, and maintain serum albumin and oncotic pressure. in the first 24 hours following burn injury, direct fluid therapy to maintaining the patient's metabolic fluid requirements. crystalloid fluids in the form of normosol-r, plasmalyte-m, or lactated ringer's solution can be administered according to the patient's electrolyte and acid-base status (see fluid therapy). monitor urine output, and keep it at 1 to 2 ml/kg/hour. avoid overhydration in the early stages of burn injury. in affected burn patients, calculate the amount of fluid that should be administered over a 24-hour period from the formula 1 â�� 4 ml/kg ã� percent total body surface area. administer half of this calculated dose over the first 8 hours and then the remaining half over the next 16 hours. in cats, administer only 50% to 75% of this calculated volume. to administer this volume and also avoid fluid overload is often difficult in critically ill patients with pulmonary involvement associated with smoke inhalation injury. avoid colloids in the first 6 hours after burn injury. monitor the patient closely for serous nasal discharge, chemosis, and rales that may signify pulmonary edema. as burns become exudative, weigh the patient at least twice daily. infused fluid should equal fluid output in the form of urine and wound exudates. acute weight loss signifies acute fluid loss and that crystalloid fluid infusion should be more aggressive. ideally, keep the patient's serum albumin equal to or greater than 2.0 g/dl and total protein between 4.0 and 6.5 g/dl using a combination of fresh frozen plasma or concentrated human albumin. adjunct colloidal support can be provided with synthetic colloids including hetastarch or hbocs. keep serum potassium within 3.5 to 4.5 meq/l using potassium chloride or potassium phosphate supplementation. if potassium supplementation exceeds 80 to 100 meq/l and the patient continues to have severe refractory hypokalemia, administer magnesium chloride (0.75 meq/kg/day) to enhance potassium retention. if anemia occurs, administer packed rbcs or whole blood (see blood component therapy). lavage wounds daily with lactated ringer's solution or 0.9% sodium chloride solution. place wet-to-dry bandages or bandages soaked in silver sulfadiazine or nitrofurazone ointment over the wounds. depending on the thickness of the burn, epilation and eschar formation and separation may take 2 to 10 days. at each bandage change, debride devitalized tissue to normal tissue. perform staged partial or total escharectomy, and leave the wound to heal by second intention or by reconstruction using skin advancement flaps or grafts. maintain meticulous sterility at all times, given that burn patients are at high risk for infection. administer broad-spectrum antibiotics including cefazolin and enrofloxacin. perform wound culture if a resistant bacterial infection is suspected. the most common cause of electrical injury is associated with an animal chewing on low-voltage alternating current electrical cords in the household. damage is caused by the current flowing through the path of least resistance, causing heat and thrombosis of vessels and neurons. in some cases, the owner witnesses the event. in other cases, the owner presents the patient because of vague nonspecific signs, and characteristic abnormalities on physical examination support a diagnosis of electrocution. burns on the face, paws, commissures of the mouth, tongue, and soft palate may be present. electrocution causes a massive release of catecholamines and can predispose the patient to noncardiogenic pulmonary edema within 36 hours of the incident. clinical signs may be isolated to the pulmonary system, including orthopnea, pulmonary crackles, and cyanosis. assess the patient's lips, tongue, soft palate, gingivae, and commissures of the mouth. early after electrocution, the wound may appear small and white, black, or yellow. later, the wound may become larger as tissue sloughs because of damaged vascular supply. assess the patient's respiratory status. auscultate the lungs to determine whether pulmonary crackles 110 1 emergency care are present. if the patient is stable, thoracic radiographs may demonstrate an interstitial to alveolar lung pattern in the dorsocaudal lung fields. measure the patient's heart rate, blood pressure, oxygenation as determined by pulse oximetry or arterial blood gas and urine output. immediate treatment consists of judicious use of analgesics for the burn injury, antibiotics (cefazolin, 22 mg/kg q8h; cephalexin, 22 mg/kg q8h), and humidified supplemental oxygen (50 to 100 ml/kg/minute). direct fluid therapy at providing the patient's metabolic fluid requirements. because of the risk of development of noncardiogenic pulmonary edema, avoid overzealous administration of crystalloid fluids. differential diagnoses for the patient with electrical burn injury and electrocution include chemical or thermal burn, immune-mediated glossitis, cardiogenic pulmonary edema, and pneumonia. management of the patient with electrical burn injury and electrocution primarily involves the administration of analgesic agents, supplemental humidified oxygen, and topical treatment of electrical burns. the noncardiogenic pulmonary edema is typically unresponsive to diuretics (i.e., furosemide), bronchodilators (i.e., aminophylline), and splanchnic vascular dilators (i.e., low-dose morphine). the use of glucocorticoids has no proven benefit and may impair respiratory immune function and is therefore contraindicated. oral burns may require debridement and advancement flaps if large defects or oronasal fistulas develop. if oral injury is severe, place an esophagostomy or percutaneous gastrostomy tube to ensure adequate nutrition during the healing process. if an animal survives the initial electrocution, prognosis is generally favorable with aggressive supportive care. chemical burns are associated with a number of inciting causes, including oxidizing agents, reducing agents, corrosive chemicals, protoplasmic poisons, desiccants, and vesicants. the treatment for chemical burns differs slightly from that for thermal burns, so it remains important to investigate the cause of the burn when providing initial treatment, whenever possible. at the scene, advise the owner to wrap the patient in a clean towel for transport. chilling can be avoided by then wrapping the patient in a second or third blanket. placement of ointments by well-doers should be avoided. encourage immediate transport to the nearest triage facility. the first and foremost consideration when treating a patient with chemical burn is to remove the animal from the inciting cause or offending agent. make no attempt to neutralize alkaline or acid substances because the procedure potentially could cause an exothermic reaction, leading to thermal injury in addition to the chemical injury. remove collars or leashes that may act as tourniquets or constricting devices. flush affected areas with copious amounts of cool water for several minutes, not cooling more than 10% to 20% of the body at any one time to prevent iatrogenic hypothermia. support breathing by extending the patient's head and neck. carefully clip the fur over affected areas for further evaluation of the extent of the injury. lavage exposed eyes with sterile saline, and stain the cornea to evaluate for any corneal burns. debride any wounds carefully, knowing that the full extent of the wound may not manifest itself for several days. then cover the wounds with antibiotic burn ointment such as silver sulfadiazine and an occlusive dressing. without a history of exposure, the differential diagnosis for any chemical burn includes thermal burn, necrotizing vasculitis, erythema multiforme, or superficial or deep pyoderma. contact local or national animal poison control regarding whether to attempt neutralization. perform daily bandage changes with staged debridement as the full extent of the wound manifests itself. place antimicrobial ointment and silver sulfadiazine ointment over the wound to prevent infection. the routine use of antibiotics may promote the development of a resistant bacterial infection. first-generation cephalosporin can be administered. if a more serious infection develops, perform culture and susceptibility testing to direct appropriate antibiotic therapy. the wound can heal by second intention or may require reconstructive repair for definitive closure. the primary cause of radiation injury in small animal patients is radiation therapy for neoplastic conditions. the goal of radiation therapy is to kill neoplastic cells. an unfortunate side effect is damage to adjacent normal tissue that results in necrosis, fibrosis, and impaired circulation to the affected area. radiation burns result in dermatitis, mucositis, impaired surgical wound healing, and chronic nonhealing wounds. in many cases, the degree of secondary radiation injury to normal tissue can be prevented or decreased with careful radiation planning and mapping of the radiation field, such that radiation exposure to normal tissue is limited to the smallest extent possible. with the advent of three-dimensional imaging modalities such as computed tomography (ct) and magnetic resonance imaging (mri), this has become more routine in veterinary oncology to date. radiation injury can be early and appear at the later stage of the course of radiation therapy. late effects can be delayed and occur 6 months to years after treatment. the degree of radiation injury is categorized based on the depth of tissue affected. first-degree changes cause cutaneous erythema. second-degree changes cause superficial desquamation. thirddegree changes cause deeper moist desquamation, and fourth-degree changes are associated with complete dermal destruction and ulceration. during the early stages of radiation injury, affected tissues may appear erythematous and edematous. wound exudates may be moist, or the skin may appear dry and scaly with desquamation or ulceration. later, the area may scar and depigment or may have induration, atrophy, telangiectasia, keratosis, and decreased adnexal structures. treatment for radiation dermatitis is to irrigate the area with warmed saline and to protect the area from self-mutilation. no-bite, or elizabethan, collars or loose clothing can be used to protect the area for patient-induced injury. mucositis can be treated with topical green tea baths and the administration of an oral solution of l-glutamine powder (4 g/m 2 ). local irrigation of xylocaine or lidocaine viscous jelly can be used in dogs but should be avoided in cats because of the risk of inducing hemolytic anemia and neurotoxicity. topical and systemic antibiotics (cephalexin, 22 mg/kg po tid) also can be administered. avoid antibiotics that can be sensitized by radiation (i.e., metronidazole). because most radiation burns are associated with a known exposure to radiation therapy, the cause of the patient's injury usually is known. if an animal presents to you with a scar, however, differential diagnoses may include nasal planum solar dermatitis, pemphigus foliaceus, discoid lupus, superficial necrolytic dermatitis, superficial or deep pyoderma, chemical burn, or thermal burn. treatment of radiation injury involves making the patient as comfortable as possible with analgesic drugs, prevention of self-mutilation, and staged debridement techniques. wounds can heal by second intention or may require reconstructive surgery. distress syndrome (ards), and anesthetic agents. the acute onset of bradycardia, change in mucous membrane color and capillary refill time, change in respiratory pattern, and change in mentation are signs of possible deterioration and impending cardiopulmonary arrest. the diagnosis of cardiopulmonary arrest is based on the absence of effective ventilation, severe cyanosis, absence of a palpable pulse or apex heartbeat, absence of heart sounds, and ecg evidence of asystole or other nonperfusing rhythm such as electricalmechanical dissociation (aka pulseless electrical activity) or ventricular fibrillation. the goals of cpcr are to obtain airway access, provide artificial ventilation and supplemental oxygen, implement cardiac compressions and cardiovascular support, recognize and treat dysrhythmias and arrhythmias, and provide stabilization and treatment for cardiovascular, pulmonary, and cerebral function in the event of a successful resuscitation. even with aggressive treatment and management, the overall success of cpcr is less than 5% in critically ill or traumatized patients and 20% to 30% in anesthetized patients. basic life support involves rapid intubation to gain airway access, artificial ventilation, and cardiac compressions to promote blood flow and delivery of oxygen to the brain and other important tissues (figure 1-26 ). perform the abcs or cabs of cpcr, where a is airway, b is breathing, and c is compression and circulation. recently, the paradigm has shifted to cabs. while a team member is grabbing an endotracheal tube, clearing the airway of foreign debris, and establishing airway access through endotracheal intubation, a second person starts external cardiac compressions to deliver oxygen that is in the bloodstream to the vital organs. the patient should be positioned in dorsal (> 7 kg) or lateral (< 7 kg) recumbency for external cardiac compressions. approximately 80 to 120 external compressions should be performed over the patient's sternum. a team member should palpate for a peripheral pulse to determine whether cardiac compressions are actually effective. if a peripheral pulse cannot be palpated for every chest compression, change the patient's position and have a larger individual perform compressions, or initiate open-chest cardiac resuscitation. once the patient is intubated, tie in the endotracheal tube and attach it to an oxygen source (anesthetic machine or mechanical ventilator or ambu bag) for artificial ventilation. the oxygen flow rate should be 150 ml/kg/minute. give two long breaths, and then 12 to 16 breaths per minute. simultaneous ventilation with thoracic compression increases the pressure difference in the thorax and allows more forward flow of oxygenated blood through the great vessels into the periphery. if possible, a third team member can initiate interposed abdominal compressions, compressing the abdomen when the thoracic cage is relaxed, to improve forward flow. if only one person is available to perform the thoracic compressions and ventilation, give two breaths for every 15 compressions (i.e., 15 thoracic compressions followed by two long breaths, and then start thoracic compressions again). the jen chung maneuver can be performed by placing a 25-to 22-gauge hypodermic needle through the skin of the nasal philtrum and twisting the needle into the periosteum to stimulate respirations. this maneuver appears to work better in cats than dogs at return to spontaneous respiration. advanced life support during cpcr involves ecg, pulse oximetry and capnometry monitoring, administration of drugs, and the administration of intravenous fluids (in select cases). most of the drugs used during cpcr can be administered directly into the lungs from the endotracheal tube (intratracheal tube). therefore, only in select instances is it necessary to establish vascular or intraosseous access during cpcr (figure 1-27) . if an animal experiences cardiopulmonary arrest because of extreme hemorrhage or hypovolemia, inappropriate vasodilation caused by sepsis or systemic inflammation, or vasodilation resulting from anesthesia, the administration of shock volumes (90 ml/kg/hour in dogs and 44 ml/kg/hour in cats) is appropriate. if a patient is euvolemic and experiences cardiopulmonary arrest, however, an increase in circulating fluid volume actually can impair coronary artery perfusion by increasing diastolic arterial blood pressure and is asystole is one of the most common rhythm disturbances that causes cardiac arrest in small animal patients. one of the most important things to do when the ecg looks like asystole is to make sure that the ecg monitor is working properly and that all ecg leads are attached properly to the patient. if asystole is truly present, reverse any opiate, î± 2 -agonist, or benzodiazepine drugs with their appropriate reversal agents. lowdose epinephrine (0.02 to 0.04 mg/kg diluted with 5 ml sterile saline) can be administered directly into the endotracheal tube via a rigid or red rubber catheter. if vascular access is available, epinephrine (0.02 to 0.04 mg/kg) can be administered intravenously. no drug should ever be administered directly into the heart by intracardiac injection. unless the heart is in the veterinarian's hand during open-chest cpcr, intracardiac injection is risky and potentially could lacerate a coronary artery or cause the myocardium to become more irritable and refractory to other therapies, if a drug is delivered into the myocardium and not into the ventricle. for these reasons, intracardiac injections are contraindicated. administer atropine (0.4 mg/kg iv, io, or 0.4 mg/kg it) immediately after the epinephrine. atropine, a vagolytic drug, serves to decrease tonic vagal inhibition of the sinoatrial and atrioventricular node and increase heart rate. administer atropine and epinephrine every 2 to 5 minutes during asystole while cardiac compressions, interposed abdominal compressions, and artificial ventilation are continued. although discontinuation of thoracic compressions can decrease the chance of success during cpcr, you must intermittently evaluate the ecg monitor for any rhythm change that may require different drug therapies. if the cardiac arrest was not witnessed or more than 2 to 5 minutes have passed without successful return to a perfusing rhythm, perform open-chest cpcr, if the client wishes. administer sodium bicarbonate (1 to 2 meq/kg iv) every 10 to 15 minutes during cpcr. sodium bicarbonate is the only drug used in cpcr that should not be administered intratracheally because of inactivation of pulmonary surfactant. electrical-mechanical dissociation also is known as pulseless electrical activity and is an electrical rhythm that may look wide and bizarre and irregular with no associated mechanical contraction of the ventricles. the rhythm can appear different from patient to patient. electrical-mechanical dissociation is one of the more common nonperfusing rhythms observed during cardiopulmonary arrest in small animal patients (figure 1-28) . when electrical-mechanical dissociation is identified, first confirm the rhythm and proceed with cpcr as previously described. electrical-mechanical dissociation is thought to be associated with high doses of endogenous endorphins and high vagal tone. the treatment of choice for electrical-mechanical dissociation is high-dose atropine (4 mg/kg iv, it [10 times the normal dose]) and naloxone hydrochloride (0.03 mg/kg iv, io, it). administer epinephrine (0.02 to 0.04 mg/kg diluted in 5 ml sterile 0.9% saline it). if the rhythm does not change within 2 minutes, consider open-chest cardiac massage. ventricular fibrillation can be coarse (figure 1-29) . patients with coarse ventricular fibrillation are easier to defibrillate than those with fine defibrillation. if ventricular fibrillation is identified, initiate cpcr as described previously (figure 1-30) . if an electrical defibrillator is available, administer 5 j/kg of direct current externally. when a patient in cardiopulmonary arrest is attached to ecg leads, it is important to use contact electrode paste, water-soluble gel such as ky jelly, or water, rather than any form of alcohol. electrical defibrillation of a patient who has alcohol on the ecg leads can lead to fire and thermal burns. reverse any opioid, î± 2 -agonist, and phenothiazine drugs that have been administered to the patient. if fine ventricular fibrillation is identified, administer epinephrine 1 figure 1 -28: electrical-mechanical dissociation (emd), also known as pulseless electrical activity (pea). the complexes often appear wide and bizarre without a palpable apex beat or functional contraction of the heart. this is just one example of emd, as many shapes and complexes may be observed. organized according to whether an electrical defibrillator is available. after each intervention step, the ecg should be reevaluated and the next step initiated if v-fib is still seen. if a new arrhythmia develops, the appropriate therapy for that rhythm should be inititated. if a sinus rhythm is seen with a palpable apex beat, postresuscitation measures should be implemented. perform open-chest cpcr immediately if a pathologic condition exists that prevents enough of a change in intrathoracic pressure that closed-chest cpcr will not be effective in promoting forward blood flow (box . to perform open-chest cpcr, place the patient in right lateral recumbency. clip a wide strip of fur over the left fifth to seventh intercostal space and quickly aseptically scrub over the clipped area. using a no. 10 scalpel blade, incise over the fifth intercostal space through the skin and subcutaneous tissue to the level of the intercostal muscles. with a mayo scissors, make a blunt stab incision through the intercostal muscles in the left sixth intercostal space. make sure that the person who is breathing for the patient deflates the lungs as you make the stab incision to avoid iatrogenic lung puncture. after the stab incision, open the tips of the mayo scissors and quickly open the muscle dorsally and ventrally to the sternum with a sliding motion. avoid the internal thoracic artery at the sternum and the intercostal arteries at the caudal aspect of each rib. cut the rib adjacent to the sternum and push it behind the rib in front of and at the caudal aspect of the incision to allow more room and better visualization if a rib spreading retractor is not available. visualize the heart in the pericardial sac. visualize the phrenic nerve, and incise the pericardium just ventral to the phrenic nerve. make sure to not cut the phrenic nerve. grasp the heart in your hand(s) and gently squeeze it from apex to base, allowing time for the ventricle to fill before the next "contraction." if the heart does not seem to be filling, administer fluids intravenously or directly into the right atrium. the descending aorta can be cross-clamped with a rummel tourniquet or red rubber catheter to improve perfusion to the brain and heart. postresuscitation care and monitoring (prolonged life support) postresuscitation care involves careful monitoring and management of the adverse effects of hypoxia and reperfusion injury on the brain and other vital organs. the first 4 hours after an arrest are most critical, because this is the time period in which an animal is most likely to rearrest unless the underlying cause of the initial arrest has been determine and treated (table 1 -32) . until an animal is adequately ventilating on its own, artificial ventilation by manual bagging or attaching the patient to a mechanical ventilator with supplemental oxygen must continue. the efficacy of oxygenation and ventilation can be monitored using a wright's respirometer, pulse oximetry, capnometry, and arterial blood . once an animal is extubated, administer supplemental oxygen (50 to 100 ml/ kg/minute) (see oxygen supplementation). the brain is sensitive to ischemia and reperfusion injury. the effects of cellular hypoxia and reperfusion include the development of oxygen-derived free radical species that contribute to cerebral edema. administer mannitol (0.5 to 1 g/kg iv over 5 to 10 minutes), followed by furosemide (1 mg/kg iv) 20 minutes later, to all patients that have experienced cardiopulmonary arrest and have had successful resuscitation. mannitol and furosemide work synergistically to decrease cerebral edema formation and scavenge oxygen-derived free radical species. the combination of cardiac arrest, myocardial ischemia and acidosis, and external or internal cardiac compressions often make the myocardium irritable and predisposed to dysrhythmias following successful cpcr. start lidocaine (1 to 2 mg/kg iv, followed by 50 to 100 âµg/kg/minute iv cri) in all patients following successful resuscitative efforts. monitor the ecg continuously for the presence of cardiac dysrhythmias and recurrence of nonperfusing rhythms. perform direct or indirect blood pressure monitoring. if a patient's systolic blood pressure is less than 80 mm hg, diastolic pressure is less than 40 mm hg, or mean arterial blood pressure is less than 60 mm hg, administer positive inotropic drugs (dobutamine, 1 to 20 âµg/kg/minute) and pressor agents (epinephrine, 0.02 to 0.04 mg/kg iv, io, it) to improve cardiac contractility, cardiac output, and core organ perfusion. the kidneys are sensitive to decreased perfusion and cellular hypoxia. place a urinary catheter and monitor urine output. in a euvolemic patient, normal urine output should be no less than 1 to 2 ml/kg/hour. if urine output is low, administer low-dose dopamine (3 to 5 âµg/kg/minute iv cri) in an attempt to dilate afferent renal vessels and improve renal perfusion. maintain acid-base and electrolyte status within normal reference ranges. monitor serum lactate as a rough indicator of organ perfusion and cellular oxygen extraction. the presence of elevated or rising serum lactate in the face of aggressive cardiorespiratory and cerebral support makes prognosis less favorable. cole sg, otto cm, hughes d: cardiopulmonary cerebral resuscitation: a clinical practice review part i, j vet emerg crit care 12 (4) immediate action depends largely on recognition of the primary or secondary cause of the dysrhythmia and treating the dysrhythmia and underlying cause. diagnosis of cardiac dysrhythmias is based on physical examination findings of abnormal thoracic/cardiac auscultation, the presence of abnormal pulse rhythm and quality, and recognition of ecg abnormalities. the ecg is critical to the accurate diagnosis of dysrhythmias. ventricular dysrhythmias arise from ectopic foci in the ventricles that cause the wave of depolarization to spread from cell to cell rather than spread through fast-conducting tissue. this causes the qrs complex to appear wide and bizarre, unless the ectopic focus originates close to the atrioventricular node high in the ventricle. other ecg features of ventricular dysrhythmias include a t wave polarity that is opposite to the qrs complex and nonrelated p waves. ventricular dysrhythmias may manifest as isolated ventricular premature complexes, couplets, or triplets; bigeminy; or ventricular tachycardia. relatively slow ventricular tachycardia is known as an idioventricular rhythm and is not as hemodynamically significant as faster ventricular tachycardia. idioventricular rhythm usually is less than 130 beats per minute and may alternate spontaneously with sinus arrhythmias (figures 1-31 to . supraventricular dysrhythmias arise from ectopic foci in the atria and are commonly associated with atrial dilatation and structural heart disease such as advanced acquired or congenital heart disease, cardiomyopathies, cardiac neoplasia, or advanced heartworm disease. occasionally, supraventricular dysrhythmias may be associated with respiratory or other systemic illness. sustained supraventricular tachycardia in the absence of underlying structural heart or systemic disease is disturbing and should alert the clinician that an accessory pathway conduction disturbance may be present, particularly in labrador retrievers. supraventricular dysrhythmias can manifest as isolated premature complexes (atrial premature complexes or contractions), sustained or paroxysmal supraventricular tachycardia (atrial tachycardia), or atrial fibrillation or flutter. in the dog, atrial fibrillation most commonly is associated with dilative cardiomyopathy. rarely and primarily in giant breed dogs, lone atrial fibrillation can occur with no underlying heart disease. atrial fibrillation and the resultant sustained elevation in ventricular rate are presumed to progress to dilative cardiomyopathy in such breeds. by comparison, atrial fibrillation is relatively uncommon in cats because of the small size of their atria but is associated most commonly with hypertrophic and restrictive cardiomyopathy. the ecg is critical to the diagnosis of a supraventricular dysrhythmia. the ecg usually demonstrates a normal appearance to the qrs complex unless aberrant conduction occurs in the ventricles, in which case the qrs can be wide but still originate from above the atrioventricular node. in most cases of a supraventricular dysrhythmia, some evidence of atrial activity including p waves, atrial flutter, or atrial fibrillation is apparent. in some cases, it may be difficult to diagnose the exact rhythm without slowing the rate down mechanically or through pharmacologic intervention. once a rhythm diagnosis is made, appropriate treatment strategies can be implemented (figures 1-35 and 1-36 ). treatment of ventricular dysrhythmias largely depends on the number of ectopic foci discharging, the rate and character of the dysrhythmia, and whether the presence of the abnormal beats is of adverse hemodynamic consequence, including risk of sudden death. many ventricular dysrhythmias, including slow idioventricular rhythms, ventricular bigeminy, or intermittent ventricular premature complexes, do not warrant antiarrhythmic therapy unless the patient is hypotensive and the dysrhythmia is thought to be contributing to the hypotension. in such cases, correction of the underlying disease process including hypoxia, pain, or anxiety often alleviates or decreases the incidence of the dysrhythmia. more serious ventricular dysrhythmias that warrant antiarrhythmic therapy (table 1 -33) include sustained ventricular tachycardia (>160 beats/minute in dogs; >220 beats/minute in cats), multifocal ventricular premature complexes originating from more than one place in the ventricles, and the presence of r-on-t phenomena where the t wave of the preceding complex is superimposed on the qrs of the next complex with no return to isoelectric shelf in between complexes. treat these ventricular dysrhythmias immediately and aggressively. in dogs, the mainstay of emergency treatment for ventricular dysrhythmias is lidocaine therapy. administer lidocaine (1 to 2 mg/kg iv bolus) over a period of 5 minutes to prevent the adverse side effects of seizures or vomiting. the bolus can be repeated an additional 3 times (total dose 8 mg/kg) over 15 minutes, or the patient can be placed on a constant rate infusion (50 to 100 âµg/kg/minute) if control of ventricular tachycardia is accomplished. also correct the patient's magnesium and potassium deficiencies to maximize the success of lidocaine therapy in the treatment of ventricular tachycardia. procainamide (4 mg/kg iv slowly over 3 to 5 minutes) also can be used to control ventricular tachycardia. if procainamide is successful at controlling ventricular tachycardia, administer it as a constant rate infusion (25 to 40 âµg/kg/minute). side effects of procainamide include vomiting, diarrhea, and hypotension. chronic oral therapy may or may not be necessary in the treatment of acute ventricular tachycardia. the decision to continue antiarrhythmic therapy depends on the underlying disease process and the expectation of persistent arrhythmogenesis of the underlying disease process. oral antiarrhythmic therapy is warranted in cases in which a serious ventricular dysrhythmia is recognized but the animal does not require hospitalization, such as the syncopal boxer with intermittent ventricular dysrhythmias and no evidence of structural heart disease. it deserves emphasis that asymptomatic, low-grade ventricular dysrhythmias probably do not require treatment. if maintenance therapy for ventricular dysrhythmias is needed, use an oral drug based on the underlying disease process, clinical familiarity, class of drug, dosing frequency, owner compliance, concurrent medications, cost, and potential adverse side effects. in the cat the mainstay of antiarrhythmic therapy is the use of a î²-adrenergic antagonist. in the acute management of ventricular dysrhythmias in cases of hypertrophic, restrictive, or unclassified cardiomyopathies, consider using injectable esmolol (0.05 to 1.0 mg/kg iv slowly to effect) or propranolol (0.02 to 0.06 mg/kg iv slowly to effect), particularly if the dysrhythmia results from hyperthyroidism. for chronic oral ventricular antiarrhythmic therapy in cats, propranolol (2.5 to 5.0 mg po per cat q8h) or atenolol (6.25 to 12.5 mg po per cat q12-24h) can be used. the decision to treat supraventricular dysrhythmias depends on the ventricular rate and the hemodynamic consequences of the dysrhythmia. for intermittent isolated atrial 124 1 emergency care procainamide 10-20 mg/kg po q6-8h tocainide* 10-20 mg/kg po q8h sotalol 40-120 mg per dog q12h (start low, then titrate up to effect) mexiletine 5-8 mg/kg po q8h atenolol 0.25-1.0 mg/kg po q12-24h (start low, titrate upward to effect) *do not use for longer than 2 weeks because of idiosyncratic blindness. premature contractions, couplets, and triplets, usually no treatment is required. when the ventricular rate exceeds 180 beats/minute, diastolic filling time is shortened, causing the heart to not fill adequately. the consequence is decreased cardiac output and decreased coronary artery perfusion. the goal of therapy is rhythm control or, in most cases, rate control. in cases of atrial fibrillation and congestive heart failure, conversion to a normal sinus rhythm rarely can be achieved, although electrocardioversion or pharmacoconversion can be attempted. in the dog a vagal maneuver can be attempted by pressing on the eyeballs or massaging the carotid body. for sustained supraventricular tachycardia, diltiazem (0.25 mg/kg iv), esmolol (0.05 to 0.1, titrated upward to a cumulative dose of 0.5 mg/kg iv), or propranolol (0.04 to 0.1 mg/kg iv slowly to effect) can be administered in an attempt to slow the ventricular rate in emergent situations. administer oral diltiazem (0.5 mg/kg po q8h), diltiazem (dilacor-xr) (1.5 to 6 mg/kg po q12-24h), propranolol (0.1 to 0.2 mg/kg tid, titrated up to a maximum of 0.5 mg/kg po q8h), atenolol (0.25 to 1 mg/kg q12-24h), or digoxin (0.005 to 0.01 mg/kg bid or 0.22 mg/m 2 for dogs greater than 15 kg). in the cat a vagal maneuver can be attempted by ocular or carotid massage. (diltiazem [dilacor] 30 to 60 po q12-24h), propranolol (2.5 to 10 mg/kg q12-24h), or atenolol (6.25 mg q12-24h) also can be administered. if structural heart disease is present, treat pulmonary edema and start angiotensin-converting enzyme inhibitor therapy. table 1 -34 summarizes the drugs used in the management of supraventricular dysrhythmias. severe bradycardia often results from systemic disease, drug therapy, anesthetic agents, or hypothermia and thus rarely requires specific therapy except to treat or reverse the underlying mechanisms promoting bradycardia. hemodynamically significant bradyarrhythmias that must be treated include atrial standstill, atrioventricular block, and sick sinus syndrome. atrial standstill most commonly is associated with hyperkalemia and is seen most often in urinary obstruction, renal failure, urinary trauma with uroabdomen, and hypoadrenocorticism. characteristic ecg abnormalities observed in atrial standstill are an absence of p waves, widened qrs complexes, and tall spiked t waves (figure 1-37 ). the treatment for hyperkalemia-induced atrial standstill is to correct the underlying cause and to drive potassium intracellularly and protect the myocardium from the adverse effects of hyperkalemia. regular insulin (0.25 to 0.5 units/kg iv) followed by dextrose (1 g/unit insulin iv, followed by 2.5% dextrose cri to prevent hypoglycemia) or sodium bicarbonate (1 meq/kg iv) can be administered to drive potassium intracellularly. calcium gluconate (0.5 ml/kg of 20% solution iv over 5 minutes) also can be administered as a cardioprotective drug until the cause of hyperkalemia has been identified and resolved. also administer sodium chloride fluids (0.9% sodium chloride iv) to promote kaliuresis. less commonly, atrial standstill is associated with atrial cardiomyopathy or silent atrium syndrome. persistent atrial standstill has been recognized without electrolyte abnormalities in the english springer spaniel and the siamese cat. short-term therapy for persistent atrial standstill includes atropine (0.04 mg/kg sq) until definitive treatment by implantation of a cardiac pacemaker can be performed. complete or third-degree atrioventricular block or high-grade symptomatic seconddegree atrioventricular block can be hemodynamically significant when ventricular rates are less than 60 beats/minute in the dog. classic clinical signs include weakness, exercise intolerance, lethargy, anorexia, syncope, and occasionally seizures. advanced atrioventricular block usually is caused by advanced idiopathic degeneration of the atrioventricular node. less commonly, atrioventricular block has been associated with digoxin toxicity, magnesium oversupplementation, cardiomyopathy, endocarditis, or infectious myocarditis (lyme disease). an accurate diagnosis is made based on the ecg findings of nonconducted p waves with ventricular escape beats. first-and second-degree atrioventricular block may not be hemodynamically significant and therefore may not require therapy. initially treat third-degree (complete) or symptomatic high-grade second-degree atrioventricular block (<60 beats/minute) with atropine (0.04 mg/kg sq or im). perform a follow-up ecg in 15 to 20 minutes. atropine is rarely successful in treating complete atrioventricular block. also attempt treatment with isoproterenol (0.04 to 0.08 âµg/kg/minute iv cri or 0.4 mg in 250 ml 5% dextrose in water iv slowly), a pure î²-agonist. definitive treatment requires permanent pacemaker implantation. consultation with a veterinary cardiologist who implants pacemakers is suggested. never attempt to convert or treat the observed ventricular escape beats with lidocaine ( figure 1-38) . sick sinus syndrome most commonly is recognized in the miniature schnauzer, although any dog can be affected. sick sinus syndrome usually results from idiopathic degeneration of the sinus node in the dog. in the cat, sinus node degeneration usually is associated with cardiomyopathy. dysfunction of the sinus node may manifest as marked bradycardia with periods of sinus arrest followed by junctional or ventricular escape complexes. a variant of sick sinus syndrome is the presence of severe bradycardia followed by periods of supraventricular tachycardia, often termed bradycardia-tachycardia syndrome. the most common clinical signs are syncope, exercise intolerance, and lethargy. in cats, hypertrophic cardiomyopathy is the most common form of acquired cardiac disease observed. congestive heart failure resulting from hypertrophic cardiomyopathy can occur in animals as young as 6 to 10 months of age. hypertrophic cardiomyopathy is characterized by stiff, noncompliant ventricles that do not relax during diastole, causing an increase in left atrial pressures and left atrial enlargement. other cardiomyopathies, including unclassified, restrictive, and dilated, are less common but also can occur in the cat. cats often develop acute exacerbation of clinical signs because of stress or arterial embolization. the rapid diagnosis of chf often is made on owner history, signalment, and physical examination findings (box 1-36). typical physical examination findings include a cardiac murmur or gallop dysrhythmia, abnormal breath sounds, respiratory difficulty and orthopnea, tachycardia, weak pulse quality, cool peripheral extremities, and pale or cyanotic mucous membrane. initiate immediate treatment based on physical examination findings and index of suspicion. in some cases, it is difficult to distinguish between chf and feline lower airway disease (asthma) without performing thoracic radiographs. let the animal rest and become stabilized before attempting any stressful procedures, including thoracic radiographs. immediate treatment consists of administering supplemental oxygen, decreasing circulating fluid volume with furosemide, dilating pulmonary and splanchnic capacitance vessels with topical nitroglycerine and morphine, and alleviating patient anxiety and stress (box 1-37). primary differential diagnoses are made based primarily on the patient's breed, age, clinical signs, history, and physical examination abnormalities. the most common differential diagnoses in a patient with chf are cardiac abnormalities and respiratory disease (chronic bronchitis [asthma], pulmonary hypertension, cor pulmonale, neoplasia). postpone diagnostic tests in any patient with suspected chf until the immediate treatments have taken effect and the patient is cardiovascularly more stable. in most cases, lateral and dorsoventral thoracic radiographs are one of the most important diagnostic tools in helping make a diagnosis of chf. increased perihilar interstitial to alveolar infiltrates are characteristic of pulmonary edema. left atrial enlargement may be observed as a "backpack" sign at the caudal cardiac waist. cardiomegaly of the right or left side also may 128 be present in cases of valvular insufficiency. in cats, increased sternal contact and a classic valentine-shaped heart may be observed in cases of hypertrophic cardiomyopathy. perform a vertebral heart score (sum) to measure cardiac size and determine whether cardiomegaly is present (box 1-38). also obtain arterial blood pressure and ecg readings to determine whether hypotension and dysrhythmias are present. atrial fibrillation, ventricular premature contractions, and supraventricular tachycardia are common rhythm disturbances that can affect cardiac output adversely and influence treatment choices. the echocardiogram is a useful noninvasive and nonstressful method to determine the degree of cardiac disease present. the echocardiogram is largely user-dependent. the quality of the study is based on the experience of the operator and the quality of the ultrasound machine. echocardiography can be a useful tool in making a diagnosis of pericardial effusion, dilated or hypertrophic cardiomyopathy, cardiac neoplasia, and endocarditis. the medical management of chf is designed to improve cardiac output and relieve clinical signs. the immediate goal of therapy is to reduce abnormal fluid accumulation and provide adequate cardiac output by increasing contractility, decreasing preload and ventricular afterload, and/or normalizing cardiac dysrhythmias. strict cage rest is of utmost importance when managing a patient with chf. after initial administration of furosemide, morphine, oxygen, and nitroglycerine paste, clinical signs of respiratory distress should show improvement within 30 minutes. if no improvement is observed, administer repeated doses of furosemide. reevaluate severe cases that are refractory to this standard treatment protocol. vasodilation should be the next step in the management of refractory cases, provided that a normal blood pressure is present. sodium nitroprusside is a potent balanced vasodilator that should be administered (1 to 10 âµg/kg/minute iv cri), taking care to monitor blood pressure continuously because severe vasodilation and hypotension can occur. the goal of nitroprusside therapy is to maintain a mean arterial blood pressure of 60 mm hg. sodium nitroprusside should not be considered in cases of refractory chf with severe hypotension. for more long-term management of chf, the use of angiotensin-converting enzyme (ace) inhibitors including enalapril (0.5 mg/kg po q12-24h), benazepril (0.5 mg/kg po q24h), and lisinopril (0.5 mg/kg po q24h) have become the mainstay of therapy to reduce sodium and fluid retention and decrease afterload. start angiotensin-converting enzyme inhibition as soon as a patient is able to tolerate oral medications. dobutamine (2.5 to 10 âµg/kg/minute cri diluted in 5% dextrose in water) can be administered to improve cardiac contractility, particularly in cases of dilated cardiomyopathy. at low doses, dobutamine, primarily a î²-adrenergic agonist, will improve cardiac output with minimal effects on heart rate. dobutamine must be given as a constant rate infusion with careful, continuous ecg monitoring. despite minimal effects on heart rate, emergency management of specific conditions 129 the vertebral heart sum can be calculated by performing the following steps: 1. measure the long axis of the heart from the apex to the carina on the lateral view and mark the distance on a sheet of paper. 2. measure the length of the long axis of the heart in terms of vertebral bodies, starting by counting caudally from the fourth thoracic vertebra; count the number of vertebrae that are covered by the length of the long axis of the heart. 3. measure the short axis of the heart at the caudal vena cava, perpendicular to the long axis of the heart. 4. count the number of thoracic vertebrae covered by the short axis of the heart, starting at t4. 5. add the two numbers together to yield the vertebral heart sum; a vertebral heart sum greater than 10.5 is consistent with cardiomegaly. sinus tachycardia or ventricular dysrhythmias may develop during infusion. cats are more sensitive to the effects of dobutamine than dogs. monitor carefully for seizures and facial twitching. digoxin is a cardiac glycoside that acts as a positive inotrope and negative chronotrope in the long-term management of chf. digoxin has a long (24 hours in dogs, and 60 hours in cats) half-life and so has minimal use in the emergency management of chf. in chronic management of chf resulting from dilated cardiomyopathy or advanced mitral disease, however, digoxin is extremely useful. oral digitalization protocols have been developed but are risky in that dysrhythmias and severe gastrointestinal side effects can occur. cats with chf often have fulminant pulmonary edema, pleural effusion, arterial thromboembolism, or some combination of all three. if the pleural effusion is significant, perform therapeutic thoracocentesis to relieve pulmonary atelectasis and improve oxygenation. once the diagnosis and initial management of chf has been made, formulate a plan for continued management and monitoring. tailor the therapeutic plan to the patient based on the cause of the chf, the presence of concurrent diseases, and response to therapy. an important and often overlooked part of the successful emergency management of chf is the open communication with the owner regarding the owner's emotional and financial commitment for immediate and long-term management to ensure appropriate quality of life for each patient. pathophysiology and treatment, vet j 162 (3) caval syndrome resulting from severe heartworm disease is caused by the rapid maturation of a large quantity of adult worms in the right atrium and cranial and caudal venae cavae. most cases of caval syndrome occur in regions of the world where heartworm disease is highly endemic and dogs spend a large portion of time living outdoors. caval syndrome is recognized by the following clinical signs and results of biochemical analyses: acute renal and hepatic failure, enlarged right atrium and posterior vena cava, ascites, hemoglobinuria, anemia, acute collapse, respiratory distress, dic, jugular pulses, circulating microfilariae, and sometimes tricuspid insufficiency. immediate action in cases of caval syndrome in dogs involves immediate stabilization of the cardiovascular and respiratory systems with supplemental oxygen, furosemide (4 mg/kg iv), and careful crystalloid fluid infusion. diagnosis of caval syndrome is based on clinical signs of cardiogenic shock with right ventricular heart failure, intravascular hemolysis, and renal and hepatic failure. thoracic radiographs reveal cardiomegaly of the right side and enlarged tortuous pulmonary arteries. a right axis deviation may be seen on ecg tracings. clinicopathologic changes observed include azotemia, inflammatory leukogram, regenerative anemia, eosinophilia, elevated hepatocellular enzyme activities, hemoglobinuria, and proteinuria. circulating microfilariae may be observed on peripheral blood smears or in the buffy coat of microhematocrit tubes. heart worm antigen tests will be strongly positive. echocardiographic changes include visualization of a large number of heartworms in the right atrium, pulmonary arteries, and vena cava, tricuspid insufficiency, and right atrial and ventricular enlargement. treatment involves surgical removal of as many of the adult heartworms as possible from the right jugular vein and right atrium. glucocorticosteroids are recommended to decrease inflammation and microangiopathic disease associated with heartworm infection. for more long-term management, administer adulticide therapy several weeks following surgery, followed by routine microfilaricide therapy and then prophylaxis. calvert pericardial effusion often develops as a consequence of neoplasia in the older dog and cat. the most common types of neoplasia that affect the heart and pericardium include hemangiosarcoma, chemodectoma, mesothelioma, and metastatic neoplasia. more rarely, other causes of pericardial effusion include benign idiopathic pericardial effusion, coagulopathy, left atrial rupture in dogs with chronic mitral valvular insufficiency, infection, or pericardial cysts. regardless of the cause of the effusion, the development of pericardial tamponade adversely affects cardiac output. cardiac output is a function of heart rate and stroke volume. stroke volume depends on cardiac preload. the presence of pericardial effusion can impede venous return to the heart and thus adversely affect preload. in addition, as preload decreases, heart rate reflexively increases in an attempt to maintain normal cardiac output. as heart rate increases more than 160 beats/minute, diastolic filling is impaired further, and cardiac output further declines. animals with pericardial effusion often demonstrate the classic signs of hypovolemic or cardiogenic shock: anorexia, weakness, lethargy, cyanosis, cool peripheral extremities, tachycardia, weak thready pulses, hypotension, and collapse. physical examination abnormalities may include muffled heart sounds, thready femoral pulses, pulsus paradoxus, jugular venous distention, weakness, tachycardia, cyanosis, and tachypnea. electrocardiogram findings may include low amplitude qrs complexes (<0.5 mv), sinus tachycardia, ventricular dysrhythmias, or electrical alternans (figure 1-39) . thoracic radiographs often demonstrate a globoid cardiac silhouette, although the cardiac silhouette rarely may appear normal with concurrent clinical signs of cardiogenic shock in cases of acute hemorrhage. in such cases the removal of even small amounts of pericardial effusion by pericardiocentesis can increase cardiac output exponentially and alleviate clinical signs (table 1-35) . unless an animal is dying before your eyes, ideally perform an echocardiogram to attempt to determine whether a right atrial, right auricular, or heart base mass is present before pericardiocentesis. before attempting pericardiocentesis, assemble all of the required supplies (box 1-39) . to perform pericardiocentesis, follow this procedure: 1. place the patient in sternal or lateral recumbency. 2. attach ecg leads to monitor the patient for dysrhythmias during the procedure. 3. clip a 6-cm square caudal to the right elbow over the fifth to seventh intercostal space. 4. aseptically scrub the clipped area, and infuse 1 to 2 mg/kg of 2% lidocaine mixed with a small amount of sodium bicarbonate just dorsal to the sternum at the sixth intercostal space. bury the needle to the hub, and inject the lidocaine as you withdraw the needle. 5. while the local anesthetic is taking effect, assemble the intravenous extension tubing, three-way stopcock, and 60-ml syringe. 6. wearing sterile gloves, make a small nick incision in the skin to decrease drag on the needle and catheter during insertion. 7. slowly insert the needle and catheter, watching for a flash of blood in the hub of the needle, and simultaneously watching for cardiac dysrhythmias on the ecg monitor. 8. once a flash of blood is observed in the hub of the needle, advance the catheter off of the stylette further into the pericardial sac, and remove the stylette. 9. attach the length of intravenous extension tubing to the catheter, and have an assistant withdraw the fluid slowly. 10. place a small amount of fluid in a red-topped tube, and watch for clots. clot formation could signify that you have penetrated the right ventricle inadvertently or that active hemorrhage is occurring. withdraw as much of the fluid as possible, and then remove the catheter. monitor the patient closely for fluid reaccumulation and recurrence of clinical signs of cardiogenic shock. less rd, bright jm, orton ec: intrapericardial cyst causing cardiac tamponade in a cat, j am anim hosp assoc 36 (2) foreign bodies within the ear canal (e.g., foxtails) can present as emergencies because of acute inflammation and pressure necrosis of the tissue of the external auditory meatus causing pain and discomfort. clinical signs may be limited to incessant head shaking or scratching of the ear canal. complete examination of the ear canal and removal of any foreign body often requires administration of a short-acting anesthetic agent. once the animal has been restrained sufficiently and placed under anesthesia, carefully examine the ear canal and remove any foreign material with an alligator forceps. stimulation of the ear canal can cause awakening after removal of all debris and detritus, gently wipe the internal and external ear canal with a sterile gauze. place a topical antimicrobial-antifungal-steroid ointment such as otomax in the ear every 8 to 12 hours. if pain and discomfort is severe, systemically effective opioids or nsaids may be required. otitis externa is a common emergency that causes excessive head shaking, scratching, and purulent malodorous aural discharge. clean the ear canal with an irrigating solution such as epiotic and wipe it clean of debris. perform a complete aural examination to determine whether a foreign body or tumor is present and whether the tympanic membrane is intact. heat-fix any discharge and examine it cytologically for bacteria and fungal organisms. following careful cleansing, instill a topical antibiotic-antifungal-steroid ointment. in severe cases in which the ear canal has scarred and closed down with chronicity, consider administering systemically effective antibiotics (cephalexin, 22 mg/kg po tid) and antifungal agents (ketoconazole, 10 mg/kg po q12h) instead of topical therapy. systemically effective steroids (prednisone or prednisolone, 0.5 mg/kg po q12h) may be indicated in cases of severe inflammation to decrease pruritus and patient discomfort. presentation of a patient with otitis interna often is characterized by torticollis, head tilt, nystagmus, circling to the affected side, or rolling. fever, pain, vomiting, and severe depression may accompany clinical signs. most cases of severe otitis interna are accompanied by severe otitis media. both conditions must be treated simultaneously. the most common causes of otitis interna are staphylococcus aureus, pseudomonas, escherichia coli, or proteus spp. otitis interna can develop by infection spreading across the tympanic membrane, through the eustachian tubes, or by hematogenous spread from the blood supply to the middle ear. in most cases of otitis media, the tympanic membrane is ruptured. perform a culture and susceptibility test of the debris behind the tympanic membrane and within the aural canal. carefully clean the external ear canal. medicate with a topical combination antibiotic, antifungal, and antibiotic ointment. administer high-dose antibiotics (cephalexin, 22 mg/kg po q8h, or enrofloxacin, 10 to 20 mg/kg po q24h). if the tympanic membrane is not ruptured but appears swollen and erythematous, a myringotomy may need to be performed. if clinical signs of otitis media persist despite topical and systemic therapy, radiographic or ct/mri examination of the tympanic bullae may be required. chronic shaking of the head and ears or aural trauma (bite wounds) causes disruption of the blood vessels and leads to the development of unilateral or bilateral aural hematomas. aural hematomas are clinically significant because they cause patient discomfort and are often due to the presence of some other underlying problem such as otitis externa, atopy, or aural foreign bodies. acute swelling of the external ear pinna with fluid is characteristic of an aural hematoma. in some cases, swelling can be so severe that the hematoma breaks open, bathing the patient and external living environment in blood. when a patient has an aural hematoma, investigate the underlying cause. perform a complete aural examination to determine whether an aural foreign body, otitis externa, or atopy are present. carefully examine and gently clean the inner ear canal. treat underlying causes. management of an aural hematoma involves draining the hemorrhagic fluid from the aural tissue and tacking the skin down in multiple places to prevent reaccumulation of fluid until the secondary cause is resolved. many techniques have been described to surgically tack down the skin overlying the hematoma. after the animal has been placed under general anesthesia, lance the hematoma down the middle with a scalpel blade and remove the fluid and blood clot. tack down the skin with multiple through-and-through interrupted or mattress sutures through the ear. some clinicians prefer to suture through and attach a sponge or length of x-ray film to the front and back of the ear for stabilization and support. more recently, a laser can be used to drill holes in the hematoma and tack the skin down in multiple areas. compress the ear against the head with a compression bandage, whenever possible, for 5 to 7 days after the initial surgery, and then recheck the ear. the patient must wear an elizabethan collar until the surgical wound and hematoma heal to prevent selfmutilation. also systemically treat underlying causative factors such as otitis externa with antibiotics, antifungals, and steroids as indicated. investigate and treat other underlying causes such as hypothyroidism or allergies. bass electrocution usually is observed in young animals after they have chewed on an electric cord. other causes of electrocution include use of defective electrical equipment or being struck by lightning. electric current passing through the body can produce severe dysrhythmias, including supraventricular or ventricular tachycardia and first-and thirddegree atrioventricular block. the electric current also can produce tissue destruction from heat and electrothermal burns. electrocution also commonly results in noncardiogenic pulmonary edema caused by massive catecholamine release and increase in pulmonary vascular pressures during the event. ventricular fibrillation can occur, although that depends on the intensity and path of the electrical current and duration of contact. clinical signs of electrocution include acute onset of respiratory distress with moist rales, and localized necrosis or thermal burns of the lips and tongue. often the skin at the commissures of the mouth appears white or yellow and firm to the touch. muscle fasciculations, loss of consciousness, and ventricular fibrillation may occur. thoracic radiographs often reveal an increased interstitial to alveolar lung pattern in the dorsocaudal lung fields. noncardiogenic pulmonary edema can develop up to 24 to 36 hours after the initial incident. the first 24 hours are most critical for the patient, and then prognosis improves. the most important aspect in the treatment of the patient with noncardiogenic pulmonary edema is to minimize stress and to provide supplemental oxygen, with positive pressure ventilation, when necessary. although treatment with vasodilators (low-dose morphine) and diuretics (furosemide) can be attempted, noncardiogenic pulmonary edema is typically resistant to vasodilator and diuretic therapy. positive inotropes and pressor drugs may be necessary to treat shock and hypotension. opioid drugs (morphine, hydromorphone, oxymorphone) may be useful in controlling anxiety until the pulmonary edema resolves. administer broad-spectrum antibiotics (cefazolin; amoxicillin and clavulanic acid [clavamox]) to treat thermal burns. use analgesic drugs to control patient discomfort. if thermal burns are extensive and prohibit adequate food intake, place a feeding tube as soon as the patient's cardiovascular and respiratory function are stable and the patient can tolerate anesthesia. prolapse of the uterus occurs in the immediate postparturient period in the bitch and queen. excessive straining during or after parturition causes the uterus to prolapse caudally through the vagina and vulva. immediate intervention is necessary. examine the bitch or queen for a retained fetus. treatment consists of general anesthesia to replace the prolapsed tissue. if the uterus is edematous, physical replacement may be difficult or impossible. application of a hypertonic solution such as hypertonic (7%) saline or dextrose (50%) to the exposed endometrium can help shrink the tissue. that, combined with gentle massage to stimulate uterine contraction and involution and lubrication with sterile lubricating jelly, can aid in replacement of the organ into its proper place. to ensure proper placement in the abdominal cavity and to prevent recurrence, perform an exploratory laparotomy and hysteropexy. postoperatively, administer oxytocin (5 to 20 units im) to cause uterine contraction. if the uterus contracts, it is usually not necessary to suture the vulva. administer antibiotics postoperatively. recurrence is uncommon, even with subsequent pregnancies. if the tissue is damaged or too edematous to replace or if the tissue is devitalized, traumatized or necrotic, perform an ovariohysterectomy. in some instances, replacement of the damaged tissue is not necessary before removal. pyometra occurs in dogs and cats. the disease process occurs as a result of infection overlying cystic endometrial hyperplasia under the constant influence of progesterone. during the 2-month luteal phase after estrus or following copulation, artificial insemination, or administration of hormones (particularly estradiol or progesterone), the myometrium becomes relaxed and favors a quiescent environment for bacterial proliferation. clinical signs of pyometra are associated with the presence of bacterial endotoxin and sepsis. early, affected animals become lethargic and anorectic. polyuria with secondary polydipsia is often present because of the influence of bacterial endotoxin on renal tubular concentration. if the cervix is open, purulent or mucoid vaginal discharge may be observed. later in the course of pyometra, vomiting, diarrhea, and progressive debilitation resulting from sepsis occur. diagnosis is based on clinical signs in an intact queen or bitch and radiographic or ultrasonographic evidence of a fluid-filled tubular density in the ventrocaudal abdomen, adjacent to the urinary bladder (figures 1-40 and 1-41) . treatment of open and closed pyometra is correction of fluid and electrolyte abnormalities, administration of broad-spectrum antibiotics, and ovariohysterectomy. close pyometra is a life-threatening septic condition. open pyometra also can become life-threatening and so should be treated aggressively. in closed pyometra, conservative medical therapy is not advised. administration of prostaglandins and oxytocin do not reliably cause the cervix 136 1 to open and can result in ascending infection from the uterus into the abdomen or uterine rupture, both of which can result in severe peritonitis. for animals with an open pyometra, ovariohysterectomy is the most reliable treatment for chronic cystic endometrial hyperplasia. although less successful than ovariohysterectomy, medical therapy may be attempted in breeding bitches as an alternative to surgery. the most widely used medical therapy in the breeding queen and bitch is administration of prostaglandin f 2î± . this drug has not been approved for use in the queen or bitch in the united states. to proceed with medical management of pyometra, first determine the size of the uterus. start the patient on antibiotic therapy (ampicillin, 22 mg/kg iv q6h, or enrofloxacin, 10 mg/kg po q24h). administer the prostaglandin f 2î± (250 âµg/kg sq q24h) for 2 to 7 days until the size of the uterus approaches normal. measure serum progesterone concentrations if the bitch is in diestrus. as the corpus luteum degrades under the influence of prostaglandin f 2î± , serum progesterone levels will decline. prostaglandin f 2î± is an abortifacient and thus should not be administered to the pregnant bitch or queen. clinical signs of a reaction to prostaglandin f 2î± can occur within 5 to 60 minutes in the bitch and can last for as long as 20 minutes. clinical signs of a reaction include restlessness, hypersalivation, panting, vomiting, defecation, abdominal pain, fever, and vocalization. in a very ill animal, death can occur. the efficacy of prostaglandin f 2î± is limited and may require more than one treatment. the bitch should be bred on the next heat cycle and then spayed because progressive cystic endometrial hyperplasia will continue to occur. acute metritis is an acute bacterial infection of the uterus that typically occurs within 1 to 2 weeks after parturition. the most common organism observed in metritis is e. coli ascending from the vulva and vaginal vault. sepsis can progress rapidly. clinical signs of acute metritis include inability to nurse puppies, anorexia, lethargy, foul-smelling purulentsanguineous vaginal discharge, vomiting, or acute collapse. physical examination may reveal fever, dehydration, and a turgid distended uterus. septic inflammation will be observed on vaginal cytologic examination. an enlarged uterus can be observed with abdominal radiographs and ultrasonography. treatment of acute metritis is directed at restoring hydration status with intravenous fluids and treating the infection with antibiotics. because the primary cause of metritis is e. coli infection, start enrofloxacin (10 mg/kg iv or po once daily) therapy. as soon as the patient's cardiovascular status is stable enough for anesthesia, perform an ovariohysterectomy. if the patient is not critical and is a valuable breeding bitch, medical therapy can be attempted. medical management of acute bacterial metritis includes administration of oxytocin (5 to 10 units q3h for three treatments) or administration of prostaglandin f 2î± (250 âµg/kg/day for 2 to 5 days) to evacuate the uterine exudate and increase uterine blood flow. either drug should be used concurrently with antibiotics. rupture of the gravid uterus is rare in cats and dogs but has been reported. uterine rupture may occur as a consequence of parturition or result from blunt abdominal trauma. feti expelled into the abdominal cavity may be resorbed but more commonly cause the development of peritonitis. if fetal circulation is not disrupted, the fetus actually may live to term. uterine rupture is an acute surgical emergency. an ovariohysterectomy with removal of the extrauterine puppies and membranes is recommended. if only one horn of the uterus is affected, a unilateral ovariohysterectomy can be performed to salvage the remaining unaffected puppies and preserve the breeding potential for the valuable bitch. if uterine rupture occurs because of pyometra, peritonitis is likely, and copious peritoneal lavage should be performed at the time of surgery. the patient should be placed on 7 to 14 days of antibiotic therapy (amoxicillin or amoxicillin and clavulanic acid [clavamox] with enrofloxacin). vaginal prolapse occurs from excessive proliferation and hyperplasia of vaginal tissue while under the influence of estrogen during proestrus (figure 1-42) . the hyperplastic tissue usually recedes during diestrus but reappears with subsequent heat cycles. vaginal prolapse can be confused with vaginal neoplasia. the former condition occurs primarily in younger animals, whereas the latter condition occurs primarily in older animals. treatment for vaginal hyperplasia or prolapse generally is not required if the tissue remains within the vagina. the proliferation can lead to dysuria or anuria, however. in some cases, the tissue becomes 138 1 emergency care dried out and devitalized or becomes traumatized by the animal. such extreme cases warrant immediate surgical intervention. the treatment for vaginal prolapse consists of ovariohysterectomy to remove the influence of estrogen, placement of an indwelling urinary catheter if the patient is dysuric, and protection of the hyperplastic tissue until it recedes on its own. although surgical resection of the hyperplastic tissue has been recommended, excessive hemorrhage after removal can occur, and so the procedure should not be attempted. the patient should wear an elizabethan collar at all times to prevent selfmutilation. administer broad-spectrum antibiotics for a minimum of 7 to 14 days or until the hyperplastic tissue recedes. keep the tissue clean with saline solution. dystocia, or difficult birth, can occur in the dog and cat but is more common in the dog. a diagnosis of dystocia is made based on the time of onset of visible labor and the time in which the last puppy or no puppy has been born, the intensity and timing of contractions, the timing of when the amniotic membranes first appear, the condition of the bitch, and the timing of gestation. causes of dystocia can be maternal or fetal and include primary or secondary uterine inertia, narrowing of the pelvic canal, hypocalcemia, psychological disturbances, or uterine torsion. maternal-fetal disproportion, or large fetus size in relation to the bitch or queen, also can result in dystocia (box 1-40). obtain an abdominal radiograph for all cases of suspected dystocia at the time of presentation to determine the size of the fetus, presentation of the fetus (both anterior or posterior presentation can be normal in the bitch or queen, but fetal malpositioning can cause dystocia), and whether there is radiographic evidence of a uterine rupture or torsion. if maternal-fetal disproportion, uterine torsion, or uterine rupture is observed, take the patient immediately to surgery. if the puppies or kittens are in a normal position for birth, medical management can be attempted. clip the perineum and aseptically scrub it. wearing sterile gloves, insert a lubricated finger into the vagina and palpate the cervix. massage (or "feather") the dorsal wall of the vagina to stimulate contractions. place an intravenous catheter, and administer oxytocin (2 to 20 units im), repeating up to 3 times at 30-minute intervals. in some cases, hypoglycemia or hypocalcemia can contribute to uterine inertia. administration of a calciumcontaining solution (lactated ringer's solution) with 2.5% dextrose is advised. alternately, administer 10% calcium gluconate (100 mg/5 kg iv slowly). if labor has not progressed after 1 hour, immediately perform a cesarean section. uterine torsion is an uncommon emergency seen in the gravid and nongravid uterus and has been reported in dogs and cats. the onset of clinical signs of abdominal pain and straining as if to whelp/queen or defecate is usually acute and constitutes a surgical emergency. in some cases, there may have been a history of delivery of a live or dead fetus. vaginal discharge may or may not be present. radiographs or ultrasound examination reveal a fluid-filled or air-filled tubular density in the ventral abdomen. treatment consists of placing an intravenous catheter, stabilizing the patient's cardiovascular status with intravenous fluids and sometimes blood products, and performing an immediate ovariohysterectomy. if there are viable feti, the uterus should be delivered en mass and the puppies or kittens delivered. the expulsion of one or more fetus before term is known as spontaneous abortion. in dogs and cats, it is possible to expel or abort one or more fetuses and still carry viable fetuses to term and deliver normally. clinical signs of spontaneous abortion include vaginal discharge and abdominal contractions. in some cases, the fetus is found, or there may be evidence of fetal membranes or remnants. causes of spontaneous abortion in dogs include brucella canis, herpesvirus, coronavirus, and toxoplasmosis. in cats, herpesvirus, coronavirus, and feline leukemia virus can cause spontaneous abortion. in both species, trauma, hormonal factors, environmental pathogens, drugs, and fetal factors also can result in spontaneous abortion. the safest method of pregnancy termination in the bitch or queen is by performing an ovariohysterectomy. oral diethylstilbesterol is not an effective mechanism of pregnancy termination in the bitch. a so-called mismating shot, an injection of estradiol cypionate (0.02 mg/lb im) is effective at causing termination of an early pregnancy but can be associated with severe side effects, including bone marrow suppression and pyometra. estradiol cypionate is not approved for use in the bitch or queen and is not recommended. prostaglandin f 2î± is a natural abortifacient in the bitch if treatment is started within 5 days of cytologic evidence of diestrus (noncornified epithelium on a vaginal smear). the prostaglandin f 2î± causes lysis of the corpora lutea and a rapid decline in progesterone concentration. the prostaglandin f 2î± is administered for a total of eight injections (250 âµg/kg q12h for 4 days), along with atropine (100 to 500 âµg/kg sq). side effects can occur within 5 to 40 minutes of injection and include restlessness, panting, salivation, abdominal pain, urination, vomiting, and diarrhea. walking the patient for 20 to 30 minutes after each treatment sometimes decreases the intensity of the reactions. bitches in the first half of the pregnancy often resorb the embryos. if prostaglandin f 2î± is administered in the second half of the pregnancy, the fetuses are aborted within 5 to 7 days of treatment. measure serum progesterone concentrations at the end of treatment to ensure complete lysis of the corpus luteum. prostaglandin f 2î± is not approved for pregnancy termination in the bitch. in cats, prostaglandin f 2î± can terminate pregnancy after day 4 of gestation. prostaglandin f 2î± should be used only in healthy queens (100 to 250 âµg/kg sq q24h for 2 days). side effects in the queen are similar to those observed in the bitch but typically have a shorter duration (2 to 20 minutes). prostaglandin f 2î± is not approved for use in cats in the united states. the use of prostaglandin f 2î± does not preclude breeding and pregnancy at a later date. biddle d, macintire dk: obstetrical emergencies, clin tech small anim pract 15 (2) in the dog and cat the majority of injuries to the scrotum are associated with animal fights or shearing and abrasive injuries sustained in accidents involving automobiles. scrotal injuries should be categorized as superficial or penetrating. treatment of superficial injuries to the scrotum includes cleaning the wound with dilute antimicrobial cleanser and drying it. administer antiinflammatory doses of steroids (prednisolone, 0.5 to 1.0 mg/kg po q12-24h) or nsaids (carprofen, 2.2 mg/kg po q12h in dogs) for the first several days after scrotal injury to prevent or treat edema. administer topical antibiotic ointment until the wound heals. in most cases, place an elizabethan collar to prevent self-mutilation. prognosis is generally favorable; however, semen quality may be affected for months after injury because of scrotal swelling and increased scrotal temperature. penetrating injuries to the scrotum are more serious and are associated with severe swelling and infection. surgically explore and debride penetrating scrotal wounds. administer systemically effective antibiotics and analgesics. in extreme cases, particularly those that involve the testicle, consider castration and scrotal ablation. scrotal dermatitis is common in intact male dogs and can be associated with direct physical injury, self-infliction from licking, chemical irritation, burns, or contact dermatitis. in affected animals, the scrotum can become extremely inflamed, swollen, and painful. if left untreated, pyogranulomatous dermatitis can develop. make an attempt to determine whether an underlying systemic illness is present that could predispose the animal to scrotal dermatitis. widespread vasculitis with scrotal edema, pain, fever, and dermatitis has been associated with rickettsia rickettsii (rocky mountain spotted fever) infection. brucella canis also has been associated with scrotal irritation and dermatitis. if scrotal dermatitis follows from an infectious cause, empiric use of glucocorticosteroids potentially can make the condition worse by suppressing immune function. empiric treatment with antibiotics also potentially can confound making an accurate diagnosis. treatment of scrotal dermatitis is to eliminate predisposing causes, if possible. place an elizabethan collar at all times to prevent self-mutilation. bathe the scrotum with a mild antimicrobial soap and dry it to remove any offending chemical irritants. topical medications including tar shampoo, tetracaine, neomycin, and petroleum can cause further irritation and are contraindicated. use oral or parenteral administration of glucocorticosteroids or nsaids to control discomfort and inflammation. scrotal hernias occur when the contents of the abdomen (intestines, fat, mesentery, omentum) protrude through the inguinal ring into the scrotal sac. like inguinal hernias, scrotal definitive therapy for a scrotal hernia involves exploratory laparotomy and surgical reduction of the contents of the hernia, surgical correction of the rent in the inguinal ring, and castration. trauma to the epididymis or testicle can cause testicular pain and swelling of one or both testes. treat penetrating trauma to the testicle by castration to prevent infection and selfmutilation. administer oral antibiotics (amoxicillin or amoxicillin-clavulanate) for 7 to 10 days after the injury. nonpenetrating injuries to the scrotum and testicle rarely may cause acute testicular hemorrhage or hydrocele formation. palpation of the affected area often reveals a peritesticular, soft, compliant area. treatment consists of cool compresses on the scrotum and testicle and administration of antiinflammatory doses of glucocorticosteroids or nsaids. if the swelling does not resolve spontaneously in 5 to 7 days, consider surgical exploration and drainage. increased scrotal temperature and testicular inflammation can affect semen quality for months after the initial incident. testicular torsion, or torsion of the spermatic cord, causes rotation of the testicle, ultimately causing obstruction to venous drainage. testicular torsion often is associated with a neoplastic mass of a retained testicle within the abdomen but also can be observed with nonneoplastic testes located within the scrotum. the predominant clinical signs are pain, stiff stilted gait, and the presence of an abnormally swollen testicle (if located within the scrotum). if an intraabdominal testicular torsion is present, pain, lethargy, anorexia, and vomiting can occur (see acute condition in the abdomen). an intraabdominal mass may be palpable. perform an abdominal or testicular ultrasound, preferably with color flow doppler to evaluate perfusion to the testicle. treatment involves surgical removal of the involved testes. bacterial infections of the testicle or epididymis most commonly are caused by ascending infections of the normal bacterial flora of the prepuce or urethra. common inhabitants include escherichia coli, staphylococcus aureus, streptococcus spp., and mycobacterium canis. brucella canis and r. rickettsii are also capable of causing orchitis and epididymitis in the dog. clinical signs of orchitis or epididymitis include testicular enlargement, stiff stilted gait, and reluctance to walk. physical examination often reveals a fever and self-induced trauma to the scrotum from licking or chewing at the inflamed area. collect a semen sample by ejaculation, and culture it to identify the causative organism. alternately, collect samples by needle aspiration of the affected organ(s) and test serologically for b. canis. treatment of infectious orchitis involves a minimum of 3 to 4 weeks of specific antimicrobial therapy, based on culture and susceptibility testing, whenever possible. if a bacterial culture cannot be obtained, initiate fluoroquinolone therapy (enrofloxacin, 10 mg/kg po q24h). doxycycline (5 mg/kg po bid for 7 days) has been shown to suppress but not eradicate b. canis infection. testicular inflammation and increased temperature can affect sperm quality for months after infection. the most common causes of acute prostatitis are associated with acute bacterial infection (e. coli, proteus spp., pseudomonas spp., and mycoplasma spp.). less common causes include fungal infection (blastomyces dermatitidis) or anaerobic bacterial infection. acute prostatitis is characterized by fever, caudal abdominal pain, lethargy, anorexia, blood in the ejaculate, hematuria, dyschezia, and occasionally stranguria or dysuria. the patient often appears painful and depressed and may be dehydrated on physical examination. symmetric or asymmetric prostatomegaly and prostate pain may be evident on rectal palpation. in severely affected dogs, clinical signs of tachycardia, hyperemic or injected mucous membranes, bounding pulses, lethargy, dehydration, and fever may be present because of sepsis. death can occur within 2 days if a prostatic abscess ruptures. diagnosis of acute prostatitis is confirmed based on the presenting clinical signs, neutrophilic leukocytosis (with or without a left shift), and positive urine culture results. prostatic samples may be obtained from the prostatic portion of the ejaculate, prostatic massage, urethral discharge, urine, or (less commonly) prostatic aspirate. although semen samples can yield positive bacterial cultures, dogs with acute prostatitis are often unwilling to ejaculate. radiography may reveal an enlarged prostate, but this alone does not confirm the diagnosis of prostatitis. an abdominal ultrasound often reveals prostatic abscessation and allows for the collection of samples from the affected area(s) via prostatic aspirate. aspiration of the affected tissue potentially can wick infection into periprostatic tracks. cytologic examination of the patient's ejaculate or prostatic wash from a dog with acute prostatitis reveals numerous inflammatory cells and may contain bacterial organisms. the treatment of a patient with acute prostatitis is directed at correcting dysuria and constipation associated with prostatic enlargement. enrofloxaxin (10 mg/kg po sid) can penetrate the inflamed prostatic tissue and is effective in treating gram-negative and mycoplasma spp. infections. ciprofloxacin does not appear to penetrate prostatic tissue as readily. alternatives to enrofloxacin therapy are trimethoprim-sulfamethoxazole (30 mg/kg po q12h) or chloramphenicol (25-50 mg/kg po q8h) for a minimum of 2 to 3 weeks. castration is recommended because benign prostatic hyperplasia may be a predisposing factor in the development of acute prostatitis. do not perform castration until the patient has been on antibiotic therapy for a minimum of 7 days, to prevent the surgical complication of schirrous cords. finasteride (proscar, 1 mg/kg po q24h), an antiandrogen 5î±-reductase inhibitor, may help reduce the size of prostatic tissue until the effects of castration are observed. if a prostatic abscess is present, perform marsupialization, surgical drainage, or ultrasonographic drainage. surgical therapy is associated with a large incidence of complications, including incontinence, chronic drainage from fistulas and stomas, septic shock, and death. fracture of the os penis is an uncommon condition encountered in male dogs. os penis fractures can occur with minimal soft tissue damage but cause hematuria and dysuria. on physical examination, urethral obstruction and crepitus in the penis are found. a lateral abdominal radiograph is usually sufficient to document the fracture. treatment consists of conservative therapy, in most cases, and consists primarily of analgesia administration. if the urethra also is damaged, place a urethral catheter for 5 to 7 days to allow the urethral mucosa to heal. fractures of the os penis that are comminuted or severe enough to cause urethral obstruction require open reduction and fixation, partial penile amputation, or antescrotal (prescrotal) urethrostomy. lacerations of the penis cause significant bleeding because of the extensive vascular supply to the penis. dogs and cats tend to lick penile lacerations and prevent adequate clot formation. sedation or general anesthesia often is required to evaluate and treat the laceration. after sedation or general anesthesia, place a urinary catheter and examine the penis under a stream of cold water. small lacerations can be managed with cold compresses and one to several absorbable sutures. extensive suturing usually is not required. prevent erection by isolating the patient from females in estrus or allowing excitement or excessive activity. place an elizabethan collar to prevent self-mutilation. initiate systemic antibiotic therapy to prevent infection. the inability to withdraw the penis into the prepuce in male dogs or cats is known as paraphimosis. paraphimosis usually develops following an erection in young male dogs and in 144 1 emergency care older dogs after coitus. mucosal edema, hemorrhage, self-mutilation, and necrosis requiring penile amputation can occur if left untreated. treatment consists of applying cold water to the penis and reducing edema with application of an osmotic substance such as sugar. examine the base of the penis for hair rings that can prevent retraction of the penis into the prepuce. rinse the penis carefully with cold water and lubricate it with sterile lubricant and replace it into the prepuce. if the penis cannot be reduced easily into the prepuce, anesthetize the patient and make a small incision at the lateral aspect of the preputial opening. replace the penis and close the incision with absorbable suture. place a purse-string suture and leave it in place for several days to prevent recurrence. instill topical antimicrobial ointment with steroids into the prepuce several times a day. in severe cases, a urinary catheter may need to be placed to prevent urethral obstruction, until penile swelling and edema resolve. place an elizabethan collar to prevent excessive licking during the healing process. prolapse of the distal urethra is a condition usually confined to intact male english bulldogs, although isolated incidences also have been reported in yorkshire and boston terriers. the exact cause of this condition is unknown but usually is associated with a condition that causes increased intraabdominal pressure or urethral straining, including sexual excitement, coughing, vomiting, obstructed airway or brachycephalic airway syndrome, urethral calculi, genitourinary tract infection, and masturbation. the urethral prolapse usually appears as a mushroom-tip congested, irritated mass at the end of the penis that may or may not bleed (figure 1-44) . in some cases, bleeding occurs or worsens with sexual excitement. clinical signs associated with the prolapsed urethra include excessive licking of the prepuce, stranguria, and preputial bleeding. once the mass is observed, other differential diagnoses include transmissible venereal tumor, urethral polyp, trauma, urethritis, and neoplasia. in most cases, however, the prolapse occurs in intact young dogs, making neoplastic conditions less likely. treatment for urethral prolapse should occur at the time of diagnosis to prevent selfinduced trauma and infection. immediate therapy includes manual reduction of the prolapsed tissue and placement of a purse-string suture around an indwelling urinary catheter. the purse-string suture can remain in place for up to 5 days until definitive repair. until the time of surgery, place an elizabethan collar on the patient to prevent self-mutilation. several forms of surgical correction have been described. in some cases, surgical resection of the prolapsed tissue with apposition of the urethral and penile mucosa can be attempted. more recently, a technique involving placement of several mattress sutures to reduce and secure the prolapsed tissue has been described. recurrence of prolapse can occur with either technique, particularly if the inciting event recurs. because there may be a genetic predisposition in this breed and because the prolapse can recur with sexual excitement, neutering should strongly be recommended. local freezing or frostbite most commonly affects the peripheral tissues of the ears, tail, paws, and genitalia that are sparsely covered with fur, are poorly vascularized, and may have been traumatized previously by cold. clinical signs of frostbite are paleness and appearance of a blanched pink to white discoloration to the skin. the skin also may appear black and necrotic. immediate treatment consists of slowly rewarming the affected area with moist heat at 29.5â° c (85â°f) or by immersion in warm water baths. analgesics may be required to alleviate patient discomfort. carefully dry the injured areas and protect them from further trauma. the use of prophylactic antibiotics is controversial because it can promote resistant bacterial infection. use of antibiotics should be based on the presence of infection. treatments that are ineffective and may be harmful include rubbing the affected areas, pressure bandages, and ointments. corticosteroids can decrease cellular immunity and promote infection and are therefore contraindicated. many frostbitten areas that appear nonviable can regain function gradually. use care when removing areas of necrotic tissue. affected areas may take several days to a week before fully manifesting areas of demarcation between healthy viable and necrotic nonviable tissue. chilling of the entire body from exposure or immersion in extremely cold water results in a decrease in core body temperature and physiologic processes that become irreversible when the body temperature falls below 24â°c (75â°f). mild hypothermia can be 32â°to 37â°c, moderate hypothermia from 28â°to 32â°c, and severe hypothermia below 28â°c. the duration of exposure and the general condition of the animal influences its ability to survive. clinical signs and consequences associated with hypothermia include shivering, vasoconstriction, mental depression, hypotension, sinus bradycardia, hypoventilation with decreased respiratory rate, increased blood viscosity, muscle stiffness, atrial and ventricular irritability, decreased level of consciousness, decreased oxygen consumption, metabolic (lactic) acidosis, respiratory acidosis, and coagulopathies including dic. if the animal is breathing, administer warm, humidified oxygen at 4 to 10 breaths per minute. if the animal is not breathing or is severely hypoventilating, endotracheal intubation with mechanical ventilation may be necessary. place an intravenous catheter and infuse warmed crystalloid fluids. if the blood glucose is less than 60 mg/dl, add supplemental dextrose (2.5%) to the crystalloid fluids. monitor the core body temperature and ecg closely. rewarming should occur in the form of external circulating warm water blankets, radiant heat, and circulating warm air blankets (bair hugger). never use a heating pad, to avoid iatrogenic thermal burn injury. severe hypothermia may require core rewarming in the form of intraperitoneal fluids (10 to 20 ml/kg of lactated ringer's solution warmed to 39.4â°c [103â°f]). place a temporary peritoneal dialysis catheter, and repeat the dialysis every 30 minutes until the patient's body temperature reaches 36.6â°to 37.7â°c (98â°to 100â°f). the body temperature should rise slowly, ideally no more than 1â°f per hour. because the response of the body to drugs is unpredictable, avoid administering drugs whenever possible, until the body temperature returns to normal. complications observed during rewarming include dic, cardiac dysrhythmias including cardiac arrest, pneumonia, pulmonary edema, cns edema, ards, and renal failure. heat stroke and heat-induced illness in dogs can be associated with excessive exertion, exposure to high environmental temperatures, stress, and other factors that cause an inability to dissipate heat. brachycephalic breeds, obesity, laryngeal paralysis, and older animals with cardiovascular disease can be particularly affected. hyperthermia is defined as a rectal temperature of 41â°to 43â°c (105â°to 110â°f). clinical signs of hyperthermia include congested hyperemic mucous membranes, tachycardia, and panting. more severe clinical signs include collapse (heat prostration), ataxia, vomiting, diarrhea, hypersalivation, muscle tremors, loss of consciousness, and seizures. heat-induced illness can affect all major organ systems in the body because of denaturation of cellular proteins and enzyme activities, inappropriate shunting of blood, hypotension, decreased oxygen delivery, and lactic acidosis. cardiac dysrhythmias, interstitial and intracellular dehydration, intravascular hypovolemia, central nervous dysfunction, slough of gastrointestinal mucosa, oliguria, and coagulopathies can be seen as organ function declines. excessive panting can result in respiratory alkalosis. poor tissue perfusion results in a metabolic acidosis. loss of water in excess of solutes such as sodium and chloride can lead to a free water deficit and severe hypernatremia. a marked increase in pcv occurs because of the free water loss. severe abnormalities in electrolytes and ph can lead to cerebral edema and death. treatment goals for the patient with heat-induced illness are to lower the core body temperature and support cardiovascular, respiratory, renal, gastrointestinal, neurologic, and hepatic functions. at the scene the veterinarian or caretaker can spray the animal with tepid (not cold) water. immersion in cold water or ice baths is absolutely contraindicated. cold water and ice will cause extreme peripheral vasoconstriction, inhibiting the patient's ability to dissipate heat through conductive and convective cooling mechanisms. as a result, core body temperature will continue to rise despite the good intentions of well-doers at the scene. animals that present to the veterinarian that have been cooled to the point of hypothermia have a worse prognosis. once the animal has presented to the veterinarian, the goal is to cool the animal's body temperature with towels soaked in tepid water, cool intravenous fluids, and fans until the temperature has decreased to 103â°f. organ system monitoring and support is based on the severity and duration of the heat stroke and the ability of the body to compensate and respond to treatment. management of the patient with heat-induced illness involves prompt aggressive cooling without being overzealous and creating iatrogenic hypothermia. administer cool intravenous crystalloid fluids to replenish volume and interstitial hydration and correct the patient's acid-base and electrolyte abnormalities. management consists of rule of twenty monitoring (see rule of 20), taking care to evaluate, restore, and maintain a normal cardiac rhythm, blood pressure, urine output, and mentation. administer antibiotics if there are any signs of gastrointestinal bleeding that will predispose the patient to bacterial translocation. monitor baseline chemistry tests including a complete blood count, biochemical panel, platelet count, coagulation tests, and urinalysis. treat coagulopathies including dic aggressively and promptly (see also disseminated intravascular coagulation). severe changes in mentation including stupor or coma worsen a patient's prognosis. following initial therapy, monitor the patient for a minimum of 24 to 48 hours for secondary organ damage, including renal failure, myoglobinuria, cerebral edema, and dic. dogs that are going to die of heat-induced illness usually die within the first 24 hours. animals that survive longer than 24 hours have a more favorable prognosis. immediate treatment consists of cooling the patient with cooling measures as for hyperthermia and heat-induced illness (see the previous discussion), and eliminating the cause (i.e., exertion, anesthesia, or neuromuscular blockers such as succinylcholine). if the patient is under general anesthesia, hyperventilate the patient to help eliminate carbon dioxide and respiratory acidosis. administer dantrolene sodium (1 to 2 mg/kg iv) to stabilize the sarcoplasmic reticulum and decrease its permeability to calcium. animals with malignant hyperthermia should avoid any predisposing factors, including exertion, hyperthermia, and anesthesia. after an episode of malignant hyperthermia, administer crystalloid fluids intravenously to aid in the elimination of myoglobin. monitor renal function closely for myoglobinuria and pigment damage to the renal tubular epithelium. monitor and correct acid-base and electrolyte changes. walters jm: hyperthermia. in wingfield we, editor: the veterinary icu book, jackson, wyo, 2001, teton newmedia. sometimes it is difficult to assess whether an animal has been bitten by a poisonous or nonpoisonous snake. in colorado, the bull snake closely resembles the prairie rattlesnake. both snakes make similar noise and can be alarming if noticed on a hike or in the backyard. whenever possible, identify the offending reptile but never risk being bitten. know what types of venomous creatures are in the geographic area of the practice. if an animal has been bitten by a nonpoisonous snake, usually the bite marks are small with multiple small tooth punctures, and the bite is relatively nonpainful. usually local reaction is negligible. however, large boas or pythons also can inflict large crushing injuries that can cause severe trauma, including bony fractures. treatment for a nonpoisonous snakebite involves clipping the bite wound and carefully cleaning the area with antimicrobial scrub solution. broad-spectrum antibiotics (e.g., amoxicillin-clavulanate, 16.25 mg/kg po q12h) are indicated because of the extensive bacterial flora in the mouths of snakes. monitor all snakebite victims for a minimum of 8 hours after the incident, particularly when the species of the offending reptile is in question. if clinical signs of envenomation occur, modify the patient's treatment appropriately and aggressively. the two major groups of venomous snakes in north america are the pit viper and the coral snake. all venomous snakes are dangerous. the severity of any given bite depends on the toxicity of the venom, the amount of venom injected, the site of envenomation, the size of the animal bitten, and the time from bite/envenomation to seeking appropriate medical intervention. the majority of reptile envenomations in the united states are inflicted by pit vipers, including the water moccasin (cottonmouth), copperhead, and numerous species of rattlesnakes. pit vipers are characterized by a deep pit located between the eye and nostril, elliptic pupils, and retractable front fangs (figure 1-45) . localized clinical signs of pit viper envenomation may include the presence of bleeding puncture wounds, local edema close to puncture wounds, immediate severe pain or collapse, edema, petechiae, and ecchymosis with subsequent tissue necrosis. systemic signs of pit viper envenomation may include hypotension, shock, coagulopathies, lethargy, weakness, muscle fasciculations, lymphangitis, rhabdomyolysis, and neurologic signs including respiratory depression and seizures. neurologic signs largely are associated with envenomation emergency management of specific conditions 149 by the mojave and canebrake rattlesnakes, although a potent neurotoxin, mojave toxin a, also has been identified in other subspecies of rattlesnake. clinical signs of envenomation may take several hours to appear. hospitalize all suspected victims and monitor them for a minimum of 24 hours. the severity of envenomation cannot be judged solely on the basis of local tissue reaction. first aid measures by animal caretakers do little to prevent further envenomation. the most important aspect of initiating therapy is to transport the animal to the nearest veterinary emergency facility. to determine whether an animal has been envenomated by a pit viper, examine a peripheral blood smear for the presence of echinocytes. echinocytes will appear within 15 minutes of envenomation and may disappear within 48 hours. other treatment should be initiated as rapidly and aggressively as possible, although controversy exists whether some therapies are warranted. the mainstay of therapy is to improve tissue perfusion with intravenous crystalloid fluids, prevent pain with judicious use of analgesic drugs, and when necessary, reverse or negate the effects of the venom with antivenin. because pit viper venom consists of multiple fractions, treat each envenomation as a complex poisoning. obtain vascular access and administer intravenous crystalloid fluids (one fourth of a calculated shock dose) according to the patient's perfusion parameters of heart rate, blood pressure, and capillary refill time (see also shock and fluid therapy). opioid analgesics are potent and should be administered at the time of presentation. (see also pharmacologic means to analgesia: major analgesics). diphenhydramine (0.5 to 1 mg/kg im or iv) also can be administered to decrease the effects of histamine. famotidine, a histamine 1 receptor antagonist, also can be administered (0.5 to 1 mg/kg iv) to work synergistically with diphenhydramine. although antihistamines have no effect on the venom per se, they may have an effect on the tissue reaction to the venom and may prevent an adverse reaction to antivenin. the use of glucocorticosteroids is controversial. glucocorticosteroids (dexamethasone sodium phosphate [dex-sp], 0.25 to 0.5 mg/kg iv) may stabilize cellular membranes and inhibit phospholipase, an active component of some pit viper toxins. polyvalent antivenin is necessary in many cases of pit viper envenomation, except in most cases of prairie rattlesnake (crotalus viridis viridis) envenomation in colorado. a recent study demonstrated no difference in outcome with or without the use of antivenin in cases of prairie rattlesnake envenomation. clinically, however, patients that receive antivenin are more comfortable and leave the hospital sooner than those that do not receive antivenin. the exact dose of antivenin is unknown in small animal patients. administer a dose of at least 1 vial of antivenin to neutralize circulating venom. mix antivenin with a swirling, rather than a shaking motion, to prevent foaming. mix the antivenin with a 250-ml bag of 0.9% saline, and then administer it slowly over a period of 4 hours. pretreat animals with diphenhydramine (0.5 to 1 mg/kg im) before the administration of antivenin, and then monitor the animal closely for clinical signs of angioneurotic edema, urticaria, tachyarrhythmias, vomiting, diarrhea, and weakness during the infusion. administration of antivenin into the bite site is relatively contraindicated and ineffective because uptake is delayed, and systemic effects are the more life-threatening. management of pit viper envenomation largely involves maintenance of normal tissue perfusion with intravenous fluids, decreasing patient discomfort with analgesia, and negating circulating venom with antivenin. hydrotherapy to the affected bite site with tepid water is often soothing to the patient. the empiric use of antibiotics is controversial but is recommended because of the favorable environment created by a snakebite (i.e., impregnation of superficial gram-positive bacteria and gram-negative bacteria from the mouth of the snake into a site of edematous necrotic tissue). administer amoxicillin-clavulanate (16.25 mg/kg po q12h, or cephalexin, 22 mg/kg po q8h). also consider administration of nsaids (carprofen, 2.2 mg/kg po q12h). monitor the patient closely for signs of local tissue necrosis and the development of thrombocytopenia and coagulopathies including dic (see management of disseminated intravascular coagulation). treat coagulopathies aggressively to prevent end-organ damage. coral snakes are characterized by brightly colored bands encircling the body, with red and black separated by yellow. "red on black, friend of jack; red on yellow, kill a fellow." types of coral snakes include the eastern coral, texas coral, and sonoran coral snakes. clinical signs of coral snake envenomation may include small puncture wounds, transient initial pain, muscle fasciculations, weakness, difficulty swallowing/dysphagia, ascending lower motor neuron paralysis, miotic pinpoint pupils, bulbar paralysis, respiratory collapse, and severe hemolysis. clinical signs may be delayed for as long as 18 hours after the initial bite. immediate treatment with antivenin is necessary in cases of coral snake envenomation before the clinical signs become apparent, whenever possible. support respiration during paralysis with mechanical ventilation. secure the patient's airway with a cuffed endotracheal tube to prevent aspiration pneumonia. clinical signs will progress rapidly once they develop. rapid administration with antivenin is the mainstay of therapy in suspected coral snake envenomation. respiratory and cardiovascular support should occur with mechanical ventilation and intravenous crystalloid fluids. keep the patient warm and dry in a quiet place. turn the patient every 4 to 6 hours to prevent atelectasis and decubitus ulcer formation. maintain cleanliness using a urinary catheter and closed urinary collection system. perform passive range of motion and deep muscle massage to prevent disuse atrophy of limb muscles and function. treat aspiration pneumonia aggressively with broad-spectrum antibiotics (ampicillin, 22 mg/kg iv q6h, with enrofloxacin, 10 mg/kg iv q24h, and then change to oral once tolerated and the patient is able to swallow) for 2 weeks past the resolution of radiographic signs of pneumonia, intravenous fluids, and nebulization with sterile saline and coupage chest physiotherapy. several weeks may elapse before a complete recovery. the adult black widow spider (latrodectus spp.) can be recognized by a red to orange hourglass-shaped marking on the underside of a globous, shiny, black abdomen. the immature female can be recognized by a colorful pattern of red, brown, and beige on the dorsal surface of the abdomen. adult and immature females are equally capable of envenomation. the male is unable to penetrate the skin because of its small size. black widow spiders are found throughout the united states and canada. black widow spider venom is neurotoxic and acts presynaptically, releasing large amounts of acetylcholine and norepinephrine. there appears to be a seasonal variation in the potency of the venom, lowest in the spring and highest in the fall. in dogs, envenomation results in hyperesthesia, muscle fasciculations, and hypertension. muscle rigidity without tenderness is characteristic. affected animals may demonstrate clinical signs of acute abdominal pain. tonic-clonic convulsions may occur but are rare. in cats, paralytic signs predominate and appear early as a ascending lower motor neuron paralysis. increased salivation, vomiting, and diarrhea may occur. serum biochemistry profiles often reveal significant elevations in creatine kinase and hypocalcemia. myoglobinemia and myoglobinuria can occur because of extreme muscle damage. management of black widow spider envenomation should be aggressive in the cat and dog, particularly when the exposure is known. in many cases, however, the diagnosis is made based on clinical signs, biochemical abnormalities, and lack of other apparent cause. antivenin (one vial) is available and should be administered after pretreatment with diphenhydramine. if antivenin is unavailable, administer a slow infusion of calcium-containing fluid such as lactated ringer's solution with calcium gluconate while carefully monitoring the patient's ecg. the small brown nonaggressive spider is characterized by a violin-shaped marking on the cephalothorax. the neck of the violin points toward the abdomen. brown spiders are found primarily in the southern half of the united states but have been documented as far north as michigan. the venom of the brown spider has a potent dermatonecrolytic effect and starts with a classic bull's-eye lesion. the lesion then develops into an indolent ulcer into dependent tissues promoted by complement fixation and influx of neutrophils into the affected area. the ulcer can take months to heal and often leaves a disfiguring scar. systemic reactions are rare but can include hemolysis, fever, thrombocytopenia, weakness, and joint pain. fatalities are possible. immediate management of an animal with brown spider envenomation is difficult because there is no specific antidote and because clinical signs may be delayed until necrosis of the skin and underlying tissues becomes apparent through the patient's fur 7 to 14 days after the initial bite. dapsone has been recommended at a dose of 1 mg/kg for 14 days. surgical excision of the ulcer may be helpful if performed in the early stages of wound appearance. glucocorticosteroids may be of some benefit if used within 48 hours of the bite. the ulcer should be left to heal by second intention. deep ulcers should be treated with antibiotics. bufo toad species (b. marinus, aka cane toad, marine toad, giant toad; and the colorado river toad or sonoran desert toad b. alvarius) can be associated with severe cardiac and neurotoxicity if an animal licks its skin. the severity of toxicity depends largely on the size of the dog. toxins in the cane toad, b. marinus, include catecholamines and vasoactive substances (epinephrine, norepinephrine, serotonin, dopamine) and bufo toxins (bufagins, bufotoxin, and bufotenine), the mechanism of which is similar to cardiac glycosides. clinical signs can range from ptyalism, weakness, ataxia, extensor rigidity, opisthotonus, and collapse to seizures. clinical signs associated with b. alvarius toxicity are limited largely to cardiac dysrhythmias, ataxia, and salivation. the animal should have its mouth rinsed out thoroughly with tap water even before presentation to the veterinarian. if the animal is unconscious or actively seizing and cannot protect its airway, flushing the mouth is contraindicated. once an animal presents to the veterinarian, the veterinarian should place an intravenous catheter and monitor the patient's ecg and blood pressure. attempt seizure control with diazepam (0.5 mg/kg iv) or pentobarbital (2 to 8 mg/kg iv to effect). ventricular dysrhythmias can be controlled first with esmolol (0.1 mg/kg). if esmolol is ineffective, administer a longer-acting parenteral î²-antagonist such as propranolol (0.05 mg/kg iv). ventricular tachycardia also can be treated with lidocaine (1 to 2 mg/kg iv, followed by 50 to 100 âµg/kg/minute iv cri). case management largely depends on supportive care and treating clinical signs as they occur. monitor baseline acid-base and electrolyte balance because severe metabolic acidosis may occur that should be treated with intravenous fluids and sodium bicarbonate (0.25 to 1 meq/kg iv). monitor ecg, blood pressure, and mentation changes closely. control seizures and cardiac dysrhythmias. eubig pa: bufo species intoxication: big toad, big problem, vet med 96 (8) lizards of the family hemodermatidae are the only two poisonous lizards in the world. they are found in the southwestern united states and mexico. the venom glands are located on either side of the lower jaw. because these lizards are typically lethargic and nonaggressive, bite wounds are rare. the lizards have grooved teeth that introduce the venom with a chewing motion as the lizard holds tenaciously to the victim. the majority of affected dogs are bitten on the upper lip, which is very painful. there are no proven first aid measures for bites from gila monsters or mexican bearded lizards. the lizard can be disengaged by inserting a prying instrument in between the jaws 1 and pushing at the back of the mouth. the teeth of the lizard are brittle and break off in the wound. topical irrigation with lidocaine and probing with a needle will aid in finding and removing the teeth from the victim. bite wounds will bleed excessively. irrigate wounds with sterile saline or lactated ringer's solution, and place compression on the affected area until bleeding ceases. monitor the patient for hypotension. establish intravenous access, and administer intravenous fluids according to the patient's perfusion parameters. antibiotic therapy is indicated because of the bacteria in the lizard's mouth. because no antidote is available, treatment is supportive according to patient signs. the majority of musculoskeletal emergencies are the result of external trauma, most commonly from motor vehicle accidents. blunt trauma invokes injury to multiple organ systems as a rule, rather than an exception. because of this, massive musculoskeletal injuries are assigned a relatively low priority during the initial triage and treatment of a traumatized animal. perform a rapid primary survey and institute any lifesaving emergency therapies. adhere to a crash plan or the abcs of resuscitation (see initial emergency examination, management, and triage). although musculoskeletal injuries are assigned a relatively lower priority, the degree of recovery from these injuries and financial obligation for fracture repair sometimes becomes a critical factor in a client's decision whether to pursue further therapy. one of the most important deciding factors is the long-term prognosis for the patient to have a good quality of life following fracture repair. the initial management of musculoskeletal injuries is important in ensuring the best chance for maximal recovery with minimal complications after definitive surgical fracture repair. this is particularly important for open fractures, spinal cord compromise, multiple fractures, open joints, articular fractures, physeal fractures, and concomitant ligamentous or neurologic compromise (box 1-41). immediately after the initial primary survey of a patient, perform a more thorough examination, including an orthopedic examination. multiple injuries often are observed in the patient that falls from height (e.g., "high-rise syndrome"), motor vehicle accidents, gunshot wounds, and encounters with other animals (e.g., "big-dog-little-dog"). address the most life threatening injuries, and palliate musculoskeletal injuries until more definitive repair can be attempted when the patient is more stable. in animals with the history of potential for multiple injuries, search thoroughly and meticulously for areas of injury to the spinal column, extremities, and for small puncture wounds. helpful signs that can provide a clue as to an underlying injury include swelling, bruising, abnormal motion, and crepitus (caused by subcutaneous emphysema or bony fracture). if the patient is alert, look for areas of tenderness or pain. in unconscious or depressed patients, reexamine the patient after the patient becomes more mentally alert. injuries often are missed during the initial examination in obtunded patients because of the early response and attenuation of pain. unconscious or immobile patients must have radiographic examination of the spinal column following stabilization and support. palpate the skull carefully for obvious depressions or crepitus that may be associated with a skull fracture. localization of the injury can be determined by motion in abnormal locations, swelling caused by hemorrhage or edema, pain during gentle movement or palpation, deformity, angular change, or a significant increase or decrease in normal range of motion of bones and joints. perform a rectal examination in all cases to palpate for pelvic fractures and displacement. once the diagnosis of a fracture or luxation has been confirmed, look for any evidence of skin lacerations or punctures near the fracture site. in long-haired breeds, clipping the fur near the fracture site often is necessary to perform a thorough examination of the area. if any wounds are found, the fracture is classified as an open fracture until proven otherwise. in some cases, the open fracture is obvious, with a large section of bone fragment protruding through the skin. in other cases, the puncture wound may be subtle, with only a small amount of blood or pinpoint hole in the skin surface. characteristics observed with open fractures include bone penetration, fat droplets or marrow elements in blood coming from the wound, subcutaneous emphysema on radiographs, and lacerations in the area of a fracture. protect the patient from further injury or contamination of wounds. excessive palpation to intentionally produce crepitus is inappropriate because it causes severe patient discomfort and has the potential to cause severe soft tissue and neurologic injury at the fracture site. sedation and analgesia aids in making the examination more comfortable for the patient and allows localization of the injury and comparison with the opposite extremity. higher-quality radiographs can be performed to determine the extent of the injury when the animal is sedated adequately and pain is controlled. sedate the patient judiciously with analgesic drugs. opioid drugs work well for orthopedic pain, produce minimal cardiorespiratory depression, and can be reversed with naloxone if necessary. handle the fracture site gently to avoid causing further pain and soft tissue injury at the fracture site. rough or careless handling of a fracture site can cause a closed fracture to penetrate through the skin and become an open fracture. cover open fractures immediately to prevent contamination of the fracture with nosocomial infection from the hospital. administer a first-generation cephalosporin (cephalexin, 22 mg/kg po q8h, or cefazolin, 22 mg/kg iv q8h). the bandage also serves to control hemorrhage and prevent desiccation of the bones and surrounding soft tissue structures. leave the initial bandages in place until the patient's cardiorespiratory status has been determined to be stable and more definitive wound management can occur in a clean, preferably sterile location. examine the neurologic status and cardiovascular status of the limb before and after treatment. determine the vascular status of the limb by checking the color and temperature of the limb, the state of distal pulses, and the degree of bleeding from a cut nail bed. in patients with severe cardiovascular compromise and hypotension caused by hemorrhagic shock, the viability of the limb may be in question until the cardiovascular status and blood pressure are normalized. reduction of the fracture or straightening of gross deformities may return normal vascularity to the limb. when checking neurologic status, examine for motor and sensory function to the limb. swelling may increase pressure on the nerves as they run through osteofascial compartments, resulting in decreased sensory or motor function, or neurapraxia. diminished function often returns to normal once the swelling subsides. serial physical examinations in the patient and response to initial stabilization therapy can lead to a higher index of suspicion that more occult injuries are present, such as a diaphragmatic hernia, perforated bowel, lacerated liver or spleen, or uroabdomen. to prevent ongoing trauma, reduce any fracture and then stabilize the site above and below the fracture. a modified robert jones splint or bandage often works well for fractures emergency management of specific conditions 155 involving the distal extremities. fractures of the humerus or femur are difficult to immobilize without the use of spica or over-the-hip coaptation splints to prevent mobility. inappropriate bandaging of humerus or femur fractures can result in a fulcrum effect and worsen the soft tissue and neurologic injuries. further displacement of vertebral bodies or luxations can cause cord compression or laceration such that return to function becomes impossible. immediately place any patient with a suspected spinal injury on a flat surface, and tape down the animal to prevent further movement until the spine has been cleared by a minimum or two orthogonal radiographic views (lateral and ventrodorsal views performed as a cross-table x-ray technique). wounds associated with musculoskeletal trauma are common and include injury to the bones, joints, tendons, and surrounding musculature (box 1-42). major problems associated with these cases are the presence of soft tissue trauma that makes wound closure hazardous or impossible, because of the risk of infection. chronic deep infection of traumatized wounds can cause delayed healing and sequestrum to develop, particularly if there is avascular bone or cartilage within the wound. in the early management of an open fracture, the areas should be splinted without pulling any exposed bone back into the soft tissue. the wound should not be probed or soaked, as nosocomial bacteria and other external contaminants can be introduced into the wound, leading to severe infection. because of the risk of actually causing infection, probing, flushing, or replacing tissues back into the wound should be performed at the time of formal debridement when the patient is physiologically stable. immediate bactericidal antibiotic therapy with a first-generation cephalosporin should be started immediately to obtain adequate concentrations of antibiotics at the fracture site. the duration of antibiotic therapy should ideally be limited to 2-3 days to prevent the risk of superinfection. treatment of open musculoskeletal injury involves three considerations: initial inspection and wound debridement, stabilization and repair, and wound bandaging. 156 1 emergency care when associated with a fracture, wound is created from the inside out by penetration of bone fragments through the skin or from a low-energy gunshot. simple or comminuted fracture pattern good stability of the two main bone segments treatment and prognosis are good and similar to those of a closed injury if wound is debrided and stabilized within 6 to 8 hours. when associated with a fracture, wound is created from the outside in. major deep injury with considerable soft tissue stripping from bone and muscle damage simple or comminuted fracture pattern prognosis is good if wound is debrided within 6 hours of injury and provided rigid stabilization with a bone plate or external fixator. results from major external force severe damage and necrosis of skin, subcutaneous tissue, muscle, nerve, bone, tendon, and arteries soft tissue damage may vary from crush injury to shearing injury associated with bite wounds or low-speed automobile accidents. requires immediate and delayed sequential debridement and rigid external fixation can require prolonged healing times guarded prognosis initial inspection and wound debridement include the following steps: 1. after the patient's cardiovascular status has been stabilized and it has been determined that it can withstand anesthesia, place the animal under general anesthesia and remove the temporary splint. 2. keeping the wound covered, shave the surrounding fur. 3. remove the covering and then place sterile lubricant jelly over the wound. shave the fur to the edges of the wound margin. 4. wash away any entrapped fur and the lubricant jelly. 5. complete an antiseptic scrub of the surrounding skin. 6. if the wound is a small puncture (e.g., gunshot pellets or bites), probe the wound with a sterile hemostat. do a thorough debridement if tissues deep to the hole are cavitated. if not deep, create a hole for drainage. 7. flush the wound with a physiologic solution (lactated ringer's solution is preferred). 8. debride the wound from outward to inward. cut away damaged areas of skin and deeper tissues to open up underlying cavitations and tissue injury. 9. continuously irrigate with warm physiologic solution (lactated ringer's solution is preferred). the stream must be strong enough to flush debris out of the bottom of the wound. to accomplish this, attach a 20-gauge needle to a 35-ml syringe (will deliver 7 psi). excise any obviously devitalized tissue. 10. do not remove any bone fragments that are firmly attached to soft tissue. do not cut into healthy soft tissue to find bullet or bone fragments, unless the bullet can cause injury to joints or nerve tissue. 11. do a primary repair of tendons and nerves if the wound is type i and recent (within 8 hours of the initial injury). if the wound is too severe or if there is obvious infection, tag the ends of the tendons and nerves for later repair. it is best to stabilize and repair open fractures as soon as the patient's cardiovascular and respiratory status can tolerate general anesthesia, provided that adequate stabilization is possible. if this is not possible because of the level of experience of the surgeon or the lack of necessary equipment, it is best to perform wound management and place a temporary splint until definitive repair can be performed. wound bandaging is discussed in the section on bandaging techniques. structural injuries to the joints are common and can involve both ligaments and articular cartilage injuries. cartilage does not heal well; therefore, injuries involving articular cartilage can lead to a significant loss of function and degenerative joint disease (osteoarthritis). cartilage injuries that are superficial evoke a short-lived enzymatic and metabolic response that does not stimulate enough cellular growth to repair the defect. superficial lesions remain as defects but do not progress to chondromalacia or osteoarthritis. deep cartilage lacerations that extend to subchondral bone produce an exuberant healing response from the cells of the underlying cartilage. in many cases, this material undergoes degeneration and leads to osteoarthritis. impact injuries to surface cartilage can cause chondrocyte and underlying bone injury. these lesions rapidly progress to osteoarthritis; however, they may be totally or partially reversible. treatment of grade i injuries requires short-term coaptation splints and has a good prognosis. grade ii injuries require surgical treatment with a suture stent and consistent postoperative coaptation splints to heal and maintain good function. healing of grade iii injuries often is a problem, and suture stents or surgical reapproximation may be indicated. failure to immobilize joints that are frequently flexed (elbow and stifle) can result in late complications of ligament repair. ligamentous injuries of joints, particularly the collateral ligaments of the stifle, elbow, and hock, and carpal hyperextension injuries are commonly missed and may require surgical fixation, including arthrodesis (box 1-43). fractures in immature animals differ from those in adults in that young puppies and kittens have a great ability to remodel bone. remodeling is dependent on the age of the patient and the location of the fracture. the younger the puppy or kitten and the closer the fracture to the epiphysis or growth plate, the greater the potential for remodeling and the development of angular limb deformities. remodeling occurs more effectively in longlimbed breeds of dogs than in short-limbed breeds. fractures through the growth plate of immature animals may potentially cause angular limb deformities, joint dislocations or incongruity, and osteoarthritis. this form of injury is commonly observed in the distal ulnar growth plate and the proximal and distal radial growth plates. high-rise syndrome in cats is seen in cats that fall from a height usually greater than 30 feet. it occurs most frequently in high-rise buildings in urban areas where cats lie on window ledges and suddenly fall out the window. the most common lesions observed in cats that fall from heights are thoracic injuries (rib and sternal fractures, pneumothorax, and pulmonary contusions) and facial and oral trauma (lip avulsions, mandibular symphyseal fractures, fractures of the hard palate, and maxillary fractures). limb and spinal cord fractures and luxations, radius and ulna fractures, abdominal trauma, urinary tract trauma, and diaphragmatic hernias are also common. the injuries sustained are often found in combination, rather than as an isolated injury of one area of the body. follow the mnemonic a crash plan when managing a cat suffering from high-rise syndrome, treating the animal immediately for shock. following cardiovascular and respiratory stabilization, evaluate thoracic and abdominal radiographs, including those of the spine. evaluate the bladder closely, making sure that the cat is able to urinate effectively. examine the hard palate, maxilla, and mandibular symphysis for fractures. palpate the pelvis and carefully manipulate all limbs to examine for fractures or ligamentous injuries. finally, perform a complete neurologic examination. patients that fall less than five stories often have a more guarded prognosis than patients that fall from higher levels. sometimes the owner witnesses the ingestion of a foreign body during play, such as throwing a stick or fetching a ball. cats tend to play with string or thread that becomes caught around the base of the tongue. in many cases, however, ingestion of the foreign object is not witnessed, and diagnosis is made based on clinical signs and physical examination. foreign bodies lodged in the oral cavity often cause irritation and discomfort, including difficulty breathing and difficulty swallowing. often, an animal paws at its mouth in an attempt to dislodge a stick or bones wedged across the roof of the mouth. irritation, inability to close the mouth, and blockage of the orpharynx can result in excessive drooling. the saliva may appear blood-tinged due to concurrent soft tissue trauma (figs 1-46 and 1-47) . obstruction of the glottis by a foreign body (e.g., tennis ball or toy) can result in cyanosis secondary to an obstructed airway and hypoxemia. in many cases, the object is small enough to enter the larynx but too large to be expelled. if a foreign object is lodged in the mouth for more than several days, halitosis and purulent discharge may be present. many animals are anxious at the time of presentation and may require sedation or a light plane of anesthesia to remove the foreign object. the animal may bite personnel and may have bitten the owner during his or her attempt to remove the object from the mouth en route to the hospital. propofol (47 mg/kg iv) or a combination of propofol with diazepam (0.5-1 mg/kg iv) is an excellent combination for a light plane of anesthesia. exercise caution when anesthetizing a patient with a ball lodged in the airway, as further compromise of respiratory function may occur and cause worsening of the hypoxemia. before inducing anesthesia, assemble all supplies necessary to remove the object. make sure that rigid towel clamps, sponge forceps, and bone forceps are on hand, because the foreign object is often very slippery with saliva. hemostats and carmalts may slip and not be useful in the removal of the foreign object. place a peripheral intravenous catheter to secure vascular access prior to anesthetic induction. have available the supplies necessary for an emergency tracheostomy, if the foreign object cannot be removed by usual methods. induce a light plane of anesthesia and then grasp the object with the sponge forceps or towel clamps, and extract. monitor the cardiorespiratory status of the animal at all times during the extraction process. if you are unable to remove the object, and if severe respiratory distress, including cyanosis, bradycardia, or ventricular dysrhythmias, develop, perform a tracheostomy distal to the site of obstruction. once the foreign body has been removed, administer supplemental flow-by oxygen until the animal awakens. if laryngeal edema or stridor on inspiration is present, administer a dose of dexamethasone sodium phosphate (0.25 mg/kg iv, im, sq) to decrease inflammation. the patient should be carefully monitored for 24 hours, because noncardiogenic pulmonary edema can develop secondary to airway obstruction. esophageal foreign bodies pose a serious medical emergency. it is helpful if the owner witnessed ingestion of the object and noted rapid onset of clinical signs. in many cases, however, ingestion is not witnessed, and the diagnosis must be made based on clinical signs, thoracic radiographs, and results of a barium swallow. the most common clinical signs are excessive salivation with drooling, gulping, and regurgitation after eating. many animals will make repeated swallowing motions. some animals exhibit a rigid "sawhorse" stance, with reluctance to move immediately after foreign body ingestion and esophageal entrapment. after completing a physical examination, evaluate cervical and thoracic radiographs to determine the location of the esophageal obstruction. esophageal foreign objects are lodged most commonly at the base of the heart, the carina, or just orad to the lower esophageal sphincter. if the object has been lodged for several days, pleural effusion and pneumomediastinum may be present secondary to esophageal perforation. endoscopy is useful for both diagnosis and removal of the foreign object; however, it is invasive and requires general anesthesia ( fig. 1-48) . remove foreign objects lodged in the esophagus with a rigid or flexible endoscope after the patient has been placed under general anesthesia. evaluate the integrity of the esophagus both before and after removal of the material because focal perforation or pressure necrosis can be present. necrosis of the mucosa and submucosa of the esophagus often leads to stricture formation or perforation. attempt to retrieve the object with a flexible fiberoptic endoscope if available. rigid tube endoscopy can also be performed. in many cases, smooth objects that cannot be easily grasped can be pushed into the stomach and allowed to dissolve or may be removed by gastrotomy. if the foreign body is firmly lodged in the esophagus and cannot be pulled or pushed into the stomach, or if perforation has already occurred, the prognosis for return to function without strictures is not favorable. in such cases, referral to a surgical specialist is recommended for esophagostomy or esophageal resection. after removal of the object, carefully examine the esophagus and then administer gastroprotectant agents (famotidine, 0.5 mg/kg po bid; sucralfate slurry, 0.5-1.0 g/dog) for a minimum of 5 to 7 days. to rest the esophagus, the patient should receive nothing per os (npo) for 24 to 48 hours. if esophageal irritation or erosion is moderate to severe, a percutaneous gastrotomy tube should be placed for feeding until the esophagus heals. perform repeat endoscopy every 7 days to evaluate the healing process and to determine whether stricture formation is occurring. persistent vomiting immediately or soon after eating is often associated with a gastric foreign body. in some cases, the owner knows that the patient has ingested a foreign body of some kind. in other cases, continued vomiting despite lack of response to conservative treatment (npo, antiemetics, gastroprotectant drugs) prompts further diagnostic procedures, including abdominal radiographs and bloodwork. obstruction to gastric outflow and vomiting of hydrochloric acid often cause a hypochloremic metabolic acidosis. radiopaque gastric foreign bodies may be observed on plain films. radiolucent cloth material may require a barium series to delineate the shape and location of the foreign body ( fig. 1-49) . treatment consists of removal with flexible endoscopy or a simple gastrotomy. most animals with uncomplicated gastric foreign bodies are relatively healthy, but any metabolic and electrolyte abnormalities should be corrected prior to anesthesia and surgery. small intestinal obstruction can be caused by foreign bodies, tumors, intussusception, volvulus, or strangulation within hernias. regardless of the cause, clinical signs of small intestinal obstruction depend on the location and degree of obstruction, and whether the bowel has perforated. clinical signs associated with a high small intestinal obstruction are usually more severe and more rapid in onset compared with partial or complete obstruction of the jejunum or ileum. complete obstructions that allow no fluid or chyme to pass are worse than partial obstructions, which can cause intermittent clinical signs interspersed with periods of normality (table 1 -36). the most common clinical signs associated with a complete small intestinal obstruction are anorexia, vomiting, lethargy, depression, dehydration, and sometimes abdominal pain. early clinical signs may be limited to anorexia and depression, making a diagnosis challenging unless the owner has a suspicion that the animal ingested some kind of foreign object. obstructions cranial to the common bile duct and pancreatic papillae lead to vomiting of gastric contents, namely hydrochloric acid, and a hypochloremic metabolic alkalosis. obstructions caudal to the common bile duct and pancreatic papillae result in loss of other electrolytes and sometimes mixed acid-base disorders. eventually, all animals with small intestinal obstruction vomit and have fluid loss into dilated segments of bowel, leading to dehydration and electrolyte abnormalities. increased luminal pressure causes decreased lymphatic drainage and bowel edema. the bowel wall eventually becomes ischemic and may rupture. linear foreign bodies should be suspected in any vomiting patient, particularly cats. string or thread often is looped around the base of the tongue and can be visualized in many cases by a thorough oral examination. to look properly under the tongue, grasp the top of the animal's head with one hand, and pull the lower jaw open with the index finger of the opposite hand while pushing up the thumb simultaneously on the tongue in between the intermandibular space. thread and string can be observed lying along the ventral aspect of the tongue. in some cases, if a linear foreign body is lodged very caudally, it cannot be visualized without heavy sedation or anesthesia. linear foreign bodies eventually cause bowel obstruction and perforation of the intestines along the mesenteric border. the foreign material (e.g., string, thread, cloth, pantyhose) becomes lodged proximally, and the intestines become plicated as the body attempts to push the material caudally through the intestines ( fig. 1-50) . continued peristalsis eventually causes a sawing motion of the material and perforation of the mesenteric border of the intestines. once peritonitis occurs, the prognosis is less favorable unless prompt and aggressive treatment is initiated. reevaluate any patient that does not respond to conservative symptomatic therapy, performing a complete blood count, serum biochemical panel (including electrolytes), and abdominal radiographs. intestinal masses may be palpable on physical examination and are often associated with signs of discomfort or pain when palpating over the mass. radiography and abdominal ultrasound are the most useful diagnostic aids. plain radiographs may be diagnostic when the foreign object is radiodense or there is characteristic dilation or plication of bowel loops. as a rule of thumb, the width of a loop of small bowel should be no larger than twice the width of a rib. diagnosis of small intestinal obstruction or ileus can be based on the appearance of stacking loops of dilated bowel. comparison of the width of the bowel with the width of a rib is often performed. with mild dilation, the bowel width is three to four times the rib width; with extensive dilation, five to six times the rib width ( fig.1-51) . in cases of linear foreign bodies, c-areas (comma-shaped areas) of gas trapped in the plicated bowel will appear stacked on one another. blunt, wedge-shaped areas of gas or square linear areas of gas adjacent to a distended bowel loop are characteristic of a foreign body lodged in the intestine. contrast radiography is indicated when confirmation of the suspected diagnosis is necessary and ultrasonography is not available. contrast material may outline the object or abruptly stop orad to the obstruction. the definitive treatment of any type of small intestinal foreign body is surgical removal. linear foreign bodies sometimes pass, but they should never be left untreated in a patient that is demonstrating clinical signs of inappetence, vomiting, lethargy, and dehydration. the timing of surgery is critical because the risk of intestinal perforation increases with time. prior to surgery, correct any acid-base and electrolyte abnormalities with intravenous fluid therapy. administer broad-spectrum antibiotics. perform an enterotomy or intestinal resection and anastomosis as soon as possible once the patient's acid-base and electrolyte status have been corrected. clinical signs of a foreign body in the large bowel are usually nonexistent. in most cases, if a foreign object has passed successfully through the small bowel, it will pass through the large bowel without incident unless bowel perforation and peritonitis occur. penetrating foreign bodies such as needles often cause localized or generalized peritonitis, abdominal pain, and fever. hematochezia may be present if the foreign object causes abrasion of the rectal mucosa. symptomatic patients should have abdominal radiographs performed. colonoscopy or exploratory laparotomy should be performed if survey radiographs are suggestive of a large intestinal obstruction or perforation. in most cases, large intestinal foreign bodies will pass without incident. surgery is required to treat perforations, peritonitis, or abscesses. 164 1 emergency care 1 figure 1 -51: after 60 minutes, the barium has stopped moving and has reached a blunt, intraluminal intestinal foreign body. note that barium appears wedge-shaped or square at the site of the foreign body. foreign bodies in the rectum and anus often are the result of ingestion of bones, wood material, needles, and thread, or malicious external insertion. often the material can pass through the entire gastrointestinal tract and then get stuck in the anal ring. clinical signs include hematochezia and dyschezia with straining to defecate. diagnosis is made by visual examination of the item in the anus, or by careful digital palpation after heavy sedation or short-acting general anesthesia. radiography is helpful in locating needles that have penetrated the rectum and lodged in the perirectal or perinatal tissues. treatment consists of careful removal of the needle digitally or surgically. intussusception is the acute invagination of one segment of bowel (the intussusceptum) into another (the intussuscipiens). the proximal segment always invaginates into the distal segment of bowel. intussusception most commonly occurs in puppies and kittens less than 1 year of age but can occur in an animal of any age with hypermotility of the small bowel, gastrointestinal parasites, and severe viral or bacterial enteritis. intussusception occurs primarily in the small bowel in the jejunum, ileum, and ileocolic junction. clinical signs include vomiting, abdominal discomfort, and hemorrhagic diarrhea. usually, hemorrhagic diarrhea is the first noticeable sign, and in puppies, may be due to parvoviral enteritis, with secondary intussusception. usually, the obstruction is partial with mild clinical signs. more serious clinical signs develop as the obstruction becomes more complete. differential diagnoses include hemorrhagic gastroenteritis, parvoviral enteritis, gastrointestinal parasites, intestinal foreign body, bacterial enteritis, and other causes of vomiting and diarrhea. the diagnosis of intussusception is often made based on palpation of a sausage-shaped firm, tubular structure in the abdomen accompanied by clinical signs and abdominal pain. plain radiographs may demonstrate segmental or generalized dilated segments of bowel, depending on the duration of the problem. ultrasonographs of the palpable mass resemble the layers of an onion, with hyperechoic intestinal walls separated by less echogenic edema. treatment consists of correction of the patient's acid-base and electrolyte abnormalities with intravenous fluids and surgical reduction or removal of the intussusception with resection and anastomosis. although enteroplication has been suggested, the technique has fallen out of favor because of the increased risk of later obstruction. the primary cause of intestinal inflammation and hypermotility must be identified and corrected. gastric dilatation can occur with or without volvulus in the dog. gastric dilatationvolvulus (gdv) occurs primarily in large-and giant-breed dogs with deep chests, such as the great dane, labrador retriever, saint bernard, german shepherd dog, gordon and irish setters, standard poodle, bernese mountain dog, and bassett hound. the risk of gdv increases with age; however, it can be seen in dogs as young as 4 months. deep, narrow-chested breeds are more likely to develop gdv than dogs with broader chests. the overall mortality for surgically treated gastric dilatation-volvulus ranges from 10% to 18%, with most deaths occurring in patients that required splenectomy and partial gastrectomy. clinical signs of gdv include abdominal distention, unproductive vomiting or retching, lethargy, weakness, sometimes straining to defecate, and collapse. the owner may think that the animal is vomiting productively because of the white foamy froth (saliva) that is not able to pass into the twisted stomach. in some cases, there is a history of the dog's being fed a large meal or consuming a large quantity of water prior to the onset of clinical signs. instruct the owner of any patient with a predisposition for and clinical signs of gdv to transport the animal to the nearest veterinary facility immediately. physical examination often reveals a distended abdomen with a tympanic area on auscultation. in dogs with very deep chests, it may be difficult to appreciate abdominal distention if the stomach is tucked up under the rib cage. depending on the stage of shock, the patient may have sinus tachycardia with bounding pulses, cardiac dysrhythmias with pulse deficits, or bradycardia. the mucous membranes may appear red and injected or pale with a prolonged capillary refill time. the patient may appear anxious and attempt to retch unproductively. if the patient is nonambulatory at the time of presentation, the prognosis is more guarded. the definitive diagnosis of gdv is based on clinical signs, physical examination findings, and radiographic appearance of gas distention of the gastric fundus with dorsocranial displacement of the pylorus and duodenum (the so-called "double-bubble" or "popeye arm" sign) ( fig.1-52) . in simple gastric dilatation without volvulus, there is gas distention of the stomach with anatomy appearing normal on radiography. with "food bloat," or gastric distention from overconsumption of food, ingesta is visible in the distended stomach ( fig. 1-53) . as soon as a patient presents with a possible gdv, place a large-bore intravenous catheter in the cephalic vein(s) and assess the patient's ecg, blood pressure, heart rate, capillary refill time, and respiratory function. obtain blood samples for a complete blood count, serum biochemistry profile, immediate lactate measurement, and coagulation tests before taking any radiographs. rapidly infuse a colloid (hetastarch or oxyglobin, 5 ml/kg iv bolus) along with shock volumes of a crystalloid fluid (up to 90 ml/kg/hour) (see section on shock). monitor perfusion parameters (heart rate, blood pressure, capillary refill time, and ecg) and titrate fluid therapy according to the patient's response. the use of short-acting glucocorticosteroids is controversial. glucocorticosteroids may help stabilize cellular membranes and decrease the mechanisms of ischemia-reperfusion injury, but no detailed studies have proved them to be beneficial versus not using glucocorticosteroids in the patient with gdv. attempt gastric decompression, either with placement of an orogastric tube or by trocharization. to place an orogastric tube, position the distal end of the tube at the level of the patient's last rib ( fig. 1-54 ) and place it adjacent to the animal's thorax; then put a piece of tape around the tube where it comes out of the mouth, once it is in place. put a roll of 2-inch tape in the patient's mouth behind the canine teeth and then secure the roll in place by taping the mouth closed around the roll of tape. lubricate the tube with lubricating jelly and slowly insert the tube through the center of the roll of tape into the stomach. the passing of the tube does not rule out volvulus. in some cases, the front legs of the patient need to be elevated, and the caudal aspect of the patient lowered (front legs standing on a table with back legs on the ground) to allow gravity to pull the stomach down to allow the tube to pass. once the tube has been passed, air within the stomach is relieved, and the stomach can be lavaged. the presence of gastric mucosa or blood in the efflux from the tube makes the prognosis more guarded. if an orogastric tube cannot be passed, clip and aseptically scrub the patient's lateral abdomen and then insert 16-gauge over-the-needle catheter. "pinging" the animal's side with simultaneous auscultation allows determination of the location that is most tympanic-that is, the proper location for catheter insertion. once intravenous fluids have been started in the animal, take a right lateral abdominal radiograph to document gdv. if no volvulus is present, the owner may elect for more conservative care, and the animal should be monitored in the hospital for a minimum of 24 hours. because some cases of gdv intermittently twist and untwist, the owner should be cautioned that although the stomach is not twisted at that moment, a volvulus can occur at any time. if radiographs demonstrate food bloat, induce emesis (apomorphine, 0.04 mg/kg iv) or perform orogastric lavage under general anesthesia. documentation of gastric dilatation-volvulus constitutes a surgical emergency. 1 figure 1 -53: example of "food bloat" with severe gastric distention caused by overconsump-following diagnosis of gdv, continue administration of intravenous fluids. serum lactate measurements greater than 6.0 mmol/l are associated with an increased risk of gastric necrosis, requirement for partial gastrectomy, and increased mortality. administer fresh frozen plasma (20 ml/kg) to patients with thrombocytopenia or prolonged pt, activated partial thromboplastin time (aptt), or activated clotting time (act). cardiac dysrhythmias, particularly ventricular dysrhythmias, are common in cases of gdv and are thought to occur secondary to ischemia and proinflammatory cytokines released during volvulus and reperfusion. lidocaine (1-2 mg/kg followed by 50 mcg/kg/minute iv cri) can be used to treat cardiac dysrhythmias preemptively that are associated with ischemia-reperfusion injury, or administration can be started when ventricular dysrhythmias are present. correct any electrolyte abnormalities, including hypokalemia and hypomagnesemia. the use of nonsteroidal antiinflammatory drugs (flunixin meglumine, carprofen, ketoprofen) that can potentially decrease renal perfusion and predispose to gastric ulcers is absolutely contraindicated. administer analgesic drugs (fentanyl, 2 âµ/kg iv bolus, followed by 3-20 âµ/kg/hour iv cri; or hydromorphone, 0.1 mg/kg iv) before anesthetic induction. after carrying out a balanced anesthesia protocol, the patient should be taken immediately to surgery for gastric derotation and gastropexy. postoperatively, assess the patient's ecg, blood pressure, platelet count, coagulation parameters, and gastric function (see section on rule of twenty). if no resection is required, the animal can be given small amounts of water beginning 12 hours after surgery. depending on the severity of the patient's condition, small amounts of a bland diet can be offered 12 to 24 hours postoperatively. continute supportive care with analgesia and crystalloid fluids until the patient is able to tolerate oral analgesic drugs (tramadol, 1-3 mg/kg po q8-12h). once the patient is ambulatory and able to eat and drink on its own, it can be released from the hospital; instruct the owner to feed the animal multiple small meals throughout the day for the first week. when the intestines twist around the root of the mesentery, a small intestinal or mesenteric volvulus occurs. the problem is most common in the young german shepherd dog, although it has been observed in other large and giant breeds. predisposing factors include pancreatic atrophy, gastrointestinal disease, trauma, and splenectomy. clinical signs of mesenteric volvulus include vomiting, hemorrhagic diarrhea, bowel distention, acute onset of clinical signs of shock, abdominal pain, brick-red mucous membranes (septicemia), and sudden death. diagnosis is based on an index of suspicion and the presence of clinical signs in a predisposed breed. plain radiographs often reveal grossly distended loops of bowel in a palisade gas pattern. in some dogs, multiple, tear-drop-shaped, gas-filled loops appear to rise from a focal point in the abdomen. usually, massive distention of the entire small bowel is observed ( fig. 1-55) . the presence of pneumoperitoneum or lack of abdominal detail secondary to the presence of abdominal fluid is characteristic of bowel perforation and peritonitis. in a patient with mesenteric volvulus, immediate aggressive action is necessary for the animal to have any chance of survival. treatment consists of massive volumes of iv crystalloid and colloid fluids (see section on iv therapy), broad-spectrum antibiotics (ampicillin, 22 mg/kg iv qid, with enrofloxacin, 10 mg/kg iv once daily), and surgical correction of the bowel. because of the massive release of proinflammatory cytokines, bacterial translocation, and ischemia, treatment for shock is of paramount importance (see sections on rule of twenty and shock). prognosis for any patient with mesenteric volvulus is poor. obstipation (obstructive constipation) is most common in the older cat. in cases of simple constipation, rehydrating the animal with intravenous fluids and stool softeners is often volvulus. this consistutes an immediate surgical emergency, and the prognosis is often poor. this condition is most common in young german shepherd dogs, but can be observed in any breed. sufficient for it to regain the ability to have a bowel movement. obstipation, however, is caused by adynamic ileus of the large bowel that eventually leads to megacolon. affected cats usually are anorectic, lethargic, and extremely dehydrated. treatment consists of rehydration with intravenous crystalloid fluids, correction of electrolyte abnormalities, enemas, and promotility agents such as cisapride (0.5 mg/kg po q8-24h). the use of phosphate enemas in cats is absolutely contraindicated because of the risk of causing acute, fatal hyperphosphatemia. in many cases, the patient should be placed under general anesthesia and manual deobstipation is performed with warm water soapy enemas and a gloved finger to relieve and disimpact the rectum. stool softeners such as lactulose and docusate stool sofener (dss) may also be used. predisposing causes of obstipation such as narrowing of the pelvic canal, perineal hernia, and tumors should be ruled out. adenocarcinoma is the most common neoplasm of the gastrointestinal tract that causes partial to complete obstruction. adenocarcinomas tend to be annular and constricting, and they may cause progressive obstruction of the lumen of the small or large bowel. siamese cats tend to have adenocarcinomas in the small intestine, whereas in dogs, the tumor tends to occur in the large intestine. clinical signs of adenocarcinoma are both acute and chronic and consist of anorexia, weight loss, and progressive vomiting that occur over weeks to months. effusion may be present if metastasis to peritoneal surfaces has occurred. diagnosis is based on clinical signs and physical examination findings of a palpable abdominal mass, radiographic evidence of an abdominal mass and small or large intestinal obstruction, or ultrasonographic evidence of an intestinal mass. treatment consists of surgical resection of the affected bowel segment. the prognosis for long-term survival (10-12 months) is good if the mass is completely resected and if other clinical signs of cachexia or metastasis are observed at the time of diagnosis. median survival is 15 to 30 weeks if metastasis to lymph nodes, liver, or the peritoneum are absent at the time of diagnosis. in dogs, the prognosis is more guarded. leiomyoma and leiomyosarcoma are tumors that can cause partial or complete obstruction of the bowel. clinical signs are often referred to progressive anemia, including weakness, lethargy, inappetence, and melena. hypoglycemia can be observed as a paraneoplastic syndrome, or due to sepsis and peritonitis secondary to bowel perforation. leiomyomas are most commonly observed at the ceco-colic junction or in the cecum. surgical resection and anastomosis is usually curative, and has a favorable prognosis. incarceration of a loop of bowel into congenital or acquired defects in the body wall can cause small bowel obstruction. pregnant females and young animals with congenital hernias are most at risk. rarely, older animals with perineal hernias and animals of any age with traumatic hernias can be affected. clinical signs are consistent with a small intestinal obstruction: anorexia, vomiting, lethargy, abdominal pain, and weakness. diagnosis is often made based on physical examination of a reducible or nonreducible mass in the body wall. hernias whose contents are reducible are usually asymptomatic. treatment consists of supportive care and rehydration, administration of broad-spectrum antibiotics, and surgical correction of the body wall hernia. in some cases, intestinal resection and anastomosis of the affected area is necessary when bowel ischemia occurs. the potential for bowel perforation should be suspected whenever there is any penetrating injury (knife, gunshot wound, bite wound, stick impalement) of the abdomen. injuries that result in bowel ischemia and rupture can also occur secondary to nonpenetrating blunt 170 1 emergency care trauma or shear forces (e.g., big dog-little dog/cat). perforation of the stomach and small and large intestines can occur with use of nonsteroidal antiinflammatory drugs. diagnosis of bowel perforation first depends on the alertness to the possibility that the bowel may have been perforated or penetrated. as a general rule, all penetrating injuries of the abdomen should be investigated by exploratory laparotomy. diagnostic peritoneal lavage (dpl) can be performed; however, early after penetrating injury of the bowel, dpl may be negative or nondiagnostic until peritonitis develops. whenever any patient with blunt or penetrating abdominal trauma does not respond to initial fluid therapy, or responds and then deteriorates, the index of suspicion for bowel injury should be raised. the findings of pneumoperitoneum on abdominal radiographs or of intracellular bacteria, extracellular bacteria, bile pigment, bowel contents, and cloudy appearance of fluid obtained by abdominocentesis or diagnostic peritoneal lavage fluid (see sections on abdominocentesis and diagnostic peritoneal lavage) warrant immediate surgical exploration. treatment largely consists of stabilizing the patient's cardiovascular and electrolyte status with intravenous fluids, administration of broad-spectrum antibiotics, and definitive surgical exploration and repair of injured structures. prolapse of the rectum is observed most frequently secondary to parasitism and gastrointestinal viral infections in young puppies and kittens with chronic diarrhea. older animals with rectal prolapse often have an underlying problem such as a tumor or mucosal lesion that causes straining and dyschezia. the diagnosis of a rectal prolapse is made based on physical examination findings. the diagnosis of rectal prolapse is sometimes difficult to distinguish from small intestinal intussusception. in rare cases, the intussusception can invaginate through the large bowel, rectum, and anus. the two entities are distinguished from one another by inserting a lubricated thermometer or blunt probe into the cul-de-sac formed by the junction of the prolapsed mucosa and mucocutaneous junction at the anal ring. inability to insert the probe or thermometer indicates that the rectal mucosa is prolapsed. passage of the probe signifies that the prolapsed segment is actually the intussusceptum. treatment can be performed easily if the prolapse is acute and the rectal mucosa is not too irritated or edematous. the presence of severely necrotic tissue warrants surgical intervention. to reduce an acute rectal prolapse, after placing the patient under general anesthesia, lubricate the prolapsed tissue and gently push it back into the rectum, using a lubricated syringe or syringe casing. apply a loose purse-string suture, leaving it in place for a minimum of 48 hours. de-worm the patient and administer stool softeners. if a rectal prolapse cannot be reduced, or if the tissue is nonviable, surgical intervention is warranted. in patients in which viable tissue does not stay reduced with a purse-string suture, a colopexy can be performed during a laparotomy. first, place tension on the colon to reduce the prolapse, and then suture the colon to the peritoneum of the lateral abdominal wall with two to three rows of 2-0 or 3-0 monofilament suture material. if the prolapsed tissue is nonviable, it must be amputated. place four stay sutures at 90-degree intervals through the wall of the prolapse at the mucocutaneous junction. resect the prolapse distal to the stay sutures and then reestablish the rectal continuity by suturing the seromuscular layers together in one circumferential line and the mucosal layers together in the other. replace the suture incision into the anal canal. following surgery, de-worm the patient and administer a stool softener and analgesic drugs. avoid using thermometers or other probes in the immediate postoperative period because they may disrupt suture lines. acute gastritis may be associated with a variety of clinical conditions, including oral hemorrhage, ingestion of highly fermentable nondigestable foods or garbage, toxins, foreign bodies, renal or hepatic failure, inflammatory bowel disease, and bacterial and viral infections. diarrhea often accompanies or follows acute gastritis. hemorrhagic gastroenteritis often occurs as a shock-like syndrome with a rapidly rising hematocrit level. clinical signs of gastritis include depression, lethargy, anterior abdominal pain, excessive water consumption, vomiting, and dehydration. differential diagnosis of acute gastritis includes pancreatitis, hepatic or renal failure, gastrointestinal obstruction, and toxicities (box 1-44). the diagnosis is often a diagnosis of exclusion of other causes (see preceding text). a careful and thorough examination of the vomitus may be helpful in arriving at a diagnosis. a complete blood count, serum biochemistry profile including amylase and lipase, parvovirus test (in young puppies), fecal flotation and cytology, abdominal radiographs (plain and/or contrast studies), and abdominal ultrasound may be warranted to rule out other causes of acute vomiting. while diagnostic tests are being performed, treatment consists of withholding all food and water for a minimum of 24 hours. after calculating the patient's degree of dehydration, administer a balanced crystalloid fluid to normalize acid-base and electrolyte status. control vomiting with antiemetics such as metoclopramide, prochlorperazine, chlorpromazine, dolasetron, and ondansetron (table 1-37). if vomiting is accompanied by diarrhea, administer broad-spectrum antibiotics (cefazolin, 22 mg/kg iv q8h, with metronidazole, 10 mg/kg iv q8h; or ampicillin, 22 mg/kg iv q6h, with enrofloxacin, 10 mg/kg iv q24h) to decrease the risk of bacterial translocation and bacteremia/septicemia. although antacids (famotidine, ranitidine, cimetidine) do not have a direct antiemetic effect, their use can decrease gastric acidity and esophageal irritation during vomiting. if gastritis is secondary to uremia or nonsteroidal antiinflammatory drug use, administer gastroprotectant and antiemetic drugs (ranitidine, 1 mg/kg po q12h; sucralfate, 0.25-1 g/dog po q8h; or omeprazole (0.5-1 mg/kg po q24h) to decrease acid secretion and coat areas of gastric ulceration (table 1 -37) . once food and water can be tolerated, the patient can be placed on an oral diet and medications, and intravenous fluids can be discontinued. do not use until a gastrointestinal obstruction has been ruled out. hemorrhagic gastroenteritis (hge) is an acute onset of severe hemorrhagic vomiting and diarrhea most commonly observed in young small-breed dogs (e.g., poodles, miniature dachshunds, miniature schnauzers) 2 to 4 years of age. clinical signs develop rapidly and include vomiting and fetid diarrhea with hemorrhage, often strawberry jam-like in appearance. the hematocrit can rise from 55% to 75%. often, the animal is extremely hypovolemic but has no apparent signs of abdominal pain. there is no known cause of hge, although clostridium perfringens, escherichia coli, campylobacter, and viral infections have been suggested but not consistently confirmed. other differential diagnoses of of hematemesis and hemorrhagic diarrhea include coronavirus, parvovirus, vascular stasis, sepsis, hepatic cirrhosis with portal hypertension, and other causes of severe shock. immediate treatment consists of placement of a large-bore intravenous catheter and replenishment of intravascular fluid volume with crystalloid fluids (up to 90 ml/kg/hour), while carefully monitoring the patient's hematocrit and total protein. administer broad-spectrum antibiotics (ampicillin, 22 mg/kg iv q6h, and enrofloxacin 10 mg/kg iv q24h) because of the high risk of bacterial translocation and sepsis. control vomiting with antiemetic drugs. monitor the patient's platelet count and coagulation tests for impending disseminated intravascular coagulation (dic), and administer fresh frozen plasma and heparin, as needed (see section on disseminated intravascular coagulation). when vomiting has ceased for 24 hours, offer the animal small amounts of water, and then a bland diet (e.g., boiled chicken and rice or boiled ground beef and rice mixed with low-fat cottage cheese). pancreatitis occurs most frequently in dogs but can occur in cats as well. in dogs, the onset of pancreatitis is sometimes preceded by ingestion of a fatty meal or the administration of drugs (e.g., potassium bromide or glucocorticoids). glucocorticoids can increase the viscosity of pancreatic secretions and induce ductal proliferation, resulting in narrowing and obstruction of the lumen of the pancreatic duct. pancreatitis can also occur following blunt or penetrating abdominal trauma, high duodenal obstruction causing outflow obstruction of the pancreatic papilla, pancreatic ischemia, duodenal reflux, biliary disease, and hyperadrenocorticism. in cats, acute necrotizing pancreatitis is associated with anorexia, lethargy, hyperglycemia, icterus, and sometimes acute death. chronic pancreatitis is more common in cats and results in intermittent vomiting, anorexia, weight loss, and lethargy. predisposing causes of chronic pancreatitis in cats include pancreatic flukes, viral infection, hepatic lipidosis, drugs, organophosphate toxicity, and toxoplasmosis. clinical signs of acute pancreatitis include sudden severe vomiting, abdominal pain, and lethargy. depending on the severity of pancreatic inflammation, depression, hypotension, and systemic inflammatory response syndrome (sirs) may be present. subacute cases may have minimal clinical signs. severe pancreatic edema can result in vascular changes and ischemia that perpetuates severe inflammation. hypovolemic shock and dic can also decrease pancreatic perfusion. severe pancreatic edema, autolysis, and ischemia lead to pancreatic necrosis. duodenal irritation is manifested as both vomiting and diarrhea. pain may be localized to the right upper abdominal quadrant or may be generalized if peripancreatic saponification occurs. differential diagnosis of pancreatitis is the same as for any other cause of vomiting. complications that occur in patients with severe pancreatitis include dehydration, acidbase and electrolyte abnormalities, hyperlipemia, hypotension, and localized peritonitis. hepatic necrosis, lipidosis, congestion, and abnormal architecture can develop. inflammatory mediators (bradykinin, phospholipase a, elastase, myocardial depressant factor, and bacterial endotoxins) stimulate the inflammatory cascade and can lead to sirs, with severe hypotension, clotting system activation, and dic. electrolyte imbalances and hypovolemia secondary to vomiting all can lead to multiple organ dysfunction syndrome (mods), and ultimately, death. if a patient survives an episode of acute pancreatitis, long-term sequelae can include diabetes mellitus. monitor patients with recurrent pancreatitis for clinical signs of polyuria, polydipsia, polyphagia, hyperglycemia, and glucosuria. the diagnosis of pancreatitis is based on the presence of clinical signs (which may be absent in cats), laboratory findings, and ultrasonographic evidence of pancreatic edema and increased peripancreatic echogenicity. serum biochemistry analyses can sometimes support a diagnosis of pancreatitis; however, serum amylase and lipase are often unreliable indicators of pancreatitis, depending on the chronicity of the process in the individual patient. both serum amylase and lipase are excreted in the urine. impaired renal clearance/ function can cause artifactual elevations of serum amylase and lipase in the absence of pancreatic inflammation. furthermore, serum lipase levels can be elevated as a result of gastrointestinal obstruction (e.g., foreign body). early in the course of the disease, levels can be two to six times normal, but they may decrease to within normal ranges at the time of presentation to the veterinarian. the transient nature of amylase elevation makes this test difficult to interpret, and it is not highly sensitive if a normal value is found. lipase levels also increase later in the course of the disease. amylase and lipase should be tested concurrently with the rest of the biochemistry profile. other changes often observed are elevations in bun and creatinine levels secondary to dehydration and prerenal azotemia, hyperglycemia, and hyperlipemia. hypocalcemia can occur secondary to peripancreatic fat saponification, and its presence warrants a more negative prognosis. a more specific measure is pancreatic lipase immunoreactivity, which becomes elevated in dogs and cats with pancreatitis. this test, combined with ultrasonographic or computed tomography evidence of pancreatitis, is the most sensitive and specific test available for making an accurate diagnosis. however, because the results of this test take time to obtain, animals must be treated in the meantime. abdominal effusion or fluid from diagnostic peritoneal lavage can be compared with serum amylase and lipase activity. abdominal lipase and amylase concentrations in the fluid greater than that in the peripheral blood are characteristic of chemical peritonitis associated with pancreatitis. wbc counts greater than 1000 cells/mm 3 , the presence of bacteria, toxic neutrophils, glucose levels less than 50 mg/dl, or lactate levels greater than that of serum are characteristic of septic peritonitis, and immediate exploratory laparotomy is warranted. if a biopsy sample obtained during laparotomy does not demonstrate inflammation, but this does not rule out pancreatitis, because disease can be focal in nature and yet cause severe clinical signs. abdominal radiographs may sometimes reveal a loss of abdominal detail or a ground glass appearance in the right upper quadrant. pancreatic edema and duodenal irritation can displace the gastric axis toward the left, toward the left with dorsomedial displacement of the proximal duodenum (the so-called "backwards 7" or "shepherd's crook" sign). ultrasonography and ct are more sensitive in making a diagnosis of pancreatitis. treatment of pancreatitis is largely supportive in nature and is designed to correct hypovolemia and electrolyte imbalances, prevent or reverse shock, maintain vital organ perfusion, alleviate discomfort and pain, and prevent vomiting (see section on rule of twenty). when treating pancreatitis in dogs, all food and water should be restricted. however, food should not be withheld from cats with chronic pancreatitis. give fresh frozen plasma to replenish alpha-2-macroglobulins. administer antiemetics such as chlorpromazine (use with caution in a hypovolemic or hypotensive patient), dolasetron, ondansetron, or metoclopramide to prevent or control vomiting. analgesic drugs can be provided in the form of constant rate infusion (fentanyl, 3-7 âµ/kg/hour iv cri, and lidocaine, 30-50 âµ/kg/minute iv cri), intrapleural injection (lidocaine, 1-2 mg/kg q8h), or intermittent parenteral injections (morphine, 0.25-1 mg/kg sq, im; hydromorphone, 0.1 mg/kg im or sq). because the pancreas must be rested, consider using parenteral nutrition. acute hepatic failure may be associated with toxins, adverse reaction to prescription medication, and bacterial or viral infections. the most frequent clinical signs observed in a patient with acute hepatic failure are anorexia, lethargy, vomiting, icterus, bleeding, and cns depression or seizures (associated with hepatic encephalopathy). differential diagnosis and causes of acute hepatic failure are listed in box 1-45. diagnosis of acute hepatic failure is based on clinical signs and biochemical evidence of hepatocellular (ast, alt) and cholestatic (alk phos, t bili, ggt) enzyme elevations. ultrasonography may be helpful in distinguishing the architecture of the liver, but unless a mass or abscess is present, cannot provide a specific diagnosis of the cause of the hepatic damage. management of the patient with acute hepatic failure includes correction of dehydration and acid-base and electrolyte abnormalities, as shown in the following list: â�¢ hypoalbuminemia: plasma or concentrated albumin. plasma also is an excellent source of clotting factors that can become depleted. â�¢ clotting abnormalities: vitamin k 1 (2.5 mg/kg sq or po q8-12h) to â�¢ severe anemia: fresh or stored blood â�¢ gastric hemorrhage: gastroprotectant drugs (omeprazole, ranitidine, famotidine, cimetidine, sucralfate) â�¢ hypoglycemia: dextrose supplementation (2.5%-5%) â�¢ hepatic failure, particularly when hypoglycemia is present: broad-spectrum antibiotics (ampicillin 22 mg/kg iv q6h; with enrofloxacin, 5 mg/kg iv q24h) â�¢ hepatic encephalopathy: lactulose or betadine enemas â�¢ cerebral edema: mannitol (0.5-1.0 g/kg iv over 10 to 15 minutes) followed by furosemide (1 mg/kg iv 20 minutes later). deterioration of clinical signs may signify the development of cerebral edema. applewhite aa, cornell kk, selcer ba: diagnosis and treatment of intussusception in dogs. comp cont educ pract vet 24 (2) often, systemic hypertension is diagnosed when the animal is seen by the veterinarian because of some other clinical sign, such as acute blindness, retinal detachment, hyphema, epistaxis, and cns signs following intracranial hemorrhage. diagnosis of systemic hypertension is often difficult in the absence of clinical signs and without performing invasive or noninvasive blood pressure monitoring. normal blood pressure (bp) measurements in dogs and cats are listed in table 1-38. hypertension is defined as a consistent elevation in systolic bp >200 mm hg, consistent diastolic bp >110 mm hg, and consistent mean arterial blood pressure >130 mm hg. the effects of systemic hypertension include left ventricular hypertrophy, cerebrovascular accident, renal vascular injury, optic nerve edema, hyphema, retinal vascular tortuosity, retinal hemorrhage, retinal detachment, vomiting, neurologic defects, coma, and excessive bleeding from cut surfaces. 176 1 emergency care dog 100-160 80-120 90-120 cat 120-150 70-130 100-150 patients with systemic hypertension should have a thorough diagnostic work-up to determine the underlying cause. although uncommon, hypertensive emergencies can occur with pheochromocytoma, acute renal failure, and acute glomerulonephritis. sodium nitroprusside (1-10 âµ/kg/minute iv cri) or diltiazem (0.3-0.5 mg/kg iv given slowly over 10 minutes, followed by 15 âµ/kg/minute) can be used to treat systemic hypertension. with the use of sodium nitroprusside or diltiazem, monitor carefully for hypotension. diagnosis is based on consistent elevations in systolic, diastolic, and/or mean arterial bp. because many of the clinical signs associated with systemic hypertension involve hemorrhage into some closed cavity, other causes of hemorrhage, such as vasculitis, thrombocytopenia, thrombocytopathia, and hepatic or renal failure, should be investigated (see section on coagulation disorders). diagnostic testing is based on clinical signs and index of suspicion for an underlying disease and may include a complete blood count; urinalysis; urine protein:creatinine ratio; acth stimulation test; thoracic and abdominal radiographs; thoracic and abdominal ultrasound; tick serology; brain ct or mri; and assays of serum electrolytes, aldosterone concentration, t4, endogenous tsh, plasma catecholamine, and growth hormone. management of systemic hypertension involves treatment of the primary underlying disorder, whenever possible. long-term adjunctive management includes sodium restriction in the form of cooked or prescription diets to decrease fluid retention. obese animals should be placed on dietary restrictions and undergo a weight reduction program. thiazide and loop diuretics may be used to decrease sodium retention and circulating blood volume. alpha-and beta-adrenergic blockers may be used, but they are largely ineffective as monotherapeutic agents for treating hypertension. calcium channel blockers and angiotensin-converting enzyme (ace) inhibitors are the mainstay of therapy in the treatment of hypertension in dogs and cats ( diabetic ketoacidosis (dka) is a potentially fatal and terminal consequence of unregulated insulin deficiency and possible glucagon excess. in the absence of insulin, unregulated lipolysis results in the beta-hydroxylation of fatty acids by abnormal hepatic metabolism. as a result, ketoacids-namely, acetoacetic acid, beta-hydroxybutyric acid, and acetoneare produced. early in the course of the disease, patients exhibit clinical signs associated with diabetes mellitus: weight loss, polyuria, polyphagia, and polydipsia. later, as ketoacids stimulate the chemoreceptor trigger zone, vomiting and dehydration occur, with resulting hypovolemia, hypotension, severe depression, abdominal pain, oliguria, and coma. at the time of presentation, often a strong odor of ketones (acetone) is present on the patient's breath. physical examination often reveals dehydration, severe depression or coma, and hypovolemic shock. in extreme cases, the patient exhibits a slow, deep kussmaul respiratory pattern in an attempt to blow off excess co 2 to compensate for the metabolic acidosis. a serum biochemistry profile and complete blood count often reveal prerenal azotemia, severe hyperglycemia (blood glucose >400 mg/dl), hyperosmolarity (>330 mosm/kg), lipemia, hypernatremia (sodium >145 meq/l), elevated hepatocellular and cholestatic enzyme activities, high anion gap, and metabolic acidosis. although a whole body potassium deficit is usually present, the serum potassium may appear artifactually elevated in response to metabolic acidosis. with severe metabolic acidosis, potassium moves extracellularly in exchange for a hydrogen ion. phosphorus too moves intracellularly in response to acidosis, and serum phosphorus is usually decreased. hypophosphatemia >2 mg/dl can result in intravascular hemolysis. urinalysis often reveals 4+ glucosuria, ketonuria, and a specific gravity of 1.030 or greater. the urine of all diabetic animals should be cultured to rule out a urinary tract infection or pyelonephritis. treatment of a patient with dka presents a therapeutic challenge. treatment is aimed at providing adequate insulin to normalize cellular glucose metabolism, correcting acidbase and electrolyte imbalances, rehydration and restoration of perfusion, correcting acidosis, providing carbohydrate sources for utilization during insulin administration, and identifying any precipitating cause of the dka. obtain blood samples for a complete blood count, and serum biochemistry electrolyte profiles. whenever possible, insert a central venous catheter for fluid infusion and procurement of repeat blood samples. calculate the patient's dehydration deficit and maintenance fluid requirements and give appropriate fluid and electrolytes over a period of 24 hours. it is advisable to rehydrate patients with severe hyperosmolarity for a minimum of 6 hours before starting insulin administration. use a balanced electrolyte solution (e.g., plasmalyte-m, normosol-r, lactated ringer's solution) or 0.9% saline solution for maintenance and rehydration. balanced electrolyte solutions contain small amounts of potassium and bicarbonate precursors that aid in the treatment of metabolic acidosis. treat animals with severe metabolic acidosis with an hco 3 â�� >11 meq/l or a ph <7.1 with supplemental bicarbonate (0.25-0.5 meq/kg). add supplemental dextrose to the patient's fluids as a carbohydrate source during insulin infusion. both insulin and carbohydrates are necessary for the proper metabolism of ketone bodies in patients with dka. the rate and type of fluid and amount of dextrose supplementation will change according to the patient's blood glucose concentration. serum potassium will drop rapidly as the metabolic acidosis is corrected with fluid and insulin administration. measure serum potassium every 8 hours, if possible, and supplement accordingly (see section on fluid therapy for chart of potassium supplementation). if the patient's potassium requirement exceeds 100 meq/l, or if the rate of potassium infusion approaches 0.5 meq/ kg/hour in the face of continued hypokalemia, magnesium should be supplemented. magnesium is required as a cofactor for many enzymatic processes and for normal function of the na,k-atpase pump. hypomagnesemia is a common electrolyte disturbance in many forms of critical illness. replenishing magnesium (mgcl 2 , 0.75 meq/kg/day iv cri) often helps to correct the refractory hypokalemia observed in patients with dka. patients with hypophosphatemia that approaches 2.0 mmol/l should receive potassium phosphate (0.01-0.03 mmol/kg/hour iv cri). when providing potassium phosphate supplementation, be aware of the additional potassium added to the patient's fluids, so as to not exceed recommended rates of potassium infusion. to determine the amount of potassium chloride (kcl) to add along with potassium phosphate (kpo 4 ), use the following formula: meq k + derived from kcl = total meq of k + to be administered over 24 hours â�� meq in which k + is derived from kpo 4 clinical signs of severe hypophosphatemia include muscle weakness, rhabdomyolysis, intravascular hemolysis, and decreased cerebral function that can lead to depression, stupor, seizures, or coma. regular insulin can be administered either im or as a constant rate infusion in the treatment of patients with dka. subcutaneous insulin should not be administered. because of the severe dehydration present in most patients with dka, subcutaneous insulin is poorly absorbed and is not effective until hydration has been restored. in the low-dose intravenous method, place regular insulin (1.1 units/kg for a cat, and 2.2 units/kg for a dog) in 250 ml of 0.9% saline solution. run 50 ml of this mixture through the intravenous line to allow the insulin to adsorb to the plastic tubing. administer the patient's insulin fluid rate according to blood glucose levels ( table 1 -40) . adjust the patient's total fluid volume according to changes in the insulin fluid rate as necessary. in many cases, multiple bags of fluids are necessary because they must be changed when fluctuations in blood glucose concentrations occur in response to therapy. infusion of the insulin mixture should be in a separate intravenous catheter. to replenish hydration, use a second intravenous line for the more rapid infusion of non-insulin-containing fluids. to administer the regular insulin im, first give 0.22 unit/kg im and then re-check the patient's blood glucose every hour. additional injections of regular insulin (0.11 unit/kg other fluid type (ml/hour) >250 10 0.9% nacl 200-250 7 0.45% nacl + 2.5% dextrose 150-200 5 0.45% nacl + 2.5% dextrose 100-150 5 0.45% nacl + 2.5% dextrose <100 0 0.45% nacl + 5% dextrose im) should be administered based on the patient's response to subsequent injections. once the patient's blood glucose falls to 200 to 250 mg/dl, add 2.5% to 5% dextrose to the fluids to maintain the blood glucose concentration at 200 to 300 mg/dl. continue intramuscular injection of regular insulin (0.1-0.4 unit/kg q4-6h) until the patient is rehydrated, no longer vomiting, and able to tolerate oral fluids and food without vomiting. even in patients with intramuscular regular insulin therapy, a central venous catheter should be placed for frequent blood sample collection. as the patient begins to respond to therapy, monitor electrolytes, glucose, and acid-base status carefully. hypokalemia, hypophosphatemia, and hypomagnesemia can occur. when the patient's hydration and acid-base status has normalized and the patient is able to tolerate oral food and water, a longer-acting insulin can be administered as for treatment of a patient with uncomplicated diabetes. extreme hyperosmolarity can result in a coma, if uncorrected. in patients with diabetes mellitus, hyperglycemia and hypernatremia secondary to osmotic diuresis and free water loss can lead to severe hyperosmolarity. in dogs, normal serum osmolality is <300 mosm/l of serum. hyperosmolarity is expected when serum osmolality is >340 mosm/l. if equipment for determining serum osmolarity is not available, osmolarity can be calculated by the following formula: osm/l = 2(na + k) + (glucose/18) + (bun/2.8) patients with severe dehydration, hyperglycemia, hypernatremia, and azotemia may experience cerebral edema without ketonemia. treatment is directed solely at rehydrating the patient and slowly reducing blood glucose levels using a hypotonic solution such as 0.45% nacl + 2.5% dextrose or 5% dextrose in water (d 5 w). after the initial rehydration period, administer potassium supplementation conservatively. red blood cells and the brain absolutely depend on the oxidation of glucose for energy. hypoglycemia can be caused by various systemic abnormalities that can be related to intestinal malabsorption of nutrients, impaired hepatic glycogenolysis or gluconeogenesis, and inadequate peripheral utilization of glucose. clinical signs of hypoglycemia are extremely variable and can include weakness, tremors, nervousness, polyphagia, ataxia, tachycardia, muscle twitching, incoordination, visual disturbances, and generalized seizures. clinical signs typically occur when serum glucose levels are <60 mg/dl. the combination of the clinical signs listed previously, documentation of low serum glucose, and alleviation of clinical signs upon glucose administration is known as whipple's triad. whenever a patient presents with hypoglycemia, consider the following important factors: the age of onset, the nature of the hypoglycemic episode (transient, persisent, or recurrent) , and the pattern based on the patient's history . treatment of hypoglycemia is directed at providing glucose supplementation and determining any underlying cause. administer supplemental dextrose (25%-50% dextrose, 2-5 ml/kg iv; or 10% dextrose, 20 ml/kg po) as quickly as possible. do not attempt oral glucose supplementation in any patient having a seizure or if the airway cannot be protected. administer intravenous fluids (e.g., normosol-r, lactated ringer's solution, 0.9% saline solution) with 2.5%-5% supplemental dextrose until the patient is eating and able to maintain euglycemia without supplementation. in some cases (e.g., insulinoma), eating or administration of supplemental dextrose can promote insulin secretion and exacerbate clinical signs and hypoglycemia. in cases of refractory hypoglycemia secondary to iatrogenic insulin overdose, glucagon (50 mg/kg iv bolus, then 10-40 ng/kg/minute iv cri) can also be administered along with supplemental dextrose. to make a glucagon infusion of 1000 ng/ml, reconstitute 1 ml (1 mg/ml) of glucagon according to the manufacturer's instructions and add this amount to 1000 ml of 0.9% saline solution. 1 emergency care the diagnosis of eclampsia (puerperal tetany) is often made on the basis of history and clinical signs. clinical signs can become evident when total calcium decreases to <8.0 mg/dl in dogs and <7.0 mg/dl in cats. the disease is often observed in small, excitable dogs, and stress may play a complicating role in the etiology. in most bitches, the disease manifests itself 1 to 3 weeks after parturition. in some cases, however, clinical signs can develop before parturition occurs. hypophosphatemia may accompany hypocalcemia. clinical signs of hypocalcemia include muscle tremors or fasciculations, panting, restlessness, aggression, hypersensitivity, disorientation, muscle cramping, hyperthermia, stiff gait, seizures, tachycardia, a prolonged qt interval on ecg, polydipsia, polyuria, and respiratory arrest. treatment of eclampsia consists of slow, cautious calcium supplementation (10% calcium gluconate, 0.15 mg/kg iv over 30 minutes). severe refractory tetanus can be controlled with intravenous diazepam. supportive care includes intravenous fluid administration and cooling (see section on hyperthermia and heat-induced illness). instruct the owner to give the patient oral calcium supplements (e.g., 1 to 2 tablets of tums bid-tid) after discharge from the hospital. also instruct the owner about how to wean the puppies, allowing the bitch to dry up, in order to prevent recurrence. recurrence with subsequent pregnancies is common, particularly in patients that receive calcium supplementation during gestation (table 1-41) . hypercalcemia can occur from a variety of causes. the gosh darn it mnemonic can be used to remember the various causes of hypercalcemia in small animal patients (box 1-47) . the gastrointestinal, renal, and nervous systems are most commonly affected, particularly when serum total calcium rises above 16.0 mg/dl. clinical signs of severe hypercalcemia include muscle weakness, vomiting, seizures, and coma. ecg abnormalities include prolonged pr interval, rapid qt interval, and ventricular fibrillation. the most serious clinical signs are often seen when hypercalcemia is observed in combination with hyperphosphatemia or hypokalemia. pay special attention to the "calcium ã� phosphorus product." if this product exceeds 70, dystrophic calcification can occur, leading to renal failure. renal complications include polyuria, polydipsia, dehydration, and loss of renal tubular concentrating ability. renal blood flow and the glomerular filtration rate (gfr) are impaired when serum total calcium exceeds 20 mg/dl. the extent, location, and number of renal tubular injuries are the main factors in determining whether renal damage secondary to hypercalcemia is reversible or irreversible. emergency therapy of hypercalcemia is warranted when severe renal compromise, cardiac dysfunction, or neurologic abnormalities are present, or if no clinical signs occur but the calcium ã� phosphorus product exceeds 70. the treatment of choice is correction of the underlying cause of hypercalcemia, whenever possible. in some cases, the results of diagnostic tests take time, and emergency therapy should be initiated immediately, before a definitive cause of the hypercalcemia is found. emergency management of hypercalcemia consists of reduction of serum calcium levels. administer intravenous fluids (0.9% saline solution) to expand extracellular fluid volume and promote calciuresis. to promote diuresis, initial intravenous fluid rates should approach two to three times maintenance levels (120-180 ml/kg/day). potassium supplementation may be required to prevent iatrogenic hypokalemia. administration of a loop diuretic such as furosemide (2-5 mg/kg iv) will promote calcium excretion. calcitonin (4 iu/kg im q12h for cats and 8 iu/kg im q24h for dogs) can be administered to decrease serum calcium levels. in severe refractory hypercalcemia secondary to cholecalciferol toxicity, more aggressive calcitonin therapy (4-7 iu/kg sq q6-8h) can be attempted. side effects of calcitonin treatment include vomiting and diarrhea. alternatively, bisphosphonates (pamidronate, 1.02-2.0 mg/kg iv) are useful in rapidly reducing serum calcium concentrations. glucocorticosteroids reduce calcium release from the bone, decrease intestinal absorption of calcium, and promote renal calcium excretion. administer glucocorticosteroids only after the underlying cause of hypercalcemia has been determined and appropriate therapy started. because many forms of neoplasia can result in hypercalcemia as a paraneoplastic syndrome, empiric use of glucocorticosteroids can induce multiple drug resistance, making the tumor refractory to the effects of chemotherapeutic agents. hypoadrenocorticism is most commonly observed in young to middle-aged female dogs, but it can occur in animals of any age, gender, and breed. clinical signs, which are referable to deficiency in glucocorticoid (cortisol) and mineralocorticoid (aldosterone) hormones, may develop slowly over time, leading to a waxing and waning course; acute clinical signs occur when >90% of the adrenal functional reserve has been destroyed. in such cases, complete adrenocortical collapse can result in an addisonian crisis. lack of aldosterone causes a lack of renal sodium and water retention, and impaired potassium excretion. the most significant clinical signs associated with hypoadrenocorticism are depression, lethargy, weakness, anorexia, shaking, shivering, vomiting, diarrhea, weight loss, abdominal pain, weakness, hypotension, dehydration, and inappropriate bradycardia (box 1-48) . the diagnosis of hypoadrenocorticism is made based on the patient's clinical signs in combination with electrolyte abnormalities that include hyperkalemia, hyponatremia, and hypochloremia. serum sodium concentration (115-130 meq/l) is often greatly reduced, and serum potassium is elevated (>6.0 meq/l). a sodium:potassium ratio of <27 is characteristic of hypoadrenocorticism, although not exactly pathognomonic. electrocardiographic changes associated with hyperkalemia include inappropriate bradycardia, absence of p waves, elevated spiked t waves, and widened qrs complexes. other more variable bloodwork abnormalities include a lack of a stress leukogram, eosinophilia, hypoglycemia, hyperphosphatemia, hypercalcemia, azotemia, and hypocholesterolemia. a definitive diagnosis of hypoadrenocorticism is based on an adrenocorticotropic hormone (acth) stimulation test. in patients with hypoadrenocorticism, baseline cortisol levels are usually low, with a lack of appropriate cortisol release after administration of acth analogue. rarely, animals with "atypical" hypoadrenocorticism lose glucocorticoid secreting ability from the zona fasciculata, but retain mineralocorticoid secretory ability from the zona glomerulosa. atypical addisonian patients have normal serum electrolytes but still have clinical signs of vomiting, diarrhea, weakness, lethargy, inappetence, muscle wasting, and weight loss. the diagnosis is more difficult in such cases because of the presence of normal electrolytes. an acth stimulation test should be considered, particularly in predisposed breeds. treatment of hypoadrenocorticism includes placement of a large-bore intravenous catheter, infusion of intravenous crystalloid fluids (0.9% saline solution), and replenishment of glucocorticoid and mineralocorticoid hormones. administer dexamethasone or dexamethasone-sodium phosphate (0.5-1.0 mg/kg iv). dexamethasone will not interfere with the acth stimulation test, unlike other longer-acting steroids (e.g., prednisolone, methylprednisolone sodium succinate, triamcinolone). depending on the severity of the patient's condition, consider monitoring using the rule of twenty. administer antiemetics and gastroprotectant drugs to treat nausea, vomiting, and hematemesis. give the patient broad-spectrum antibiotics (ampicillin, 22 mg/kg iv q6h) if hematochezia or hemorrhagic diarrhea is present. if severe gastrointestinal blood loss occurs, whole blood, packed red blood cells, or fresh frozen plasma may be required. control hypoglycemia with 2.5%-5.0% dextrose. use sodium bicarbonate, regular insulin with dextrose, or calcium gluconate to correct severe hyperkalemia with atrial standstill (see section on atrial standstill). chronic therapy for hypoadrenocorticism consists of mineralocorticoid and glucocorticosteroids supplementation for the rest of the animal's life. mineralocorticoid supplementation can be in the form of desoxycorticosterone pivalate (docp) (2.2 mg/kg im) or fludrocortisone acetate (0.1 mg/2.5-5 kg body weight daily). fludrocortisone acetate possesses both mineralocorticoid and glucocorticoid activities and can be used as the sole daily treatment of hypoadrenocorticism. (because fludrocortisone is poorly absorbed in some dogs, it may not completely normalize electrolyte abnormalities in these animals.) docp is primarily a mineralocorticoid. give supplemental glucocorticosteroids in the form of prednis(ol)one (1-0.25 mg/kg/day). in dogs, iatrogenic hypoadrenocorticism can be caused by abrupt discontinuation of glucocorticosteroid treatment. long-term glucocorticosteroid supplementation can downregulate the pituitary gland's excretion of endogenous acth and the zona fasciculata's ability to excrete cortisol. however, the zona glomerulosa's ability to secrete aldosterone does not appear to be affected. clinical signs of iatrogenic hypoadrenocorticism include inability to compensate for stress, weakness, lethargy, vomiting, diarrhea, and collapse. treatment of iatrogenic hypoadrenocorticism is the same as for naturally occurring disease. following immediate emergency treatment, the patient should be weaned slowly from exogenous glucocorticosteroid supplementation. severe hyperthyroidism can manifest as a medical emergency as a result of hypermetabolism. clinical signs in affected cats with severe thyrotoxicosis include fever, severe tachycardia (heart rate >240 bpm), vomiting, hypertension, congestive heart failure with pulmonary edema, and fulminant collapse. clinical signs typically are manifested as an end-stage of chronic debilitation associated with hyperthyroidism and are often preceded by polyphagia, weight loss, cardiac murmur, polyuria/polydipsia (pu/pd), vomiting, and diarrhea. treatment of thyrotoxicosis includes antagonizing the adrenergic activity by administration of a beta-adrenergic blocker (esmolol, (25-50 âµ/kg/minute, or propranolol, 0.02 mg/ kg/hour). administration of glucocorticosteroids (dexamethasone, 1 mg/kg) may inhibit the conversion of thyroxine (t 4 ) to the active form triiodothyronine (t 3 ) and decrease peripheral tissue responsiveness to t 3 , effectively blocking its effects. correct hypoglycemia with supplemental dextrose (2.5%). use care to avoid overhydration in a patient with cardiac failure or insufficiency. start the patient on methimazole as quickly as possible and consider the use of radioactive iodine therapy. to maintain cerebral perfusion pressure, blood pressure must be normalized. if other concurrent injuries are suspected (e.g., pulmonary contusions), administer synthetic colloid fluids (dextran-70, 5-10 ml/kg iv, or hetastarch, 5-10 ml/kg iv) to normalize blood pressure. although the use of colloids is controversial because of their potential to leak into the calvarium, the benefits of reestablishing cerebral perfusion far outweigh the risks of their use. hypertonic saline (7.5% nacl, 3-5 ml/kg iv) can also be administered over 10 to 15 minutes to expand intravascular volume. maintain blood glucose within normal reference ranges whenever possible, because hyperglycemia is a negative prognostic indicator in cases of head trauma. if tremors or seizures cause hyperthermia or increased metabolism, active cooling of the patient is warranted (see sections on hyperthermia and heat-induced injury). all patients with head trauma should receive care and monitoring based on the rule of twenty (see section on rule of twenty). examine the patient's level of consciousness, response to various stimuli, pupil size and reactivity to light, physiologic nystagmus, and cranial nerve deficits. in dogs, damage to the midbrain often produces coma and decerebrate rigidity. initial consciousness followed by a unconsciousness or stupor usually involves an injury to the brainstem. brainstem lesions can be caused by compressive skull fractures, extradural or subdural hematomas, or herniation through the foramen magnum from cerebral edema (box 1-49) . the patient's pupil size and response to light can be used to localize a diagnosis and give a rough prognosis for severity of disease and possibility for return to function. pupils can be normal in size, mydriatic, or miotic. whenever a pupil appears miotic, direct ocular 186 1 emergency care unconscious with no response to noxious stimuli injury with uveitis or secondary miosis due to brachial plexus injury should be ruled out. the eyes should always be examined to rule out ocular trauma. in a patient with head trauma, a change from dilated to constricted to normal pupil size is suggestive of improvement in clinical function. bilateral mydriatic pupils that are unresponsive to light in an unconscious animal are a grave prognostic sign and usually indicate an irreversible severe midbrain contusion. bilateral miotic pupils with normal nystagmus and ocular movements are associated with diffuse cerebral or diencephalic lesions. miotic pupils that become mydriatic indicate a progressive midbrain lesion with a poor prognosis. unilateral, slowly progressive pupillary abnormalities in the absence of direct ocular injury are characteristic of brainstem compression or herniation caused by progressive brain swelling. asymmetric pupils are seen in patients with rostral brainstem lesions and can change rapidly. unresponsive pupils that are seen in the midposition occur with brainstem lesions that extend into the medulla and are a grave sign. visual deficits are common with intracranial injury. lesions that are less severe and limited to the cerebrum produce contralateral menace deficits with normal pupillary light response. bilateral cerebral edema can cause blindness with a normal response to light if the midbrain is not disturbed. a patient that is severely depressed and recumbent may not respond to menacing gestures, even when visual pathways are intact. ocular, optic tract, optic nerve, or optic chiasm lesions can interfere with vision and the pupillary light response. brainstem contusion and cerebral edema may produce blindness and dilated unresponsive pupils due to disturbance of the oculomotor area. examine all cranial nerves carefully. cranial nerve abnormalities can indicate direct contusion or laceration of the neurons in the brainstem or where they exit the skull. cranial nerves that are initially normal then later lose function indicate a progressively expanding lesion. when specific cranial nerve deficits are present, the prognosis is considered guarded. clinical signs such as rolling to one side, torticollis, head tilt, and abnormal nystagmus are usually associated with petrosal bone or cerebellomedullary lesions that produce vestibular neuron dysfunction. fractures of the petrosal temporal bone often cause hemorrhage and cerebrospinal fluid (csf) leak from the external ear canal. if the lesion is limited to the membranous labyrinth, the loss of balance will be toward the injured side and the quick phase of the nystagmus will be toward the injured side. normal physiologic nystagmus requires that the pathway is between the peripheral vestibular neurons and the pontomedullary vestibular nuclei to the nuclei of the cranial nerves that innervate the extraocular muscles (iii, iv, vi). severe brainstem lesions disrupt this pathway. disruption of the pathway is manifested as an inability to produce normal physiologic nystagmus by moving the patient's head from side to side. in patients with severe central nervous system depression, this reflex may not be observed. next, assess postural changes and motor function abilities. a loss of the normal oculocephalic ("dolls-eye") reflex is an early sign of brainstem hemorrhage and a late sign of brainstem compression and herniation. any intracranial injury may be accompanied by a concurrent cervical spinal cord injury. handle animals with such injuries with extreme care to avoid causing further damage. whenever there is uncertainty whether a spinal cord lesion exists, strap the patient down to a flat surface and obtain radiographs of the spine. at least two orthogonal views may be required to see fractures; however, do not manipulate the patient until radiography has been completed. crosstable views, in which the bucky is turned perpendicular to the patient's spine, with a radiograph plate secured behind the patient, may be required to minimize patient motion. in patients with cerebral lesions, hemiparesis usually resolves within 1 to 3 days. evaluation of cranial nerve function at frequent intervals may reveal an initial injury or a progressively expanding lesion in the brain. signs of vestibular disorientation, marked head tilt, and abnormal nystagmus occur with contusions of the membranous labyrinth and fracture of the petrous temporal bone. hemorrhage and cerebrospinal fluid otorrhea may be visible from the external ear canal. rolling movements indicate an injury to the cerebellar-medullary vestibular system. respiratory dysfunction and abnormal respiratory patterns are sometimes observed with severe head injury. lesions of the diencephalon produce cheyne-stokes respirations, in which the patient takes progressively larger and larger breaths, pauses, then takes progressively smaller and smaller breaths. mesencephalic lesions cause hyperventilation and can result in respiratory alkalosis. medullary lesions result in a choppy, irregular respiratory pattern. clinical signs of respiratory dysfunction in the absence of primary respiratory damage indicate a guarded prognosis. after injury, seizures may be associated with intracranial hemorrhage, trauma, or an expanding intracranial mass lesion. immediately begin medical therapy to control the seizure. administer diazepam (0.5 mg/kg iv or 0.1-0.5 mg/kg/hour iv cri) to treat seizures. if diazepam is not effective in combination with other treatments to control intracranial edema, consider giving pentobarbital . loading doses of phenobarbital (16-20 mg/kg iv divided into 4 or 5 doses, given every 20 to 30 minutes) may be beneficial in preventing further seizures. severe refractory seizures or decreased mentation may be associated with cerebral edema and increased intracranial pressure. mannitol, an osmotic diuretic, is effective at reducing cerebral edema (0.5-1.0 g/kg iv over 10 to 15 minutes). mannitol also acts as a free radical scavenger that can inhibit the effects of cerebral ischemia-reperfusion injury. mannitol works synergistically with furosemide (1 mg/kg iv given 20 minutes after the mannitol infusion). corticosteroids have not been demonstrated to be beneficial in the treatment of head trauma and may induce hyperglycemia. hyperglycemia has been shown to be a negative prognostic indicator in cases of head trauma. also, glucocorticoids can suppress immune system function and impair wound healing. because of the known risks and lack of known benefits of glucocorticosteroids, their use in treatment of head trauma is contraindicated. the prognosis for any patient with severe head trauma is guarded. management of head trauma patients may include intense nursing care for a period of weeks to months, depending on the presence and extent of concurrent injuries. if progressive loss of consciousness occurs, surgery for decompression of compressive skull injuries should be considered. the most common injury associated with head trauma in small animals is a contusion with hemorrhage in the midbrain and pons. subdural or extradural hemorrhage with space-occupying blood clots is uncommon. diagnostic tests of head trauma may include skull radiographs, ct, and mri of the brain. special studies can help detect edema and hemorrhage in the brain and brainstem, and aid in making an accurate diagnosis and prognosis. a cerebrospinal fluid tap is contraindicated in patients with head trauma because of the risk of causing a rapid decrease in intracranial pressure and brainstem herniation. if a compressive skull fracture is present, the patient should be stabilized for surgery to remove the compression. surgery to alleviate increased intracranial pressure is rarely performed in veterinary medicine because of the poor prognosis and results. in some cases, when a lesion can be localized to one area, 1-to 2-cm burr holes can be placed through the skull over the affected area of the cerebrum, exposing the underlying brain tissue. blood clots can be removed through the holes. the bone flap may or may not be replaced, depending on the surgeon's preference and the degree of brain swelling. spinal cord injuries may be associated with trauma, disk rupture, fractures, and dislocation of the spinal column. proceed with caution when moving a patient with suspected spinal cord injury. avoid flexion, extension, and torsion of the vertebral column. all animals that are unconscious following a traumatic event should be considered to have cervical or thoracolumbar spinal injury until proved otherwise by radiography, ct, or mri. the animal should be moved onto a flat surface (e.g., board, door, window, picture frame) and taped down to prevent motion and further displacement of vertebrae. sedation with analgesics or tranquilizers may be necessary to keep the animal immobile and to minimize patient motion. whenever possible, avoid the use of narcotics in patients with head trauma because of the risk of increasing intracranial pressure. as in other emergencies, the abcs 188 1 emergency care should be evaluated, and the patient treated for shock, hemorrhage, and respiratory compromise. once the cardiovascular and respiratory systems have been evaluated and stabilized, a more thorough neurologic examination can be performed. protrusion of an intervertebral disk indicates that the disk is bulging into the vertebral canal as a result of dorsal shifting of the nuclear pulposus disk material. disk extrusion refers to the rupture of the outer disk membrane and extrusion of the nuclear material into the vertebral column. in dogs and cats, there are 36 intervertebral disks that potentially can cause a problem. chondrodystrophic breeds of dogs are predisposed to endochondral ossification and include the dachshund, shih tzu, french bulldog, bassett hound, welsh corgis, american spaniel, beagle, lhasa apso, and pekingese. initial examination of the patient with suspected intervertebral disk disease includes identifying the neuroanatomic location of the lesion based on clinical signs and neurologic deficits and then establishing a prognosis. the neurologic examination should be carried out without excessive manipulation of the animal. the presence of pain, edema, hemorrhage, or a visible deformity may localize an area of vertebral injury. once an area of suspected lesion is localized based on physical examination findings, take radiographs to establish a diagnosis and to institute therapy. in most cases, the animal must receive a short-acting anesthestic for proper radiographic technique and to prevent further injury. lateral and crosstable ventrodorsal (vd) or dorsoventral (dv) radiographs require less manipulation of the animal compared with traditional vd and dv projections. myelography is often required to delineate the location of the herniated disk material. prognosis in spinal cord injury depends on the extent of the injury and the reversibility of the damage. perception of noxious stimuli, or the presence of "deep pain," by the animal when the stimulus is applied caudal to the level of the lesion is a good sign. to apply a noxious stimulus, apply firm pressure to a toe on one of the rear limbs using a thick hemostat or a pair of pliers. flexion or withdrawl of the limb is simply a local spinal reflex, and should not be perceived as a positive response to or patient perception of the noxious stimulus. turning of the head, vocalization, dilation of the pupils, change in respiratory rate or character, or attempts to bite are behaviors that are more consistent with perception of the noxious stimulus. absence of perception of the noxious stimulus ("loss of deep pain") is a very poor prognosis for return to function. focal lesions are usually associated with vertebral fractures and displacement of the vertebral canal. focal lesions in one or more of the spinal cord segments from t 3 to t 4 can cause complete dysfunction of the injured tissue as a result of concussion, contusion, or laceration. the degree of structural damage cannot be determined from the neurologic signs alone. transverse focal lesions result in paraplegia, with intact pelvic limb spinal reflexes and analgesia of the limbs and body caudal to the lesion. clinical signs in patients with spinal injury are summarized in table 1 -43. carefully evaluate the cardiovascular and respiratory status of patients with spinal injuries. immediately address specific injuries such as pneumothorax, pulmonary contusions, hypovolemic shock, and open wounds. if there is palpable or radiographic evidence of a vertebral lesion causing compressive injury, surgery is the treatment of choice unless the displacement has compromised most or all of the vertebral canal. displacements through 50% to 100% of the vertebral canal are associated with a poor prognosis, particularly if deep pain is absent caudal to the lesion. in the absence of a radiographic lesion and in the presence of continued neurologic deficits, an mri or ct scan or myelography is warranted to localize a potentially correctable lesion. surgical exploration can be considered: with the objectives of providing spinal cord decompression by hemilaminectomy or laminectomy with removal of disk material or blood clots, realign and stabilize the vertebral column, and perform a meningotomy, if necessary. place the patient on a backboard or other rigid surface, taped down for transport and sedated, to be transported to a surgical specialist. the presence of worsening or ascending clinical signs may signify ascending-descending myelomalacia and is characteristic of a very poor prognosis.in acute spinal trauma, the use of glucocorticoids has been the mainstay of therapy; however, controversy exists about whether they actually offer any benefit. traditional glucocorticosteroid therapy is listed in box 1-50. more recently, the use of propylene glycol has proved to be beneficial in the treatment of acute traumatic herniated disk. high-dose glucocorticoids should only be used for the first 48 hours after initial injury. side effects of glucocorticosteroid therapy include gastric and intestinal ulceration. the prophylactic use of gastroprotectant drugs will not prevent gastrointestinal ulcer formation; however, if signs of gastrointestinal ulcer are present, institute gastroprotectant therapy. management of the patient with spinal cord injury includes aggressive nursing care and physical therapy. many patients with spinal cord injury have little to no control over bladder function, which results in chronic dribbling or retention of urine and overdistention of the urinary bladder with overflow incontinence. urinary bladder retention can lead to urinary tract infection, bladder atony, and overflow incontinence. manual expression of the bladder several times a day may be enough to keep the bladder empty. alternatively, place a urinary catheter to maintain patient cleanliness and to keep the bladder decompressed. (see section 5 on urinary catheterization). paralytic ileus and fecal retention are frequent complications of spinal cord injury. to help prevent constipation, provide highly digestable foods and maintain the patient's hydration with oral and intravenous fluids. mild enemas or stool softeners can also be used to treat fecal retention. to prevent decubital ulcer formation, turn the patient every 4 to 6 hours, and use clean, dry, soft padded bedding. apply deep muscle massage and passive range of motion exercises to prevent disuse atrophy of the muscles and dependent edema. the radial nerve innervates the extensor muscles of the elbow, carpus, and digits. the radial nerve also supplies sensory innervation to the distal craniolateral surface of the forearm and the dorsal surface of the forepaw. injuries to the radial nerve at the level of the elbow 190 1 emergency care cranial to c6 spastic tetraplegia or tetraparesis hyperreflexive all four limbs severe injury can result in death from respiratory failure. c6-t2 tetraparesis or tetraplegia depressed thoracic limb spinal reflexes (lower motor neuron) hyperreflexive pelvic limbs (upper motor neuron) t1-t3 horner' syndrome (prolapsed nictitans, enophthalmos, and miosis) t3-l3 schiff-sherrington syndrome (extensor rigidity of thoracic limbs, flaccid paralysis with atonia, areflexia, and analgesia of pelvic limbs) result in an inability to extend the carpus and digits. as a result, the animal walks and bears weight on the dorsal surface of the paw. there is also loss of cutaneous sensation, which leads to paw injury. injuries to the radial nerve above the elbow (in the shoulder area) results in an inability to extend the elbow and bear weight on the affected limb. it can take weeks before the full extent of the injury and any return to function are manifested. the animal may need to be placed in a carpal flexion sling or have eventual amputation if distal limb injury or self-mutilation occurs. the sciatic nerve primarily innervates the caudal thigh muscles that flex the stifle and extend the hip. the tibial branch of the sciatic nerve innervates the caudal leg muscles that extend the tarsus and flex the digits. the tibial nerve provides the sole cutaneous sensory innervation to the plantar aspect of the paw and digits. the peroneal branch of the sciatic nerve provides the sole sensory cutaneous innervation to the dorsal surface of the paw ( table 1 -44) . sciatic nerve injury may occur with pelvic fractures, particularly those that involve the body of the ileum at the greater ischiatic notch, or with sacroiliac luxations that contuse the l6 and l7 spinal nerves that pass ventral to the sacrum to contribute to the sciatic nerve. with sciatic nerve injury, there is decreased stifle flexion and overflexion of the hock (tibial nerve), and the animal walks on the dorsal surface of the paw (peroneal nerve). clinical signs of tibial or peroneal damage are seen with femur fractures or with inadvertent injection of drugs into the caudal thigh muscles. the femoral nerve innervates the extensor muscles of the stifle. the saphenous branch of the femoral nerve provides the sole cutaneous innervation to an area on the medial distal thigh, the leg, and the paw. the femoral nerve is protected by muscles and is rarely injured in pelvic fractures. clinical signs of femoral nerve injury are inability to support weight on the pelvic limb, absence of a patellar reflex, and analgesia in the area of cutaneous innervation. coma is complete loss of consciousness, with no response to noxious stimuli. in some animals that present in a coma or stuporous state, the immediate cause will be apparent. in other cases, however, a careful and thorough diagnostic work-up must be performed. a coma scale devised to assist in the clinical evaluation of the comatose patient is shown in table 1 -45. whenever an animal presents in a comatose state, immediately secure the emergency management of specific conditions 191 c6-t2 nerve roots radial nerve paralysis musculocutaneous nerve inability to flex the elbow axillary or thoracodorsal dropped elbow nerve median and ulnar nerves loss of cutaneous sensation on the caudal surface of the forearm and palmar and lateral surfaces of the paw; inability to flex the carpus and digits c8-t1 nerve roots radial, median, or ulnar nerve injury c6-c7 nerve roots musculocutaneous, suprascapular, and axillary injury c7-t3 horner's syndrome (miosis, enophthalmos, and prolapsed nictitans) airway by placing an endotracheal tube (see section on endotracheal intubation). if necessary, provide respiratory assistance, or at a minimum, supplemental oxygen. control existing hemorrhage and treat shock, if present. take a careful and thorough history from the owner. make careful note of any seizure, trauma, or toxin exposure, and whether prior episodes of coma have ever occurred. perform a careful physical examination, taking note of the patient's temperature, pulse, and respiration. an elevated temperature may suggest the presence of systemic infection, such as pneumonia or hepatitis, or a brain lesion with loss of hypothalamic thermoregulatory control. very high temperatures associated with shock and coma are often observed in animals with heat stroke (see section on heat stroke and heat-induced illness). circulatory collapse or barbiturate overdose can produce coma and hypothermia. abnormal respiratory patterns also may be observed in a comatose patient. hypoventilation may occur with elevated intracranial pressure or barbiturate overdose. rapid respiratory rate may be associated with pneumonia, metabolic acidosis (dka, uremia), or brainstem injury. examine the skin for any bruises or external trauma. examine the mucous membranes and make note of color and capillary refill time. icterus with petechiae or ecchymotic hemorrhage in a comatose patient may be associated with end-stage hepatic failure and hepatic encephalopathy. smell the patient's breath for the odor of ketones that may signify dka or end-stage hepatic failure. motor activity 6 normal gait, normal spinal reflexes hemiparesis, tetraparesis, or decerebrate activity 5 recumbent, intermittent extensor rigidity 4 recumbent, constant extensor rigidity 3 recumbent, constant extensor rigidity with opisthotonus 2 recumbent, hypotonia of muscles, depressed or absent spinal reflexes 1 normal papillary reflexes and oculocephalic reflexes 6 slow pupillary light reflexes and normal to reduced oculocephalic reflexes 5 bilateral unresponsive miosis with normal to reduced oculocephalic reflexes 4 pinpoint pupils with reduced to absent oculocephalic reflexes 3 unilateral, unresponsive mydriasis with reduced to absent oculocephalic reflexes 2 bilateral, unresponsive mydriasis with reduced to absent oculocephalic reflexes 1 occasional periods of alertness and responsive to environment 6 depression of delirium, capable of responding to environment but response 5 may be inappropriate semicomatose, responsive to visual stimuli 4 semicomatose, responsive to auditory stimuli 3 semicomatose, responsive only to repeated noxious stimuli 2 comatose, unresponsive to repeated noxious stimuli 1 *neurologic function is assessed for each of the three categories and a grade of 1 to 6 is assigned according to the descriptions for each grade. the total score is the sum of the three category scores. this scale is designed to assist the clinician in evaluating the neurologic status of the craniocerebral trauma patient. as a guideline and according to clinical impressions, a consistent total score of 3 to 8 represents a grave prognosis, 9 to 14 a poor to guarded prognosis, and 15 to 18 a good prognosis. (modified from the glasgow coma scale used in humans.) from shores a: craniocerebral trauma. in kirk rw, ed: current veterinary therapy x. small animal practice. philadelphia, wb saunders, 1989, p 849. finally, conduct a complete neurologic evaluation. the presence of asymmetric neurologic signs may suggest an intracranial mass lesion (e.g., hemorrhage, neoplasia, injury). usually, toxicities or metabolic disturbances (e.g., dka, hepatic encephalopathy) cause symmetric clinical signs of neurologic dysfunction, with cerebral signs predominating. in hepatic encephalopathy, pupils are usually normal in size and responsive to light. in toxicities, the pupils are abnormal in size and may be unresponsive to light. obtain a complete blood count, serum biochemistry profile, urinalysis, and specific tests for glucosuria and ketonuria. findings of a drastically elevated blood glucose with glucosuria, ketonuria, and high specific gravity are characteristic of dka. fever and uremic encephalopathy are characterized by severe azotemia with a low urine specific gravity. if barbiturate intoxication is suspected, save urine for later toxin analysis. evaluate urine sediment for calcium oxalate crystalluria that may indicate ethylene glycol toxicity. calculate plasma osmolality (see following section) to check for nonketotic hyperosmolar diabetes mellitus. elevated blood ammonia levels may be associated with hepatic encephalopathy. in uncontrolled diabetes mellitus, hyperosmolarity can result in clinical signs of disorientation, prostration, and coma. plasma osmolarity can be calculated from the formula: mosm/l = 2(na + k) + (glucose/18) + (bun/2.8) clinical signs of hyperosmolarity can occur when the plasma osmolarity exceeds 340 mosm/l. treatment of dka or nonketotic hyperosmolar syndrome is aimed at reducing ketoacid production, stimulating carbohydrate utilization, and impeding peripheral release of fatty acids. the treatment of choice is rehydration and provision of supplemental regular insulin and a carbohydrate source (see section on diabetic ketoacidosis). during ketosis, insulin resistance may be present. slow rehydration with 0.9% saline solution or other balanced crystalloid fluids (e.g., normosol-r, plasmalyte-m, lactated ringer's solution), should occur, with the goal of rehydration over 24 to 48 hours. too rapid rehydration can result in cerebral edema and exacerbation of clinical signs. hepatic encephalopathy (he) is characterized by an abnormal mental state associated with severe hepatic insufficiency. the most common cause of he is congenital or acquired c o m a portosystemic shunts. acute hepatic destruction can also be caused by toxins, drugs, or infectious causes. the treatment of he is considered a medical emergency (table 1 -46) . absorption of ammonia and other nitrogenous substances from the gastrointestinal tract is thought to be one of the complicating factors in he. prevent absorption of ammonia and other nitrogenous substances from the gastrointestinal tract by restricting dietary protein to 15% to 20% for dogs, and to 30% to 35% (on a dry matter basis) for cats. dietary protein should be from a nonanimal plant source (e.g., soybean) whenever possible. caloric requirements are met with lipids and carbohydrates. also prescribe cleansing enemas to rid the colon of residual material, and antibiotic therapy to reduce gastrointestinal tract bacteria. neomycin (15 mg/kg q6h) can be administered as a retention enema. metronidazole (7.5 mg/kg po, q8-12h) or amoxicillin-clavulanate (16.25 mg po q12h) can also be administered. administer lactulose (2.5-5.0 ml q8h for cats; 2.5-15 ml q8h for dogs) to trap ammonia in the colon to prevent absorption (table 1 -46) . administer lactulose orally to an alert animal, or as a retention enema to a comatose animal. if lactulose is not available, betadine retention enemas will change colonic ph and prevent ammonia absorption. a side effect of lactulose administration (po) is soft to diarrheic stool. a seizure is a transient disturbance of brain function that is sudden in onset, ceases spontaneously, and has a tendency to recur, depending on the cause. most seizures are generalized and result in a loss of consciousness and severe involuntary contraction of the skeletal muscles, resulting in tonic-clonic limb activity and opisthotonus. mastication, salivation, urination, and defecation are common. partial (petit mal) seizures range from limited limb activity, facial muscle twitching, and episodic behavioral abnormalities to brief loss of consciousness. similar clinical signs also can occur with syncopal episodes. conduct a careful cardiac examination in any patient with a history of petit mal seizures. seizures of any form constitute a medical emergency, particularly when they occur in clusters, or as status epilepticus. most seizures are of short duration and may have subsided by the time the animal is presented for treatment. whenever a seizure occurs, however, it is important that the animal does not inadvertently injure itself or a bystander. it is important to evaluate whether the patient has a coexisting disease that can predispose it to seizures, such as hepatic failure, uremia, diabetes mellitus, hypoglycemia, toxin exposure, insulin-secreting tumors, and thiamine deficiency. many toxins are responsible for clinical signs of tremors or seizures (see section on poisons and toxins). treatment of a primary disease entity can help control seizures, in some cases, provided that the underlying cause is investigated and treated. status epilepticus, a state of continuous uncontrolled seizure activity, is a medical emergency. when an animal is in a state of status epilepticus, immediately place a lateral or medial saphenous intravenous catheter and administer diazepam (0.5 mg/kg iv) to help control the seizure. in most cases, the seizure must be controlled before a diagnostic workup is attempted. whenever possible, however, blood samples should be collected before administration of any anticonvulsant agent because of the risk of incorrect test results. for example, the propylene glycol carrier in diazepam can cause a false-positive ethylene glycol test using an in-house testing kit. whenever possible, check blood glucose levels, particularly in young puppies or kittens, to evaluate and treat hypoglycemia as a cause of seizures. if hypoglycemia exists, administer 25% dextrose (1 g/kg iv). if diazepam partially controls the status epilepticus, administer a constant rate infusion (0.1 mg/kg/hour in 5% dextrose in water). diazepam is sensitive to light, and the bag and infusion line must be covered to prevent degradation of the drug. if diazepam fails to control status epilepticus, give pentobarbital (3-25 mg/kg iv to effect). the animal's airway should be intubated and protected while the patient is kept in the drug-induced coma. protracted cases of seizures may require mannitol and furosemide therapy to treat cerebral edema. administer intravenous fluids (balanced crystalloid at maintenance doses [see section on intravenous fluid therapy]). the patient should be turned every 4 to 6 hours to 194 1 emergency care prevent atelectasis. insert a urinary catheter for cleanliness, and place the animal on soft dry padded bedding to prevent decubital ulcer formation. depending on the length of time that the patient is rendered unconscious, apply passive range of motion exercises and deep muscle massage to prevent disuse atrophy of the muscles and dependent or disuse edema. monitor the patient's oxygenation and ventilation status by arterial blood gas measurement or pulse oximetry and capnometry (see section 5 on blood gas, pulse oximetry, and capnometry). administer supplemental oxygen to any patient that is hypoxemic secondary to hypoventilation or other causes. severe refractory seizures can result in the development of neurogenic pulmonary edema. lubricate the animal's eyes every 4 hours to prevent drying out and corneal abrasions. depending on the cause of the seizure, administer phenobarbital at a loading dose of 16 to 20 mg/kg iv given in four to five injections, every 20 to 30 minutes; make sure that the patient is rousable in between injections). seizures in cats often are associated with structural brain disease. the occurrence of partial focal seizures is unequivocally associated with a focal cerebral lesion and acquired structural brain disease. an initial high frequency of seizures is also a strong indication that structural brain disease is present. seizure activity in cats may occur as mild generalized seizures or complex partial seizures and may be associated with systemic disorders such as feline infectious peritonitis virus, toxoplasmosis, cryptococcus infection, lymphosarcoma, meningiomas, ischemic encephalopathy, and thiamine deficiency. thiamine deficiency in the cat can be a medical emergency characterized by dilated pupils, ataxic gait, cerebellar tremor, abnormal oculocephalic reflex, and seizures. treatment consists of administration of thiamine (50 mg/day) for three days. steffen f, grasmueck s: propofol for treatment of refractory seizures in dogs and a cat with intracranial disorders. j small anim pract 41 (11) (1997) (1998) (1999) . j am vet med assoc 218 (7): [1124] [1125] [1126] [1127] [1128] [1129] 2001 . an ocular emergency is any serious condition that causes or threatens to cause severe pain, deformity, or loss of vision. treat ocular emergencies immediately, within 1 to several hours after the emergency, whenever possible (box 1-51, 1-52). to assess the location and degree of ocular injury, perform a complete ocular examination. in some cases, short-acting sedation or general anesthesia in conjunction with topical local anesthetic may be necessary to perform the examination, because of patient discomfort and blepharospasm. the equipment listed in box 1-53 may be necessary and may be invaluable in making an accurate diagnosis. to perform a systematic and thorough ocular examination, first obtain a history from the owner. has there been any prior incident of ocular disease? is there any history of trauma or known chemical irritant or exposure? did the owner attempt any irrigation or medical techniques prior to presentation? when was the problem first noticed? has it changed at all since the owner noticed the problem? after a history has been obtained, examine the patient's eyes for discharge, blepharospasm, or photophobia. if any discharge is present, note its color and consistency. do not attempt to force the eyelids open if the patient is in extreme discomfort. administer a short-acting sedative and topical local anesthetic such as 0.5% proparacaine. note the position of the globe within its orbit. if the eye is exophthalmic, strabismus and protrusion of the third eyelid are often visible. exposure keratitis may be present. in cases of retrobulbar or zygomatic salivary gland inflammation, the patient will resist opening the mouth and exhibit signs of discomfort or pain. note any swelling, contusions, abrasions, or lacerations of the eyelids. note whether the lids are able to close completely and cover the cornea. if a laceration of the lid is present, determine the depth of the laceration. palpate the orbit for fractures, swelling, pain, crepitus, and cellulitis. examine the cornea and sclera for penetrating injury or foreign material. the use of lid retractors or small forceps can be very helpful in these cases. if a wound appears to penetrate completely into the globe, look for loss of uveal tissue, lens, or vitreous. do not put any pressure on the globe, because intraocular herniation may result. examine the conjunctiva for hemorrhage, chemosis, lacerations, and foreign bodies. examine the superior and inferior conjunctival cul-de-sacs for foreign material. in such cases, placement of a topical anesthetic and use of a moistened cotton swab is invaluable to sweep the conjunctival fornix to pick up foreign bodies. use a small, fine-tipped forceps to retract the third eyelid away from the globe and examine behind the third eyelid for foreign bodies. next, examine the cornea for opacities, ulcers, foreign bodies, abrasions, or lacerations. place a small amount of fluroescein stain mixed with sterile water or saline on the dorsal sclera. close the eye to disperse the stain over the surface of the cornea, then flush gently with sterile saline irrigation. examine the cornea again for any defects. a linear defect perpendicular to the long axis of the eye should alert the clinician to investigate the conjunctiva for dystechia. record the pupil size, shape, and response to light (both direct and consensual). examine the anterior chamber and note its depth and whether hyphema or aqueous flare are present. is the lens clear and is it in the normal position? lens luxation can cause the lens tissue to touch the cornea and cause acute corneal edema. measure intraocular pressure with a schiotz tonometer or tonopen. finally, dilate the pupil and examine the posterior chamber using a direct or indirect ophthalmoscope to look for intraocular hemorrhage, retinal hemorrhage, retinal detachment, tortuous retinal vessels, optic neuritis, and inflammation. the basic surgical instruments listed in box 1-54 may be useful in the treatment of ocular lacerations and other ophthalmic injuries: bite wounds and automobile trauma commonly cause lacerations and abrasions of the lid margins. the lids can be considered to be two-layer structures, with the anterior composed of the skin and orbicularis muscle and the posterior layer composed of the tarsus and conjunctiva. the openings of the meibomian glands in the lid margin form the approximate line separating the lids into anterior and posterior segments. splitting the lid into these two segments facilitates the use of sliding skin flaps to close wound defects, if necessary. clean and thoroughly but gently irrigate the wound with sterile saline solution before attempting any lid laceration repair. use sterile saline solution to irrigate the wound and conjunctiva. a 1% povidone-iodine scrub can be used on the skin, taking care to avoid getting any scrub material in the soft tissues of the eye. drape the eye with an adhesive ocular drape, if possible, to prevent further wound contamination. trim the ragged wound edges, but be very conservative with tissue debridement. leave as much tissue as possible to insure proper wound contracture with minimal lid deformity. close a small lid wound with a figure-of-eight or two-layered simple interrupted suture of absorbable suture material or nylon in the skin. the lid margins must be absolutely apposed to prevent postoperative lid notching. direct blunt trauma to the eye can cause severe ecchymosis because of the excellent vascular supply of the eyelids. other associated ocular injuries such as orbital hemorrhage, proptosis, and corneal laceration may also occur. trauma, allergic reactions, inflammation of the sebaceous glands (hordeolum), thrombocytopenia, and vitamin k antagonist rodenticide intoxication can all cause ecchymoses of the lids. treat eyelid ecchymoses initially with cool compresses, followed by warm compresses. resorption of blood can occur from 3 to 10 days after the initial insult. ocular allergies respond well to topical application (dexamethasone ophthalmic ointment q6-8h) and systemic administration of glucocorticosteroids, along with cool compresses. in order to fully assess the conjunctiva for abnormalities, it may be necessary to carefully dissect it away from the underlying sclera. when performing this dissection, do not place undue pressure on the globe because of the risk of herniation of the intraocular contents through a scleral wound. repair large conjunctival lacerations with 6-0 absorbable sutures, using an interrupted or continuous pattern. carefully approximate the margins of the conjunctiva to prevent formation of inclusion cysts. when large areas of the conjunctiva have been damaged, advancement flaps may be required to close the defect. subconjunctival hemorrhage is a common sequela of head trauma, and it may also be observed in various coagulopathies. by itself, it is not a serious problem but may signify severe underlying intraocular damage. a complete ocular examination is indicated. other causes of subconjunctival hemorrhage include thrombocytopenia, autoimmune hemolytic anemia, hemophilia, leptospirosis, vitamin k antagonist rodenticide intoxication, severe systemic infection or inflammation, and prolonged labor (dystocia). uncomplicated subconjunctival hemorrhage usually clears on its own within 14 days. if the conjunctiva is exposed because of swelling and hemorrhage, administer a topical protective triple antibiotic ophthalmic ointment every 6 to 8 hours until the conjunctival hemorrhage resolves. toxic, acid, and alkaline chemical injuries to the eye can sometimes occur. the severity of the injury caused by ocular burns depends on the concentration, type, and ph of the chemical and on the duration of exposure. weak acids do not penetrate biologic tissue very well. the hydrogen ion precipitates the protein upon contact and therefore provides some protection to the corneal stroma and intraocular contents. precipitation of corneal proteins produces a ground-glass appearance in the cornea. alkaline solutions and very strong acids penetrate tissues rapidly, causing saponification of the plasma membrane, denaturation of collagen, and vascular thrombosis within the conjunctiva, episclera, and anterior uvea. severe pain, blepharospasm, and photophobia are produced by exposure of free nerve endings in the corneal epithelium and conjunctiva. severe alkaline burns cause an increase in intraocular pressure. intraocular prostaglandins are released, and the intraocular aqueous ph increases, producing changes in the blood-aqueous barrier and secondary uveitis. uveitis with anterior synechia formation, eventual chronic glaucoma, phthisis, secondary cataract, and corneal perforation can occur. healing of the corneal epithelium is usually accomplished by neovascularization and sliding and increased mitosis of the corneal epithelium. severe stromal burns within the cornea heal by degradation and removal of necrotic debris, followed by replacement of the collagen matrix and corneal epithelial cells. the release of collagenase, endopeptidase, and cathepsins from polymorphonuclear cells serves to cause further corneal breakdown. in severe cases, only pmns may be present, and fibroblasts may never invade the corneal stroma. all chemical burns should be washed copiously with any clean aqueous solution available. if any sticky paste or powder is adherent to the conjunctival sac, remove it with moist cotton swabs and irrigation. begin mydriasis and cycloplegia by topical application of 1% atropine ophthalmic drops or ointment. start antibiotic therapy with triple antibiotic ophthalmic ointment or gentocin ointment every 6 to 8 hours. treat secondary glaucomas with topical carbonic anhydrase inhibitors. to avoid fibrinous adhesions and symblepharon formation, keep the conjunctival cul-de-sacs free of proteinaceous exudate that can form adhesions. analgesics are required for pain. oral nonsteroidal antiinflammatory agents such as carprofen, ketoprofen, meloxicam, or aspirin are recommended. persistent epithelial erosions may require a conjunctival flap left in place for 3 to 4 weeks or placement of a topical collagen shield (contact lens). topical antibiotics, mydriatics, and lubricants (lacrilube or puralube ointment) should also be used. strong acid or alkali burns can result in severe corneal stromal loss. in the past, topical n-acetylcysteine (10% mucomyst) has been recommended. this treatment is very painful. other treatments are also available, such as ethylenediaminetetraacetic acid (edta) (0.2 m solution) and patient serum to inhibit mammalian collagenase activity. to prepare patient serum, obtain 10 to 12 ml of whole blood from the patient. spin it down in a serum separator tube after a clot forms and then place the serum in a red-topped tube on the patient's cage. (the contents of the tube are viable for 4 days without refrigeration.) apply the serum topically to the affected eye every 1 to 2 hours. avoid using topical steroids because they inhibit fibroblast formation and corneal healing. in severe cases, if conjunctival swelling and chemosis also are present, antiinflammatory doses of oral steroids can be administered short-term. oral steroids and nonsteroidal antiinflammatory drugs should never be administered to the patient concurrently, because of the risk of gastrointestinal ulcer and perforation. corneal abrasions are associated with severe pain, blepharospasm, lacrimation, and photophobia. animals with such intense pain are often difficult to examine until analgesia has been administered. topical use of proparacaine (0.5% proparacaine hydrochloride) is usually sufficient to permit relaxation of the eyelids so that the eye can be examined. using a focal source of illumination and an eye loupe, examine the cornea, inferior and superior conjunctival fornixes, and medial aspect of the nictitans for foreign bodies. place a sterile drop of saline on a fluorescein-impregnated strip and touch the superior conjunctiva once to allow the stain to spread onto the surface of the eye. irrigate the eye to remove excess stain and then examine the corneal surface for any areas of stain uptake. if an area of the cornea persistently remains green, there is damage to the corneal epithelium in that area. initial treatment consists of application of a topical mydriatic (1 drop of 1% atropine in affected eye q12h) to prevent anterior synechiae and improve cycloplegia. triple antibiotic ointment is the treatment of choice (a 1 /4-inch strip in the affected eye q8h) until the ulcer heals. in some cases, nonhealing ulcers (e.g., boxer ulcer, indolent ulcer) form in which the epithelial growth does not adhere to the underlying cornea. gently debride the loose edges 1 of the ulcer/erosion with a cotton swab and topical anesthesia. more severe cases in which only minimal healing has occurred after 7 days of treatment require grid keratectomy, in which a 25-gauge needle is used to gently scratch the surface of the abrasion or ulcer in the form of a grid to promote neovascularization. apply a topical anesthetic before performing the procedure. a collagen contact lens also may be required to promote wound healing. all corneal abrasions should be reevaluated in 48 hours, and then every 4 to 7 days thereafter until they have healed. acute infectious keratitis secondary to bacterial infection is characterized by mucopurulent ocular discharge, rapidly progressing epithelial and corneal stromal loss, inflammatory cellular infiltrates into the corneal stroma, and secondary uveitis, often with hypopyon formation. confirmation of infectious keratitis is based on corneal scrapings and a positive gram stain. initial treatment for bacterial keratitis consists of systemic antibiotics and topical ciprofloxacin (0.3% eyedrops or ointment). penetrating injuries through the cornea may result in prolapse of intraocular contents. frequently, pieces of uveal tissue or fibrin effectively but temporarily seal the defect and permit the anterior chamber to re-form. avoid manipulation of these wounds until the animal has been anesthetized, as struggling or excitement can promote loss or dislodgement of the temporary seal and cause the intraocular contents to be extruded. superficial corneal lacerations need not be sutured and can be treated the same as a superficial corneal ulcer or abrasion. if the laceration penetrates more than 50% the thickness of the cornea, or extends more than 3 to 4 mm, it should be sutured. when placing sutures in the cornea, it is helpful to use magnification. referral to a veterinary ophthalmologist is advised. if a veterinary ophthalmologist is not available, use 7-0 or 8-0 silk, collagen, or nylon sutures on a micropoint spatula-type needle. use a simple interrupted suture pattern and leave the sutures in place for a minimum of 3 weeks. because many corneal lacerations are jagged and corneal edema forms, most of the wound edges cannot be tightly juxtaposed. in such cases, pull a conjunctival flap across the wound to prevent leakage of aqueous fluid. never suture through the full thickness of the cornea; rather, the suture should pass through the mid-third of the cornea. following closure of the corneal wound, the anterior chamber must be re-formed to prevent anterior synechia formation with secondary glaucoma. taking care to avoid iris injury, use a 25-or 26-gauge needle to insert sterile saline at the limbus. any defect in the suture line will be apparent because of leakage of the fluid from the site and should be repaired. incarceration of uveal tissue in corneal wounds is a difficult surgical problem. persistent incarceration of uveal tissue can result in development of a chronic wick in the cornea, a shallow anterior chamber, chronic irritation, edema, vascularization of the cornea, and intraocular infection that can lead to panophthalmitis. referral to a veterinary ophthalmologist is strongly recommended. the most common foreign bodies associated with ocular injuries in small animals are birdshot, bb pellets, and glass. the site of intraocular penetration of the foreign bodies may be obscured by the eyelids. a foreign body entering the eye may penetrate the cornea and fall into the anterior chamber or become lodged in the iris. foreign bodies may occasionally penetrate the lens capsule, producing cataracts. some metallic high-speed foreign bodies may penetrate the cornea, iris, and lens to lodge in the posterior wall of the eye or vitreous chamber. direct visualization of a foreign body is the best means of localization. examination of the eye with an indirect ophthalmoscope or biomicroscope (if available) is invaluable for locating foreign bodies. indirect visualization of the ocular foreign body can also be achieved through radiographic techniques. three separate views should be obtained to determine the plane of location of the foreign object. ct or mri may prove useful, although scatter from the foreign body may make it difficult to directly visualize with these techniques. ocular ultrasound is perhaps the most useful and refined radiographic technique for locating intraocular foreign bodies. before removing any foreign body from the eye, the risk and surgical danger of removing it must be weighed against the risks of leaving it in place. metallic foreign bodies in the anterior chamber are much easier to remove than nonmagnetic ones. attempted removal of foreign objects from the vitreous chamber of the eye has consistently produced poor results. for the best chance of recovery, ocular foreign bodies should be removed by a veterinary ophthalmologist whenever possible. blunt trauma to the globe can result in luxation or subluxation of the lens. the subluxated lens may move anteriorly and make the anterior chamber more shallow. trembling of the iris (iridodonesis) may be noticed when the lens is subluxated. in complete luxation, the lens may fall totally into the anterior chamber and obstruct aqueous outflow, causing secondary glaucoma. alternatively, the lens may be lost into the vitreous cavity. luxation of the lens is almost always associated with rupture of the hyaloid membrane and herniation of the vitreous through the pupillary space. emergency surgery for lens luxation is required if the lens is entirely within the anterior chamber or incarcerated within the pupil, causing a secondary pupillary block glaucoma. acute elevation in intraocular pressure can cause vision loss within 48 hours; thus, lens removal should be accomplished as quickly as possible. referral to a veterinary ophthalmologist is recommended. severe trauma to the globe or a direct blow to the head can result in retinal or vitreous hemorrhage. there may be large areas of subretinal or intraretinal hemorrhage. subretinal hemorrhage assumes a discrete globular form, and the blood appears reddish-blue in color. the retina is detached at the site of hemorrhage. superficial retinal hemorrhage may assume a flame-shaped appearance, and preretinal or vitreous hemorrhage assumes a bright-red amorphous appearance, obliterating the underlying retinal architecture. retinal and vitreous hemorrhage secondary to trauma usually resorbs spontaneously over a 2-to 3-week period. unfortunately, vitreous hemorrhage, as it organizes, can produce vitreous traction bands that eventually produce retinal detachment. expulsive choroid hemorrhage can occur at the time of injury and usually leads to retinal detachment, severe visual impairment, and total loss of vision. treatment of vitreal and retinal hemorrhage includes rest and correction of factors that may predispose to intraocular hemorrhage. more complicated cases may require vitrectomy performed by a veterinary ophthalmologist. hyphema refers to blood in the anterior chamber of the eye. the most common traumatic cause of hyphema is an automobile accident. hyphema may also present because of penetrating ocular wounds and coagulopathies. blood within the eye may come from the anterior or posterior uveal tract. trauma to the eye may result in iridodialysis or a tearing of the iris at its root, permitting excessive bleeding from the iris and ciliary body. usually, simple hyphema resolves spontaneously in 7 to 10 days and does not cause vision loss. loss of vision following bleeding into the anterior chamber is associated with secondary ocular injuries such as glaucoma, traumatic iritis, cataract, retinal detachment, endophthalmitis, and corneal scarring. treatment of hyphema must be individualized, but there are severe general principles of treatment. first, stop ongoing hemorrhage and prevent further bleeding whenever possible. this may involve correction of the underlying cause, if a coagulopathy is present. next, aid in the elimination of blood from the anterior chamber, control secondary glaucoma, and treat associated injuries, including traumatic iritis. finally, detect and treat any late complications of glaucoma. in most cases of traumatic hyphema, little can be done to arrest or prevent ongoing hemorrhage. it is best to restrict the animal's activity and prohibit exertion. rebleeding can occur within 5 days, and intraocular pressure must be monitored closely. after 5 to 7 days, the blood in the anterior chamber will change color from a bright red to bluish-black ("eight-ball hemorrhage"). if total hyphema persists and intraocular pressure rises despite therapy, surgical intervention by a veterinary ophthalmologist may be necessary. the primary route of escape of rbcs from the anterior chamber is via the anterior drainage angle. iris absorption and phagocytosis play a minor role in the removal of blood from the anterior chamber. because of the associated traumatic iritis in hyphema, topical administration of a glucocorticoid (1% dexamethasone drops or 1% prednisolone drops) is advised to control anterior chamber inflammation. a cycloplegic agent (1% atropine) should also be used. the formation of fibrin in the anterior chamber of the eye secondary to hemorrhage can produce adhesions of the iris and secondary glaucoma (see section on glaucoma secondary to hyphema) by blocking the trabecular network. hyphema secondary to retinal detachment (collie ectasia syndrome) and end-stage glaucoma are extremely difficult to treat medically and have a poor prognosis. proptosis of the globe is common secondary to trauma, particularly in brachycephalic breeds. proptosis of the globe in dolichocephalic breeds requires a greater degree of initiating contusion than the brachycephalic breeds because the orbits are so much deeper. therefore, secondary damage to the eye and cns associated with proptosis of the globe may be greater in the collie or greyhound than in the pug. when proptosis occurs, carefully evaluate the cardiovascular system for evidence of hypovolemic or hemorrhagic shock. examine the respiratory and neurologic systems. be sure to establish an airway and treat shock, if present. control hemorrhage and stabilize the cardiovascular system before attempting to replace the globe within its orbit or perform enucleation. during the initial management of the cardiovascular and respiratory systems, the eye should be covered with an ophthalmic grade ointment or sponges soaked in sterile saline to prevent the globe from drying out. proptosis of the globe can be associated with serious intraocular problems including iritis, chorioretinitis, retinal detachment, lens luxation, and avulsion of the optic nerve. stain the surface of the eye with fluorescein to look for topical abrasions or ulcers. carefully examine the sclera, cornea, and conjunctiva for penetrating injuries that may allow aqueous leakage. evaluate the size, location, and response to light of the pupil. a reactive pupil is better than a mydriatic fixed pupil. topical administration of a mydriatic (atropine 1%) to prevent persistent miosis and synechia formation is indicated, along with topical and oral antibiotics and oral analgesic therapy. reposition the proptosed globe with the patient under general anesthesia. make a lateral canthotomy incision to widen the palpebral fissure. lavage the globe with sterile saline irrigation to remove any external debris. place a copious amount of triple antibiotic ophthalmic ointment on the surface of the eye and then gently press the globe into the orbit using the flat side of a scalpel handle or a moistened sterile surgical sponge. do not probe the retro-orbital space with a needle or attempt to reduce intraocular pressure by paracentesis. when the globe is replaced in the orbit, close the lateral canthotomy incision with simple interrupted sutures. place three non-penetrating mattress sutures in the lid margins but do not draw them together. tighten the lid sutures through small pieces of a red rubber catheter or length of intravenous extension tubing to prevent the sutures from causing lid necrosis. leave the medial canthus of the eye open in order to allow topical treatment. postoperative treatment is directed at preventing further iritis and preventing infection. administer systemic broad-spectrum antibiotics (clavamox, 16.25 mg/kg po bid) and analgesic drugs. apply topical triple antibiotic ophthalmic ointment ( 1 /4 inch in affected eye q6-8h) and atropine (1% in affected eye q12h) to prevent infection, cycloplegia, and anterior synechiae. antiinflammatory doses of systemic steroids can also be added to the treatment 202 if severe periorbital inflammation is present. systemic steroids should never be used in conjunction with nonsteroidal antiinflammatory drugs, because of the risk of gastrointestinal ulceration and perforation. the sutures should remain in place for a minimum of 3 weeks. after this time, remove the sutures and inspect the globe. if proptosis recurs, repeat the treatment. following proptosis, strabismus is common secondary to periorbital muscle injury. even after extensive treatment, vision in the eye may still be lost. nonvisual eyes can remain in place, but phthisis may develop. carbonic anhydrase inhibitors such as acetazolamide and dichlorphenamide decrease aqueous secretion and may effectively reduce intraocular pressure if the trabecular outflow is still functioning at 40% of its capacity. an eye with a poorly functional trabecular outflow system will respond poorly to therapy with carbonic anhydrase inhibitors. osmotic agents such as mannitol or glycerol may be helpful in controlling glaucoma secondary to hyphema. reduction in vitreous chamber size can make the anterior chamber deeper and may allow increased aqueous outflow. evacuation of blood or blood clots from the anterior chamber is not advisable unless the glaucoma cannot be controlled medically or there is no indication after a prolonged period of time that blood is being resorbed. tissue plasminogen activator (t-pa) has proved to be useful in may be helpful in lysing blood clots and preventing excessive fibrin formation. the t-pa is reconstituted to make a solution of 250 âµ/ml, which is then frozen at â��70â°c in 0.5-ml aliquots. the thawed, warmed reconstituted t-pa is injected into the anterior chamber. blind probing of the anterior chamber of the eye and surgical intervention in an attempt to remove blood clots can cause serious complications such as rebleeding, lens luxation, iris damage, and damage to the corneal epithelium, and therefore is not advised. acute glaucoma is a rise in intraocular pressure that is not compatible with normal vision. glaucoma may present as early acute congestive or noncongestive glaucoma, or as end-stage disease. cardinal signs of glaucoma are a sudden onset of pain, photophobia, lacrimation, deep episcleral vascular engorgement, edematous insensitive cornea, shallow anterior chamber depth, dilated unresponsive pupil, loss of visual acuity, and buphthalmia. intraocular pressure usually exceeds 40 mm hg but may be normal or only slightly increased if glaucoma is secondary to anterior uveitis. most forms of clinical glaucoma in dogs are secondary to some other intraocular problem. primary glaucoma is recognized in some breeds, including the bassett hound, cocker spaniel, samoyed, bouvier des flandres, and some terrier breeds either from goniodysgenesis or a predisposition to lens luxation. other common causes of acute glaucoma are anterior uveitis and intumescent lens secondary to rapid cataract development, particularly in dogs with diabetes mellitus. treatment involves investigation of the underlying cause of the sudden rise in intraocular pressure and rapid reduction in intraocular pressure. permanent visual impairment is often associated with chronically buphthalmic globes or the presence of rippling or striae formation on the cornea. referral to a veterinary ophthalmologist is recommended. if the eye is still visual and not buphthalmic, the prognosis is favorable, depending on the cause of the acute glaucoma. treatment to reduce intraocular pressure consists of improving aqueous outflow, reducing intraocular volume with osmotic agents, and reducing aqueous formation (table 1 -47). the use of topical mydriatic agents in acute glaucoma is contraindicated because of the risk of making lens luxation or anterior uveitis worse. referral to a veterinary ophthalmologist for emergency surgery is indicated in cases of iris bombe, intumescent lens, or lens subluxation. administer osmotic agents to reduce the size of the vitreous body and the amount of aqueous. osmotic agents create an osmotic gradient between the intraocular fluids and the emergency management of specific conditions 203 vascular bed, thus allowing osmotic removal of fluid independent of the aqueous inflow and outflow systems. if no other treatments are available, oral glycerol (50%, 0.6 ml/kg or 1.4 g/kg) can be used to effectively reduce intraocular pressure. an adverse side effect of oral glycerol treatment is protracted vomiting. do not use glycerol in a diabetic patient. mannitol (1-2 g/kg iv over 1 hour) also effectively reduces intraocular pressure but does not cause vomiting. carbonic anhydrase inhibitors can be used to reduce intraocular volume by reducing aqueous production. oral administration of dichlorphenamide, methazolamide, and acetazolamide (2-4 mg/kg) is usually not very effective alone in reducing aqueous volume and intraocular pressure and also can cause metabolic acidosis. topical carbonic anhydrase inhibitors appear to be more effective (dorzolamide, trusopt) when used in conjunction with topical beta-blockers (timolol, 0.25% or 0.5% solution q8h). the most effective treatment for acute pressure reduction is use of a topical prostaglandin inhibitor (latanaprost). usually just one or two drops effectively reduces intraocular pressure in the emergency stages, until the patient can be referred to a veterinary ophthalmologist the following day. many clinical conditions that are presented as emergencies may be due in part or wholly to the presence of a neoplasm. paraneoplastic signs are summarized in table 1 -48. prompt identification of the neoplasia combined with knowledge of treatment, expected response to therapy, and long-term prognosis can aid owners and practitioners in making appropriate treatment decisions. hemorrhage or effusion can occur in any body cavity as a result of the presence of benign or malignant tumors. tumors secrete anticoagulants to allow angiogenesis to grow unchecked. hemorrhage often occurs as a result of rupture of a neoplasm or invasion of a neoplasm into a major vascular structure. effusion may be the result of direct fluid production by the mass or may be due to obstruction of lymphatic or venous flow. hemorrhagic effusions in the abdominal cavity occur most commonly with neoplastic masses of the spleen or liver. the most common causes are hemangiosarcoma and hepatocellular carcinoma. clinical signs associated with acute abdominal hemorrhage, regardless of the cause, are related to hypovolemic shock and decreased perfusion and include pale mucous membranes, tachycardia, anemia, lethargy, and acute collapse. treatment for abdominal hemorrhage includes placement of a large-bore peripheral cephalic catheter and starting one fourth of a shock dose (90 ml/kg/hour for dogs, and 44 ml/kg/hour for cats) of intravenous crystalloid fluids, taking care to carefully monitor perfusion parameters of heart rate, capillary refill time, mucous membrane color, and blood pressure. administer intravenous colloids such as dextran-70, hetastarch, and oxyglobin (5-10 ml/kg iv bolus) to restore intravascular volume and normotension. treat severe anemia with whole blood or packed rbcs to improve oxygen-carrying capacity and oxygen delivery (see sections on transfusion medicine and treatment of shock). confirm the presence of hemoabdomen abdominocentesis (see section on abdominocentesis). the presence of nonclotting hemorrhagic effusion is consistent with free blood. packed cell volume of the fluid is usually the same or higher than that of the peripheral blood. an abdominal compression bandage can be placed while further diagnostics are being performed. in cases of acute hemoabdomen, obtain right lateral, left lateral, and ventrodorsal or dorsoventral thoracic radiographs to help rule out obvious metastasis. monitor the patient's ecg and correct dysrhythmias as necessary (see section on cardiac dysrhythmias). surgery is indicated once the patient is stabilized. in some cases, hemorrhage is so severe that the patient should be taken immediately to surgery. when recommending surgery for a hemorrhaging intraabdominal mass, it is important to discuss likely diagnoses and long-term prognosis with the owner. hemangiosarcoma usually involves the spleen or liver or both. the presence of free abdominal hemorrhage is associated with a malignant tumor in 80% of cases. even when free abdominal hemorrhage is not present, the tumor is malignant in 50% of cases. approximately 66% (two thirds) of masses in the spleen are malignant (hemangiosarcoma, lymphoma, mast cell tumor, malignant fibrous histiocytoma, leiomyosarcoma, fibrosarcoma), and approximately one third are benign (hematoma, hemangioma). hepatocellular carcinoma usually affects one liver lobe (usually the left), and surgery is the treatment of choice. with complete surgical excision, median survival in dogs is longer than 300 days. if diffuse disease is observed at the time of surgery, the prognosis is poor. nonhemorrhagic effusions are associated with mesothelioma, lymphoma, carcinomatosis, or any mass that causes vascular or lymphatic obstruction. clinical signs of respiratory distress and abdominal distention with nonhemorrhagic effusions are usually slowly progressive in onset and not as severe as those observed with hemorrhage. treatment is usually aimed at identification of the underlying cause. obtain a fluid sample via thoracocentesis or abdominocentesis. to obtain further cells for cytologic evaluation, aspirate fluid from the thoracic or abdominal mass with ultrasound guidance. cytologic evaluation of the fluid will often elucidate the causative tumor type. an abdominal ultrasound can determine the degree of metastasis. perform therapeutic abdominocentesis or thoracocentesis if the effusion is causing respiratory difficulty. rapid re-accumulation of the fluid potentially can cause hypoproteinemia and hypovolemic shock. mesothelioma is a rare tumor most commonly observed in urban environments. in humans, mesothelioma has been associated with exposure to asbestos. it is sometimes difficult to differentiate between reactive mesothelial cells and malignant mesothelial cells. treatment is aimed at controlling the neoplastic effusion. intracavitary cisplatin has been demonstrated to slow rates of fluid re-accumulation, but is largely a palliative therapy. lymphoma is another tumor type that can cause thoracic or abdominal effusion. cytologic evaluation of the fluid usually reveals abundant lymphoblasts. treatment with multiagent chemotherapy protocols, with or without adjunctive radiation therapy, can prevent tumor remission and stop fluid accumulation. carcinomatosis occurs as a result of diffuse seeding of the abdominal cavity with malignant carcinomas and has a poor prognosis. carcinomatosis may occur de novo or from 1 metastasis of a primary tumor. treatment consists of fluid removal when respiratory difficulty occurs, with or without intracavitary cisplatin as a palliative measure. cisplatin should never be used in cats due to fatal acute pulmonary edema. clinical signs of hemorrhagic thoracic effusion include acute respiratory distress, anemia, hypovolemic or cardiogenic shock, and collapse. hemorrhagic thoracic effusions are rare in association with neoplastic effusions. a notable exception is intrathoracic hemorrhage in young dogs with osteosarcoma of the rib. hemorrhage can result when a primary lung tumor erodes through a vessel. hemangiosarcoma of the lungs or right auricular area can also result in hemorrhagic thoracic effusion. in many cases, hemorrhage may be confined to the pericardial sac with a right auricular mass, causing a globoid cardiac silhouette on thoracic radiographs. treatment consists of pericardiocentesis (see section on pericardial effusion and pericardiocentesis) and placement of a pericardial window, or the mass may be removed if it is in the right auricular appendage and resectable. although surgery can resolve clinical signs of right-sided heart failure, metastatic disease often develops soon afterward. nonhemorrhagic thoracic effusion is more common than hemorrhagic thoracic effusion, and is caused most commonly by mesothelioma, lymphoma, carcinomatosis, and thymoma. clinical signs develop gradually and include respiratory difficulty, cyanosis, and cough. supplemental oxygen should be administered. in many cases, thoracocentesis can be therapeutic and diagnostic. obtain thoracic radiographs both before and after thoracocentesis to determine whether a mass effect is present. following identification of a cause, definitive therapy can be instituted. mesotheliomas are rare and are associated with diffuse serosal disease. they are more common in dogs than in cats. effusions caused by mesotheliomas can affect the pleural or pericardial cavities. treatment is directed at removing effusion fluid and controlling reaccumulation with use of intracavitary platinum compounds, carboplatin, and cisplatin can be used in dogs. (cisplatin and carboplatin should never be used in cats.) chemical or physical pleurodesis may be helpful in controlling reaccumulation of fluid, but it is very painful in small animal patients. thoracic effusion secondary to lymphoma often is associated with an anterior mediastinal mass. t-cell lymphoma is the most common type of mediastinal mass observed in dogs. b-cell lymphoma is associated with a decreased response to chemotherapy and shorter survival times. treatment consists of combination chemotherapy with or without radiation therapy to decrease mass size. carcinomatosis is a diffuse disease of the pleural cavity that often is a result of metastasis from a primary pulmonary carcinoma or mammary adenocarcinoma. treatment is similar to that for mesothelioma and is aimed at controlling the effusion and delaying its recurrence. thymomas have been documented in both dogs and cats. dogs most commonly present with a cough, while cats present with clinical signs of respiratory distress and a restrictive respiratory pattern associated with the presence of pleural effusion. an anterior mediastinal mass is often observed on thoracic radiographs. in some cases, the pleural effusion must be drained via thoracocentesis before a mass is visible. ultrasound-guided aspiration and cytologic evaluation of the mass reveal a malignant epithelial tumor with small lymphocytes and mast cells. prognosis is good if the tumor can be completely excised. treatment consists of surgical removal with or without presurgical radiation therapy to shrink the mass. paraneoplastic syndromes of myasthenia gravis have been documented in dogs with thymomas. if megaesophagus or aspiration pneumonia is present, the prognosis is more guarded because of the high rate of complications. obstructive lesions affecting the urinary tract can be extramural (intra-abdominal, pelvic, or retroperitoneal) or intramural (urethral, bladder, or urethral wall) . transitional cell 1 carcinoma is the most common type of bladder tumor observed in dogs. prostatic adenocarcinoma, or neoplasia of the sublumbar lymph nodes (lymphoma, adenocarcinoma from apocrine gland adenocarcinoma), also can cause urethral obstruction. treatment is aimed at relieving the obstruction and then attempting to identify the cause of the disease. to alleviate the obstruction, pass a urinary catheter whenever possible. perform cystocentesis only as a last resort because of the risk of seeding the peritoneal cavity with tumor cells if transitional cell carcinoma is the cause of the obstruction. institute supportive therapy including intravenous fluids and correction of electrolyte abnormalities. plain radiographs may reveal a mass lesion or may not be helpful without double contrast cystography. abdominal ultrasound is more sensitive in identifying a mass lesion in the urinary bladder. masses in the pelvic urethra are difficult to visualize with ultrasonography. double contrast cystourethrography is preferred. once the patient is stabilized, biopsy or surgery is indicated to identify the cause of the mass and attempt resection. urine tests for transitional cell carcinoma are available for identification of transitional cell carcinoma in the dog. complete surgical excision of transitional cell carcinoma or removal of benign tumors of the urinary bladder yields a favorable prognosis. poorer prognosis is seen with incomplete excision. many transitional cell carcinomas are located in the trigone region of the bladder and cannot be completely excised. the nonsteroidal antiinflammatory drug piroxicam is helpful in alleviating clinical signs for a reported 7-month median survival. in some dogs, cisplatin and carboplatin may delay recurrence of transitional cell carcinoma. tumors of the prostate gland are always malignant and occur with equal frequency in castrated and uncastrated male dogs. diagnosis of prostatic tumors is based on ultrasonographic evidence of a mass effect or prostatomegaly and on transrectal or transabdominal aspiration or biopsy. surgery, chemotherapy, and radiation therapy generally are unrewarding over the long term, although palliative radiation therapy may relieve clinical signs for 2 to 6 months. luminal tumors of the gastrointestinal tract typically cause obstruction, with slowly progressive clinical signs including vomiting, inappetence, and weight loss, or with acute severe protracted vomiting. extraluminal obstructive lesions usually arise from adhesions, or strangulation may occur, resulting in obstruction. perforation of the mass through the gastric or intestinal wall can cause peritonitis. treatment consists of initial stabilization and rehydration, evaluation for evidence of metastasis, and surgical resection of the affected area in cases of adenocarcinoma, leiomyoma, leiomyosarcoma, and obstructive or perforated lymphoma. gastric and intestinal adenocarcinoma are the most common gastrointestinal tumors observed in dogs. affected animals typically have a history of anorexia, weight loss, and vomiting. obtain an abdominal ultrasound before performing any surgery. fine needle aspirates of the mass and adjacent lymph nodes are usually diagnostic and can determine whether there is local metastasis. many tumors are not resectable, and metastasis occurs in approximately 70% of cases. dogs with smaller tumors that can be resected typically have longer survival times. leiomyosarcomas occur in the intestines of dogs, and carry a more favorable prognosis than adenocarcinoma if the mass can be completely resected. with complete resection, the average survival time is longer than 1 year. the paraneoplastic syndrome of hypoglycemia has been observed with this tumor type. gastrointestinal lymphoma is the most common tumor of the gastrointestinal tract observed in cats. in comparison, it is relatively rare in dogs. unless there is complete obstruction or perforation of the gastrointestinal tract, surgical treatment for gastrointestinal lymphoma is not indicated. rather, multiple chemotherapy drugs are used in combination to achieve remission and resolution of the clinical signs of anorexia, weight loss, and vomiting. treatment responses unfortunately are poor. mast cell tumors of the gastrointestinal tract typically are manifested as gastrointestinal ulceration and hemorrhage in up to 83% of patients. the gastrointestinal hemorrhage that occurs with mast cell tumors results from increased acid secretion as a result of histamine receptor stimulation. treatment consists of histamine or proton pump inhibition (ranitidine, famotidine, cimetidine, or omeprazole). bowel perforation is a rare complication. many chemotherapy agents exert their effects on rapidly dividing normal and neoplastic cells. normal tissues that are commonly affected include the bone marrow, gastrointestinal tract, skin and hair follicles, and reproductive organs. some drugs have unique organspecific toxicities that must be monitored. knowledge and recognition of the expected type and onset of complications can alleviate their severity by rapid treatment, when complications occur (see table 1 -48) . neutropenia is the most common bone marrow toxicity observed secondary to chemotherapy in small animal patients (table 1 -49) . in most cases, the neutropenia is dose-dependent. the nadir, or lowest neutrophil count, is typically observed 5 to 10 days after chemotherapy treatment. once the nadir occurs, bone marrow recovery is observed, with an increase in circulating neutrophils within 36 to 72 hours (table 1 -49) . treatment of myelosuppression is largely supportive to treat or prevent sepsis. prophylactic antibiotics are recommended in the afebrile patient with a neutrophil count <2000/âµl. acceptable antibiotics include trimethoprim-sulfa and amoxicillin-clavulanate. granulocyte-colony stimulating factor (g-csf) (e.g., neupogen) is a recombinant human product that stimulates the release of neutrophils from the bone marrow, and its use shortens the recovery time following myelosuppressive drug therapy. disadvantages of g-csf include antibody production in response to the drug within 4 weeks of use and its high cost. to prevent ongoing neutropenia, subsequent chemotherapy dosages should be decreased by 25%, and the interval in between treatments increased. whenever possible, overlap of myelosuppressive drugs should be avoided. acute gastrointestinal toxicity can occur within 6 to 12 hours after administration of cisplatin and actinomycin d. in many cases, pretreatment with the antiemetics metoclopramide, butorphanol, chlorpromazine, dolasetron or ondansetron can prevent chemotherapyinduced nausea and vomiting. vomiting can also occur as a delayed side effect 3 to 5 days after treatment with doxorubicin (adriamycin), actinomycin d, methotrexate, and cytoxan. in delayed reactions, vomiting and diarrhea are caused by damage to intestinal crypt cells. treatment consists of administration of antiemetics, intravenous fluids, and a bland highly digestible diet. doxorubicin also can cause hemorrhagic colitis within 5 to 7 days of administration. treatment includes a bland diet, metronidazole, and tylosin tartrate (tylan powder). 1 emergency care mild to none not observed vincristine (low-dose), l-asparaginase, glucocorticosteroids moderate 7-10 days melphalan, cisplatin, mitoxantrone, actinomycin d severe 7-10 days doxorubicin, cyclophosphamide, vinblastine 1 paralytic ileus can be observed 2 to 5 days after administration of vincristine. this side effect is more common in humans than animals and can be treated with metoclopramide once a gastrointestinal obstruction has been ruled out. cardiotoxicity doxorubicin (adriamycin) causes a dose-dependent dilative cardiomyopathy when the cumulative dose reaches 100 to 150 mg/m 2 . in many cases, however, clinical signs do not occur until the cumulative dose is 240 mg/m 2 . the myocardial lesions are irreversible. treatment of cardiac dysrhythmias is dependent on the type of dysrhythmia (see section on treatment of dysrhythmias). discontinue doxorubicin and administer diuretics and positive inotropic therapy for dilative cardiomyopathy in order to delay the progression of congestive heart failure (see sections on treatment of congestive heart failure). if abnormalities are shown on electrocardiography performed before beginning therapy, substitute liposome-encapsulated doxorubicin or mitoxantrone substituted in the chemotherapy protocol. cardioprotectant drugs such as vitamin e, selenium, and n-acetyl cysteine have shown some promise in the prevention of doxorubicin-induced cardiotoxicity. cyclophosphamide can cause a sterile hemorrhagic cystitis. damage to the urinary bladder mucosa and vessels is caused by the toxic metabolite acrolein. clinical signs of sterile hemorrhagic cystitis include a history of cyclophosphamide administration, stranguria, hematuria, and pollakiuria. treatment for sterile hemorrhagic cystitis is discontinuation of the drug, treatment of any underlying urinary tract infection with antibiotic therapy based on susceptibility testing, and intravesicle drug administration. in extremely refractory cases, surgical debridement and cauterization of the bladder mucosa may be necessary. prevention of sterile hemorrhagic cystitis includes emptying the bladder frequently and administering the drug in the morning. concurrent administration of prednisone can induce polyuria and polydipsia. if sterile hemorrhagic cystitis occurs, chlorambucil can be substituted as a chemotherapeutic agent. anaphylactic reactions have been observed with the administration of l-asparaginase, adriamycin, etoposide, and paclitaxel. the risk of anaphylaxis increases with repeated administration, although in some animals anaphylaxis will occur on the first exposure to the drug. treatment consists of administration of epinephrine, diphenhydramine, famotidine, and glucocorticosteroids, as with any other life-threatening allergic reaction (see section on treatment of allergic reactions). to decrease the risk of an adverse reaction, give diphenhydramine (2.2 mg/kg im) 15 to 30 minutes before drug administration. slowing the rate of intravenous infusion also can decrease the chance of an anaphylactic reaction. cisplatin can cause a fatal irreversible pulmonary edema in cats, even at low dosages. 5-fluorouracil (5-fu) can cause a severe neurotoxicity in cats that results in ataxia and seizures. never use cisplatin or 5-fu in cats. poisoning cases benefit from a rapid, organized approach. key points in this approach are giving appropriate advice over the telephone, being able to access information sources, and providing appropriate treatment. there are only a few classes of poisons that account for the majority of toxicities reported in dogs and cats. every veterinarian should develop a familiarity with the clinical management of rodenticide and insecticide toxicity and be prepared with antidotes on hand. beyond the most common toxins, the spectrum of possibilities is endless, and the veterinarian must rely on appropriate information resources. it is important to have available a comprehensive source of pharmaceutical and plant identification resources. remarkably, considering the myriad of potentially toxic substances to which an animal can be exposed, relatively few specific antidotes are commonly used in veterinary medicine. because of the lack of specific antidotes, the veterinarian must treat each toxicity with general methods of poison management, applying basic critical care in the treatment of specific clinical signs associated with the poison exposure or toxicity. the adage "treat the patient, not the poison" often comes into play when the exact toxic substance is unknown, or has no specific antidote. before an animal arrives, the staff should be prepared to ask specific questions over the phone, and provide initial advice for clients, particularly if the animal lives some distance from the hospital (box 1-55.) it is important to have access to a database of information on toxic substances. thousands of potentially toxic substances are available on the market today. the american society for the prevention of cruelty to animals (aspca) animal poison control center provides direct access to veterinary toxicologists 24 hours a day, 365 days a year. for additional information, call the nearest veterinary school or emergency center (box 1-56). also, see section 6 for a table of emergency hotlines. check your local telephone book for a poison control center listing under emergency numbers, usually found on the front cover. although these numbers are for human poisonings, they have access to extensive poison and toxin databases and can potentially provide useful information for veterinarians, particularly regarding antidotal substances suitable for out of the ordinary toxins and human medications. information on the toxic ingredients in thousands of medications, insecticides, pesticides, and other registered commercial products has been confidentially placed by the government in these poison control centers. as new products are marketed, information regarding toxin ingredients is forwarded to the centers. various e-mail discussion lists can serve as an informative resource for practitioners, but access generally requires an initial subscription and may have the disadvantage of delayed 1 *do not keep the client on the telephone for too long. lengthy histories can be performed once the animal is at your hospital and you have started to initiate treatment. â�  hair dressing products sometimes have hydrogen peroxide as a 30% w/v; this concentration is not suitable for induction of emesis. is your animal breathing or does it have respiratory difficulty? what is the color of the gums or tongue? is your animal able to walk? is there any vomiting, diarrhea, trembling, or seizures? does it appear lethargic or hyperactive? what is the substance that your animal ingested (was exposed to)? did you witness the ingestion or exposure? how much did the animal consume? how long ago was the exposure? was the substance swallowed, or is it on the animal's skin or eyes? how is the patient acting? how long has the animal been acting that way? or when was the last time you saw your animal act normally? 2. first aid instructions for the client: induce vomiting at home and save the vomitus. never induce vomiting if the patient is depressed, appears comatose, or is actively seizing. if the animal has ingested a caustic substance (strong alkali or acids) or a petroleum-based product (kerosene or turpentine), never recommend induction of emesis. hydrogen peroxide (3% w/v â�  ) 5 ml = 1 tsp/10 lb of body weight can repeat once if no vomiting occurs after 10 minutes 3. remind the owner to bring a sample of the toxin and the vomitus in with the patient. 4. advise the owner to transport the patient as rapidly as possible to the nearest veterinary hospital. 1 response times. they are useful for ideas on standard and long-term therapy, but not emergency stabilization. an exception to this is the veterinary interactive network (vin), which posts message board communications. previous communications from veterinarians who treated a case with the same poison/toxin can be accessed with a subscription. many manufacturers operate an information service about their products. if the product label or name is available, check for a telephone number that may route you to a specialist. there are six essential steps in treating toxicities: 1. performing a physical examination 2. stabilizing the patient's vital signs 3. taking a thorough history 4. preventing continued absorption of the toxin 5. administering specific antidotes when available 6. facilitating clearance or metabolism of the absorbed toxin it is most important to provide symptomatic and supportive care both during and following emergency treatment. immediately on presentation, perform a brief but thorough physical examination. obtain a minimum database as well as serum, urine, or orogastric lavage samples for later toxicologic analyses. it is important at this time to systematically evaluate the patient's physical status, focusing particularly on the toxins most common to a particular geographic location and the organ systems most commonly affected by toxins in veterinary medicinenamely, the neurologic and gastrointestinal tracts. a checklist is useful when performing a complete physical examination (box 1-57). the minimium database includes a urine sample, packed cell volume, total protein, serum urea, and serum glucose. the information obtained from these simple cage-side tests is useful for determining dehydration, hemoconcentration, azotemia (renal or prerenal), and hypo-or hyperglycemia. when appropriate, obtain samples for serum biochemistry profiles, serum electrolytes, blood gases, serum osmolality, a complete hemogram, and coagulation profiles. samples of serum, urine, and any vomitus or orogastric lavage contents should be collected and saved for later toxicologic analyses as required later. stabilization of vital signs includes four major goals of treatment: maintain respiration, maintain cardiovascular function, control cns excitation, and control body temperature. in any patient with clinical signs of respiratory distress or respiratory dysfunction, supplemental oxygen should be administered via flow-by, oxygen hood, oxygen cage, nasal, nasopharyngeal, or transtracheal oxygen sources. ventilatory assistance may be necessary. irritant or corrosive substances can cause damage to the oropharyngeal mucosa to such an extent that airway obstruction occurs. when necessary, a temporary tracheostomy should be performed. arterial blood gases, pulse oximetry, and capnometry may be required to monitor oxygenation and ventilation. at the time of presentation, immediately place an intravenous catheter for administration of intravenous fluids, inotropes, antiarrhythmics, and antidotes, if necessary. the initial fluid of choice is a balanced crystalloid solution such as normosol-r, plasmalyte-m, or lactated ringer's solution. fluid therapy can later be changed based on the patient's acidbase and electrolyte status. some toxins can cause severe dysrhythmias and hyper-or hypotension. monitor blood pressure and perform ecg and correct any abnormalities according to standard therapy (see sections on hypotension and cardiac dysrhythmias). what is the pupil size? what is the pupil reactivity to light? is the ocular examination normal? what is the sensitivity to light or sound? nose: is it moist, dry, bubbling, or frothy, or caked with dirt? throat: are there any characteristic odors on the breath? are there any traces of foreign material on the tongue or in the crevices of the teeth or gums? are there petechiae or ecchymosis on the gums or bleeding from the gumline? what is the mucous membrane color? is it normal and pink, or dark red (injected), pale, or icteric? what is the capillary refill time? is it fast, normal, or slow? what is the patient's heart rate? are there any pulse deficits or dysrhythmias auscultated? what is the patient's blood pressure? what is the quality of the femoral pulse? is it synchronous with the heart rate, or are there dropped pulses? is the pulse bounding, normal, thready, or not palpable? what is the patient's electrocardiogram? what is the patient's respiratory rate? what is the patient's respiratory character? is it normal, fast, shallow, or labored? what do you hear on thoracic auscultation? do you hear harsh airway sounds or pulmonary crackles? what is the patient's rectal temperature? is there excessive salivation? is there evidence of vomiting or diarrhea? is abdominal palpation painful? do the intestinal loops feel normal, or are they fluid-filled or gas-filled? what is the color and consistency of the feces? is there a palpable urinary bladder? is there urine production? what is the color of the urine? peripheral lymph nodes should be normal in poisonings. some toxins cause hemolysis, methemoglobinemia, heinz body anemia, and coagulopathies. whole blood, fresh frozen plasma, packed rbcs, or hemoglobin-based oxygen carriers should be available and used if necessary. treat methemoglobinemia with a combination of ascorbic acid and n-acetylcysteine. many toxins affect the cns, producing clinical signs of excitation and/or seizures. diazepam is the drug of choice for most but not all seizures and tremors. if an animal has cns excitation secondary to the ingestion of selective norepinephrine reuptake inhibitors, avoid using diazepam, as it can potentially exacerbate clinical signs. muscle relaxants such as guaifenesin or methocarbamol may be required to control muscle spasm and tremors associated with some toxicities. consider animals that are in status epilepticus because of toxin exposure at high risk. such patients may not require the full dose of anesthetics or sedatives for seizure control. give phenobarbital (16-20 mg/kg iv) or pentobarbital (3-25 mg/kg iv to effect) for longer-term management of seizures. core body temperature can easily increase or decrease secondary to increased muscle activity or coma. animals may present as hypo-or hyperthermic, depending on the toxin ingested and the stage of toxicity. manage hypothermia with circulating hot water or hot air blankets, or place bubble wrap or saran wrap around the animal's peripheral extremities. manage hyperthermia by placing lukewarm wet towels on the patient until the rectal temperature has decreased to 39.5â°c (103â°f). (see section on of hyperthermia and heat-induced illness). if sedatives or anesthetics have been used, initial hyperthermia may initially resolve due to hypothalamic loss of thermoregulatory control, cool water bathing should not be performed. when the patient is first presented to the veterinarian, have the owner complete a toxicologic history form (figure 1-56) while the animal is being initially assessed and vital signs are being stabilized. when initial stabilization of vital signs has been accomplished, the veterinarian can discuss the patient's history with the owner. in urgent situations, the veterinarian should obtain a brief history as an initial procedure (box 1-58). knowing when the animal was last seen as normal provides a time frame in which the toxic substance was most likely accessed, allowing differential diagnoses to be ranked in some order of probability by rate of onset. in eliciting a history from the owner about the animal's access to poisons, it is important not to take anything for granted. many owners do not realize how poisonous some substances can be, such as insecticide products, garbage, cleaning chemicals, and over-the-counter drugs commonly used by humans. many owners will deny that an animal could have ingested anything that might be toxic, not wanting to believe that the source of the toxin is within their household or property, particularly if recreational drug exposure is suspected. it is useful to phrase questions in a neutral fashion-for example, "is such-and-such present on the premises?" rather than "could the dog have eaten such-and-such?" if recreational drug exposure is suspected, another way to question the owners is to ask whether they have had any guests in their house recently that may have had such-and-such (e.g., marijuana, cocaine, methamphetamine). this approach serves to minimize the suggestion of any bias or preconceptions. when questioning an owner about recent events, it is useful to realize and acknowledge that disruption in the household routine is a distinct factor in the occurrence accidents, including poisonings. examples of such disruptive events include moving from the house, family member is ill or in the hospital, and renovations or recent construction. while these events are occurring, the safeguards followed by a normally careful owner may be disrupted. often, doors or gates may be left open, animals may be outside instead of inside (or vice versa), and inexperienced people may be pet-sitters. once owners are made aware of the importance of assessing such risks, they are often able to provide insight into otherwise baffling circumstances. various methods can be used to remove toxins from the gastrointestinal tract, including emesis, orogastric lavage, cathartics, and enemas. adsorbents, ion exchange resins, or 1 precipitating or chelating agents may be used. removal of a toxic substance from the body surface may be necessary, depending on the toxin.the use of both emesis and orogastric lavage is less and less frequent in human medicine because of the risk of aspiration pneumonia and doubts about their efficacy. currently, management of poisonings in human medicine relies heavily on the use of activated charcoal combined with sorbitol as a cathartic, when appropriate, and supportive critical care. it should be emphasized, however, that the majority of poisonings in humans are due to drug overdoses (illicit or otherwise) (which have a relatively small volume and rapid absorption), for which this treatment is appropriate. furthermore, adoption of the approach rests on the availability of a hospital intensive care infrastructure, which is not always available in veterinary practice. induce emesis if the animal's physiology and neurologic status are stable (i.e., does not have respiratory depression or is not actively seizing, obtunded, unable to swallow or protect its airway). do not administer the same emetic more than twice. if the emetic doesn't work after two doses, give a different emetic or perform orogastric lavage under general anesthesia. emetics are strictly contraindicated for toxicity from petroleum-based products and corrosives because of the risk of aspiration pneumonia and further esophageal damage. emetics may also be of little value if poisons with antiemetic properties have been ingested, such as benzodiazepines, tricyclic antidepressants, and marijuana (table 1-50) . various emetics traditionally have been recommended for use in veterinary medicine. many have fallen out of favor because of the risk of causing adverse consequences and side effects. apomorphine (0.04 mg/kg iv or in the conjunctival sac) remains the standard but is less useful in certain situations in which the poison causes cns excitation or stimulation. it is ineffective in cats. other emetics include xylazine and hydrogen peroxide. do not use table salt because of the risk of severe oropharyngeal irritation and hypernatremia. do not use mustard powder or dishwashing liquid detergent because of the risk of severe oropharyngeal, esophageal, and gastric irritation. orogastric lavage is described in detail in the section on emergency procedures gastric lavage is contraindicated in treatment of toxicity from petroleum-based compounds and acid/alkali ingestion. the procedure can be messy but is very effective if performed within 1 to 2 hours of ingestion of the poison. to prevent aspiration, the patient should be placed under general anesthesia. keep the animal's head lowered during the procedure to prevent aspiration of stomach contents into the trachea. it is sometimes helpful to put the animal in both right and left lateral recumbency to allow complete emptying of gastric contents. repeat the procedure until the fluid runs clear from the stomach. in some cases in which solid material has been ingested, this process can take a long time, so be prepared with a large volume of warm water. following successful evacuation and lavage, administer a slurry of activated charcoal through the orogastric tube before removing it. keep the endotracheal tube cuffed and in place until the animal is semi-conscious, is starting the fight the tube, and is visibly able to swallow and protect its airway. â�¢ when was the animal last seen as normal? â�¢ what clinical signs developed? â�¢ how fast did the clinical signs develop? â�¢ when was the onset of clinical signs? â�¢ what is the animal's activity level? â�¢ does the animal have access to any poisonous substances? â�¢ this includes known toxins or chemicals, over-the-counter or prescription medications (including the owner's), and recreational drugs. enemas are useful to facilitate the action of cathartics and in cases in which the poison is a solid material (e.g., compost, snail bait, garbage) (box 1-59). it is best to use just lukewarm water. commercially available phosphate enema solutions can cause severe electrolyte disturbances (hyperphosphatemia, hyponatremia, hypocalcemia, and hypomagnesemia) and acid-base abnormalities (metabolic acidosis); therefore, they are absolutely contraindicated in small animal patients. use nonsterile nonspermicidal water-soluble lubricants (k-y jelly) old intravenous fluid bag enema bag 60-to 120-ml syringe fluid warm water, with or without hand or liquid dish soap the fluid volume required depends on the size of the animal and the state of its lower gastrointestinal tract. as with orogastric lavage, continue the procedure until the water runs clear. if difficulty is encountered emptying the lower gastrointestinal tract, repeat the enema in 1 or 2 hours, rather than be overzealous on the first attempt. cathartics are useful for hastening gastrointestinal elimination of toxins, and they are particularly useful for elimination of most solid toxicants (e.g., compost, garbage, snail baits). cathartics can be used in conjunction with activated charcoal. do not use magnesium-based cathartics in patients with cns depression, because hypermagnesemia can worsen this disorder and also cause cardiac rhythm disturbances (table 1-51) . activated charcoal (1-4 ml/kg) is the safest and to date the most effective adsorbent for the treatment of ingested toxins. activated charcoal can be administered after emesis or orogastric lavage or can be administered as the sole treatment. various preparations are available on the market, including dry powder, compressed tablets, granules, liquid suspensions, and concentrated paste preparations. commercially available products are relatively inexpensive and should be used whenever possible for ease of administration. vegetableorigin activated charcoal is the most efficient adsorbent and binds compounds with weak, nonionic bonds. some preparations are combined with sorbitol to provide simultaneous administration of an adsorbent and a cathartic; this combination has been shown to be most efficacious. repeated administration of activated charcoal every 4 to 6 hours has been shown to be beneficial in the management of a toxin that undergoes enterohepatic recirculation. administration of an oily cathartic or mixing the activated charcoal with food only serves to reduce the absorptive surface of the activated charcoal and therefore is not recommended. in general, substances that are very soluble and are rapidly absorbed are not well adsorbed by activated charcoal, including alkalis, nitrates, mineral acids, ethanol, methanol, ferrous sulfate, ammonia, and cyanide. kaolin and bentonite are clays that have been used as adsorbents. both are usually less effective than activated charcoal. however, they are reported to be better adsorbents than activated charcoal for the herbicide paraquat. ion exchange resins can ionically bind certain drugs or toxins. cholestyramine is one such resin, commonly used in human medicine to bind intestinal bile acids and thereby decrease cholesterol absorption. its application in toxicology extends to the absorption of fat-soluble toxins such as organochlorine and certain acidic compounds such as digitalis. ion exchange resins also have been used to delay or reduce the absorption of phenylbutazone, warfarin, chlorothiazide, tetracycline, phenobarbital, and thyroid preparations. precipitating, chelating, and diluting agents precipitating, chelating, and diluting agents are used primarily in the management of heavy metal intoxications, such as alkaloids or oxalates. they work by binding preferentially to the metal ion and creating a more soluble complex that is amenable to renal excretion. those chelating agents in common usage are calcium edta, deferoxamine, and d-penicillamine. calcium edta and deferoxamine should both be on hand in the veterinary hospital because they are necessary to treat zinc and iron toxicity, respectively, both of which have a short window of opportunity for therapeutic intervention. d-penicillamine has a wide application for a number of metal toxicities but tends to be used for long-term chronic therapy because it can be administered orally. various agents used for nonspecific dilution of toxins, including milk of magnesia and egg whites, although old-fashioned, still have wide application in many cases in which low-grade irritants have been ingested. bathing the animal is an important aspect of treatment for topical exposures to toxins such as insecticidal products, petroleum-based products, and aromatic oils. bathing an animal is not an innocuous procedure. to avoid hypothermia and shock, use warm water at all times. actively dry the animal to further minimize the risk of hypothermia. when bathing the animal, use rubber gloves and a plastic apron to avoid exposure to noxious agents. in most cases, a mild dishwashing soap is appropriate. medicated or antibacterial shampoos are less appropriate in this situation. for petroleum-based products in particular, dawn dishwashing liquid that "cuts the grease" works well to remove the oils. if dawn is not available, mechanics' hand cleaners or coconut oil-based soaps can be used instead. as a general principle, best results are obtained by barely wetting the patient's fur until the detergent is worked well into the fur, keeping the amount of water to a minimum until ready for the rinse. oil-based paint is best removed by clipping rather than by attempting removal with solvents, because solvents are also toxic. to remove powder products, brush and vacuum the animal before bathing it to eliminate further toxic exposure. with caustic alkaline or acidic products, the primary treatment is to dilute and flush the skin with warm water; do not attempt neutralization. neutralization can cause an exothermic reaction that causes further damage to the underlying tissues. eliminating poison from the eyes for ocular exposures, irrigate the eyes for a minimum of 20 to 30 minutes with warm (body temperature) tap water or warmed 0.9% sterile saline solution. the use of neutralizing substances is not recommended because of the risk of causing further ocular damage. following adequate irrigation, treat chemical burns of the eyes with lubricating ointments and possibly a temporary tarsorrhaphy. atropine may be indicated as a cycloplegic agent. systemic nonsteroidal antiinflammatory drugs can be used to control patient discomfort. daily follow-up examinations are required because epithelial damage may be delayed, especially with alkali burns, and it is difficult to predict the final extent of ocular damage. topical glucocorticosteroids are contraindicated if the corneal epithelium is not intact. if severe conjunctival swelling is present with a corneal ulcer, parenteral glucocorticosteroids can be administered to help alleviate inflammation, but nonsteroidal antiinflammatory drugs should not be used simultaneously due to the risk of gastrointestinal ulceration or perforation. whenever possible, administer specific antidotes to negate the effects of the toxin and prevent conversion of the substance to the toxic metabolite. three categories of agents are used in the management of poisonings. the first category is specific antidotes. unfortunately, few specific antidotes are available for use in veterinary medicine. some "classic" toxins and antidotes are now considered to be rare, such as curare and physostigmine, thallium and prussian blue, and fluoride and calcium borogluconate. these and a few others have been omitted from the table. the second, broader category of antidotes includes those drugs used in the symptomatic management of clinical signs, which are part of our routine veterinary stock. drugs such as atropine, sedatives, steroids, antiarrhythmics, and beta-blockers fall into this category. the third category comprises nonspecific decontaminants such as activated charcoal, cathartics, and emetics. these were discussed previously. many patients benefit from efforts to enhance clearance or metabolism of the absorbed toxins. some specific therapies have been developed for this purpose, including 4-methylpyrazole for ethylene glycol toxicity and specific antibodies such as digibind (digoxin immune fab [ovine]) for digitalis toxicity. other strategies are aimed at promoting renal excretion. renal excretion strategies include diuresis, ion trapping, and peritoneal dialysis or hemodialysis (see section on peritoneal dialysis). diuresis and ion trapping are applicable to a large number of toxins and are discussed here in more detail. other toxins respond to urine acidification and urine alkalinization. enhancing renal excretion of substances is most useful for those organic substances that are present in significant concentrations in the plasma. substances that are non-ionic and lipid-soluble, such as certain herbicides, are likely to be less affected by attempts to promote rapid renal elimination. before starting diuresis or ion trapping, intravenous fluid therapy should be adequate as determined by normal central venous pressure, urine output, and mean arterial blood pressure. if any of these values are less than normal, use other measures to ensure adequate renal perfusion, including but not limited to a constant rate infusion of dopamine. simple fluid diuresis can influence the excretion of certain substances. the use of mannitol as an osmotic diuretic may reduce the passive reabsorption of some toxic substances in the proximal renal convoluted tubule by reducing water reabsorption. dextrose (50%) can be used as an osmotic diuretic. furosemide can be used to promote diuresis, but again, there is no substitute for intravenous fluid therapy. the use of mannitol, dextrose, and furosemide is contraindicated in hypotensive or hypovolemic patients. take care to avoid causing dehydration with any diuretic; central venous pressure monitoring is strongly recommended. ion trapping is based on the principle that ionized substances do not cross renal tubular membranes easily, and are not well reabsorbed. if the urinary ph can be changed so that the toxin's chemical equilibrium shifts to its ionized form, then that toxin can be "trapped" in the urine and excreted. alkaline urine favors the ionization of acidic compounds, and acidic urine favors the ionization of alkaline compounds. those toxins that are amenable to ion trapping are mostly weak acids and weak bases. ammonium chloride can be used to promote urinary acidification. contraindications to the use of ammonium chloride include a preexisting metabolic acidosis, hepatic or renal insufficiency, and hemolysis or rhabdomyolysis leading to hemoglobinuria or myoglobinuria. signs of ammonia intoxication include cns depression and coma. when performing urine acidification, frequently check the serum potassium concentration and urine ph. urine alkalinization can be performed with use of sodium bicarbonate. contraindications to the use of sodium bicarbonate include metabolic alkalosis (particularly with concurrent use of furosemide), hypocalcemia, and hypokalemia. as with urine acidification, monitor the serum potassium concentration and urine ph frequently. the major steps in management of poisonings discussed here must be accompanied by application of the fundamentals of critical care. respiratory and cardiovascular support have been discussed previously. renal and gastrointestinal function and analgesia are particularly important in the management of the poisoning patient. maintenance of renal perfusion is a priority in the poisoning patient. fluid, electrolyte, and acid-base balance must be controlled and be accurate. poisoning patients are at particularly high risk for renal damage and acute renal failure, whether by primary toxic insult to the renal parenchyma or by acute or prolonged renal hypoperfusion. for this reason, a protocol that aims at preventing oliguria and ensuing renal failure is one of the therapeutic strategies that should be routinely employed. this protocol is described in box 1-60. gastrointestinal protectant drugs may be indicated for the management of those poisons that are gastrointestinal irritants or ulcerogenic. commonly used gastroprotectant drugs include cimetidine, ranitidine, famotidine, omeprazole, sucralfate, and misoprostol. antiemetics may be used to suppress intractable vomiting. metoclopramide is commonly used, and it is the drug of choice for centrally mediated nausea. antiemetics that work by different mechanisms can be used in combination as necessary. examples are dopamine 2-receptor antagonists such as prochlorperazine, 5-hydroxytryptamine antagonists such as ondansetron and dolasetron, and h-1 receptor antagonists such as diphenhydramine and meclizine. analgesics are more appropriate to treat poisonings than once thought. common effects of poisons including severe gastroenteritis and topical burns or ulcerations may warrant the use of analgesics. longer-acting analgesics such as morphine, hydromorphone, and buprenorphine are particularly useful. nutritional support may be necessary in the form of enteral or parenteral feeding in patients that have esophageal or gastric damage or that need to be sedated for long periods of time. endoscopy may be useful in assessing the degree of esophageal and gastric damage, particularly after ingestion of caustic substances. introduction: acetaminophen (paracetamol) is the active ingredient in tylenol and many over-thecounter cold products. acetaminophen is converted to n-acetyl-p-benzoquinonimine in the liver, a toxic substance that can cause oxidative injury of red blood cells and hepatocytes. clinical signs of acetaminophen toxicity include respiratory distress from lack of oxygen-carrying capacity, cyanosis, methemoglobinemia (chocolate-brown appearance of the blood and mucous membranes), lethargy, vomiting, and facial and paw swelling (cats). the toxic dose of acetaminophen is >100 mg/kg for dogs, and 50 mg/kg for cats. treatment of acetaminophen toxicity includes induction of emesis or orogastric lavage if the substance has been ingested within 30 minutes. activated charcoal should also be administered. in cases of severe anemia, give supplemental oxygen along with a packed rbc transfusion. administer intravenous fluids to maintain renal and hepatic perfusion. n-acetylcysteine, vitamin c, and cimetidine are the treatments of choice for methemoglobinemia in patients with acetaminophen toxicity. introduction: hydrochloric, nitric, and phosphoric acids cause chemical burns through contact with the skin and/or eyes. localized superficial coagulative necrosis occurs upon contact. usually, the patient's skin is painful to the touch or the animal may lick or chew at an irritated area that is not visible under the haircoat. if the chemical is swallowed, do not induce emesis or perform orogastric lavage, because of the risk of worsening esophageal irritation. rinse the patient's skin and eyes with warm water or warm saline for a minimum of 1 /2 hour. use analgesics and treat corneal ulcers (see section on corneal ulcers) as required. do not attempt chemical neutralization, because of the risk of causing an exothermic reaction and worsening tissue injury. aflatoxin (aspergillus flavus) is found in moldy feed grains. clinical signs of toxicity occur after ingestion and include vomiting, diarrhea, and acute hepatitis; abortion may occur in pregnant bitches. treatment of suspected aflatoxin ingestion consists of gastric decontamination, administration of activated charcoal, intravenous fluids, and hepatic supportive care (s-adenosyl methionine [same], milk thistle). drinking (ethanol), rubbing (isopropyl), and methyl (methanol) alcohols can be harmful if ingested (4.1 to 8.0 g/kg po). all cause disruption of neuronal membrane structure, impaired motor coordination, cns excitation followed by depression, and stupor that can lead to cardiac and respiratory arrest, depending on the amount ingested. affected animals may appear excited and then ataxic and lethargic. contact or inhalant injury can occur, causing dermal irritation and cutaneous hyperemia. methanol also can cause hepatotoxicity. 1 and diarrhea result from muscarinic overload. nicotinic overload produces muscle tremors. toxicity can result in seizures, coma, and death. 1 and cause severe irritation and corrosion of the mucous membranes and skin. some compounds also can cause clinical signs similar to those observed with anticholinesterase compounds, including muscle tremors, seizures, paralysis, and coma. methemoglobinemia can occur. 1 signs of ethylene glycol intoxication and renal impairment or failure, a negative test for the presence of calcium oxalate crystalluria means that there is no more ethylene glycol in the patient's serum because it has all been metabolized. cats are very sensitive to the toxic effects of ethylene glycol. in many cases, cat may have ingested a toxic dose, but because the sensitivity of the assay is low, test results will be negative. lack of treatment can result in death. there are three phases of ethylene glycol intoxication. in the first 1 to12 hours after ingestion (stage i), the patient may appear lethargic, disoriented, and ataxic. in stage ii (12 to 24 hours following ingestion), the patient improves and appears clinically normal. in stage iii (24 to 72 hours following ingestion), the patient demonstrates clinical signs of renal failure (polyuria and polydipsia) that progress to uremic renal failure (vomiting, lethargy, oral ulceration). finally, seizures, coma, and death occur. crosses, old english sheepdogs, and some terriers. clinical signs of ivermectin toxicity include vomiting, ataxia, hypersalivation, agitation, tremors, hyperactivity, hyperthermia, hypoventilation, coma, seizures, signs of circulatory shock, bradycardia, and death. clinical signs often occur within 2 to 24 hours after ingestion or iatrogenic overdose. blood ivermectin levels can be measured, but diagnosis is often made based on clinical signs and knowledge of exposure in predisposed breeds. there is no known antidote. the clinical course can be prolonged for weeks to months before recovery occurs. to treat known exposure, induce emesis or perform orogastric lavage if the substance was ingested was within 1 hour of presentation and the patient is not symptomatic. administer activated charcoal. control seizures with phenobarbital, pentobarbital, or propofol administered as intermittent boluses or as a constant rate infusion. diazepam, which potentially can worsen central nervous stimulation, is contraindicated. administer intravenous fluids to maintain perfusion and hydration, and treat hyperthermia. supportive care may be necessary, including supplemental oxygen (or mechanical ventilation, if necessary), frequent turning of the patient and passive range-of-motion exercises, placement of a urinary catheter to maintain patient cleanliness and monitor urine output, lubrication of the eyes, and parenteral nutrition (see section on rule of twenty). specific antidotes used to treat ivermectin toxicity include physostigmine and picrotoxin. physostigmine therapy was beneficial in some patients for a short period; picrotoxin caused severe violent seizures and therefore should be avoided. introduction d-limonene and linalool are components of citrus oil extracts used in some flea control products. the toxic dose is unknown, but cats appear to be very sensitive to exposure. clinical signs of toxicity include hypersalivation, muscle tremors, ataxia, and hypothermia. treatment of d-limonene and linalool exposure includes treatment of hypothermia, administration of activated charcoal to prevent further absorption, and careful, thorough bathing to prevent further dermal exposure. lead is ubiquitous, and is found in some paints, car batteries, fishing equipment/ sinkers, and plumbing materials. lead can be toxic at doses of 3 mg/kg. if more than than 10-25 mg/kg of lead is ingested, death can occur. lead causes toxicity by inhibiting sulfur-containing enzymes, leading to increased rbc fragility, and cns damage. clinical signs of hyperexcitability, dementia, vocalization, seizures, and lower motor neuron polyneuropathy can occur. affected animals may appear blind, or vomiting, anorexia, and constipation or diarrhea may occur. if lead toxicity is suspected, blood and urine lead levels can be measured. treatment of lead toxicity is supportive and is directed at treatment of clinical signs. control seizures with diazepam or phenobarbital. if cerebral edema is present, administer mannitol (0.5-1.0 g/kg iv), followed by furosemide (1 mg/kg iv 20 minutes after mannitol). sodium or magnesium sulfate should be administered as a cathartic. initiate chelation therapy with dimercaprol, penicillamine, or calcium edta. if a lead object is identified in the gastrointestinal tract on radiographs, remove the object using endoscopy or exploratory laparotomy. 1 hyperthermia, that occurs within 15 -30 minutes of ingestion. diarrhea and convulsions can develop. if hyperthermia is severe, renal failure secondary to myoglobinuria and disseminated intravascular coagulation can result. delayed hepatic failure has been described days after initial recovery. if metaldehyde toxicosis is suspected, analysis of urine, serum, and stomach contents is warranted. to treat metaldehyde toxicity, procure and maintain a patent airway and control cns excitation and muscle tremors. if an animal has just ingested the metaldehyde and is not symptomatic, induce emesis. if clinical signs are present, perform orogastric lavage. both emesis and orogastric lavage should be followed by administration of one dose of activated charcoal. administer intravenous fluids to control hyperthermia, prevent dehydration, and correct acid-base and electrolyte abnormalities. methocarbamol is the treatment of choice to control muscle tremors. diazepam can be used to control seizures if they occur. introduction mushroom ingestion most commonly causes activation of the autonomic nervous system, resulting in tremors, agitation, restlessness, hyperexcitability, and seizures. in some cases slud (salivation, lacrimation, urination, and defecation) is seen. some mushrooms (amanita spp.) also can cause hepatocellular toxicity. clinical signs include vomiting, anorexia, lethargy, and progressive icterus. 1 hemoglobinuria and pigment damage of the renal tubular epithelium. heinz bodies may be observed on cytologic evaluation of the peripheral blood smear. 1 paint in a sorbitol or glycerol carrier. when large quantities of these osmotically active sugars are ingested, osmotic shifts of fluid cause a sudden onset of neurologic or gastrointestinal signs, including ataxia, seizures, and osmotic diarrhea caused by massive fluid shifts into the gastrointestinal tract. the loss of water in excess of solute can result in hypernatremia, a free water deficit, and increased serum osmolality. following orogastric lavage, treatment of ingestion includes administering warm water enemas to help speed the movement of the paintballs through the gastrointestinal tract. do not administer activated charcoal (usually in a propylene glycol carrier), because the compound's cathartic action will pull more fluid into the gastrointestinal tract. baseline electrolytes should be obtained and then carefully monitored. if severe hypernatremia develops, administer hypotonic solutions such as 0.45% nacl + 2.5% dextrose or 5% dextrose in water after calculating the patient's free water deficit. because of the large volume of fluid loss, intravenous fluid rates may seem excessive but are necessary to normalize acid-base, electrolyte, and hydration status. in most cases, these patients can survive if the problem is recognized promptly and corrected with careful electrolyte monitoring, aggressive decontamination strategies, and intravenous fluid support. introduction paraquat, a dipyridyl compound, is the active ingredient in some herbicides. the ld 50 of paraquat is 25-50 mg/kg. paraquat initially causes cns excitation. it also causes production of oxygen-derived free radical species in the lungs, that can lead to the development of acute respiratory distress syndrome. initial clinical signs include vomiting, diarrhea, and seizures. within 2 to 3 days, clinical signs associated with severe respiratory distress and acute respiratory distress syndrome (ards) can develop, leading to death. chronic effects include pulmonary fibrosis, if the patient survives the initial toxicity period. the prognosis for paraquat toxicity is generally unfavorable. to treat paraquat ingestion, remove the toxin from the gastrointestinal tract as rapidly as possible after ingestion. there are no known antidotes. if the compound was ingested within the past hour and the animal is able to protect its airway, induce emesis. otherwise, perform orogastric lavage. activated charcoal is not as effective as clay or bentonite adsorbents for removing this particular toxin. early in the course of paraquat toxicity, oxygen therapy is contraindicated because of the risk of producing oxygen-derived free radical species. later, oxygen therapy, including mechanical ventilation, is necessary if ards develops. experimentally, free radical scavengers (n-acetyl cysteine, vitamin c, vitamin e, same) have been shown to be useful in preventing damage caused by oxygen-derived free radical species. hemoperfusion may be useful in eliminating the toxin, if it is performed early in the course of toxicity. pennyroyal oil is an herbal flea control compound that contains menthofuran as its toxic compound. menthofuran is hepatotoxic and may cause gastrointestinal hemorrhage and coagulopathies. to treat toxicity, administer a cathartic and activated charcoal and antiemetic and gastroprotectant drugs, and thoroughly bathe the animal to prevent further dermal exposure. petroleum distillates: see fuels phenobarbital: see barbiturates phenylcyclidine (angel dust) introduction phenylcyclidine (angel dust) is an illicit recreational drug that causes both cns depression and excitation, decreased cardiac output, and hypotension. to treat phenylcyclidine toxicity, place an intravenous catheter, and administer intravenous fluids and antiarrhythmic drugs to maintain organ perfusion. administer supplemental oxygen, and administer diazepam to control seizures. urine alkalinization can help eliminate the compound. phenylephrine is an î±-adrenergic agonist in many over-the-counter decongestant preparations. clinical signs of intoxication include mydriasis, tachypnea, agitation, hyperactivity, and abnormal flybiting and staring behavior. tachycardia, bradycardia, hypertension, hyperthermia, and seizures can occur. to treat phenylephrine toxicity, place an intravenous catheter and give intravenous fluids to maintain hydration, promote diuresis, and treat hyperthermia. administer prazosin or sodium nitroprusside to treat hypertension, antiarrhythmic drugs as necessary, and diazepam to control seizures. phenylpropanolamine has both î±and î²-adrenergic agonist effects, and is used primarily in the treatment of urinary incontinence in dogs. the drug was taken off of the market for use in humans because of the risk of stroke. clinical signs of phenylpropanolamine intoxication include hyperactivity, hyperthermia, mydriasis, tachyarrhythmias or bradycardia, hypertension, agitation, and seizures. to treat toxicity, administer prazosin or nitroprusside to control hypertension, a betablocker (esmolol, propranolol, atenolol) to control tachyarrhythmias, diazepam to control seizures, and intravenous fluids to maintain hydration and promote diuresis. urine acidification may aid in facilitating excretion. if bradycardia occurs, do not use atropine. pseudoephedrine is an î±and î²-adrenergic agonist that is a component of many over-thecounter decongestants and is used in the manufacture of crystal methamphetamine. clinical signs of toxicity include severe restlessness, tremors, mydriasis, agitation, hyperthermia, tachyarrhythmias or bradycardia, hypertension, and seizures. to treat toxicity, administer activated charcoal, intravenous fluids to promote diuresis and treat hyperthermia, chlorpromazine to combat î±-adrenergic effects, a beta-blocker (propranolol, esmolol, atenolol) to treat î²-adrenergic effects, and cyproheptadine (per rectum) to combat serotoninergic effects. piperazine is a gaba agonist, and causes cervical and truncal ataxia, tremors, seizures, coma, and death. salt used for thawing ice commonly contains calcium chloride, a compound that has a moderate toxic potential. calcium chloride produces strong local irritation and can cause gastroenteritis and gastrointestinal ulcers if ingested. respiratory emergencies consist of any problem that impairs delivery of oxygen to the level of the alveoli or diffusion of oxygen across the alveolar capillary membrane into the pulmonary capillary network. decreased respiratory rate or tidal volume can result in hypoxia and buildup of carbon dioxide, or hypercarbia, leading to respiratory acidosis. conditions most frequently encountered result in airflow obstruction, prevention of normal lung expansion, interference with pulmonary gas exchange (ventilation-perfusion mismatch), and alterations of pulmonary circulation. evaluation of the patient with respiratory distress is often challenging, because the most minimal stress can cause rapid deterioration, or even death in critical cases. careful observation of the patient from a distance often allows the clinician to determine the severity of respiratory distress and localize the lesion based on the patient's respiratory pattern and effort. animals in respiratory distress often have a rapid respiratory rate (>30 breaths per minute). as respiratory distress progresses, the patient may appear anxious and start openmouth breathing. the animal often develops an orthopneic posture, characterized by neck extension, open-mouthed breathing, and elbows abducted or pulled away from the body. cyanosis of the mucous membranes often indicates extreme decompensation. clinical signs of respiratory distress can develop acutely, or from decompensation of a more chronic problem that was preceded by a cough, noisy respirations, or exercise intolerance. localization of the cause of respiratory distress is essential to successful case management. in any patient with clinical signs of respiratory distress, the differential diagnosis should include primary pulmonary parenchymal disease, airway disease, thoracic cage disorders, congestive heart failure, dyshemoglobinemias (carbon monoxide, methemoglobin), and anemia. careful observation of the patient's respiratory pattern can aid in making a diagnosis of upper airway disease/obstruction, primary pulmonary parenchymal disease, pleural space disease, and abnormalities of the thoracic cage. it is often helpful to rest a hand on the patient and breathe along with the patient's effort, to confirm the periods of inhalation and exhalation. the pharynx, larynx, and extrathoracic trachea comprise the upper airway. obstructive lesions are associated with a marked inspiratory wheeze or stridor and slow deep inspiratory effort. auscultation of the larynx and trachea may reveal more subtle obstructions of normal air flow. stridor can usually be auscultated without the use of a stethoscope. lung sounds are usually normal. the neck should be carefully palpated for a mass lesion, tracheal collapse, and subcutaneous emphysema. subcutaneous emphysema suggests tracheal damage or collapse secondary to severe trauma. in some cases, there is a history of voice, or bark, change secondary to laryngeal dysfunction. differential diagnosis is usually based on the patient's signalment, history, and index of suspicion of a particular disease process. differential diagnoses of upper airway obstruction are listed in box 1-61. diseases of the pleural space often are associated with a restrictive respiratory pattern. inspiratory efforts are short, rapid, and shallow, and there is often a marked abdominal push. the pattern has been referred to as a choppy "dysynchronous" respiratory pattern. depending on the disease present, lung sounds may be muffled ventrally and enhanced dorsally. percussion of the thorax reveals decreased resonance if fluid is present. increased resonance is present with pneumothorax. decreased compressibility of the anterior thorax may be present with an anterior mediastinal mass lesion, particularly in cats and ferrets. a pneumothorax or diaphragmatic hernia is commonly associated with evidence of trauma, with or without rib fractures. respiratory distress due to hemothorax may be exacerbated by anemia. differential diagnoses for patients with evidence of pleural cavity disease include pneumothorax, diaphragmatic hernia, neoplasia, and various types of pleural effusion. primary pulmonary parenchymal disease can involve the intrathoracic airways, alveoli, interstitial space, and pulmonary vasculature. a rapid, shallow, restrictive respiratory pattern may be observed with a marked push on exhalation, particularly with obstructive airway disease such as chronic bronchitis (asthma) in cats. crackles or wheezes are heard on thoracic auscultation. differential diagnoses for pulmonary parenchymal disease include cardiogenic and noncardiogenic pulmonary edema, pneumonia, feline bronchitis (asthma), pulmonary contusion, aspiration pneumonitis, pulmonary thromboembolism, neoplasia, infection (bacterial, fungal, protozoal, viral) , and/or chronic bronchitis. other abnormal respiratory patterns may be evident, and warrant further consideration. tachypnea present in the absence of other signs of respiratory distress can be a normal response to nonrespiratory problems, including pain, hyperthermia, and stress. a restrictive respiratory pattern with minimal thoracic excursions can be associated with diseases of neuromuscular function, including ascending polyradiculoneuritis, botulism, and tick paralysis. if adequate ventilation cannot be maintained by the patient, mechanical ventilation may be indicated. kussmaul respiration manifests as very slow, very deep respirations when a metabolic acidosis is present. this type of respiratory pattern typically is observed in patients with severe diabetic ketoacidosis and renal failure in a compensatory attempt to blow off carbon dioxide. cheyne-stokes respiration is usually observed with a defect in the central respiratory control center. the classic pattern of cheyne-stokes respiration is normal or hyperventilation followed by a period of apnea or hypoventilation. in cases of lower cervical cord damage or damage to the central respiratory control center in the cns, the diaphragm alone may assume most of the ventilatory movement. with diaphragmatic fatigue, severe hypoventilation and resultant hypoxemia may require mechanical ventilation. immediate management of any patient in respiratory distress is to minimize stress at all costs. relatively benign procedures such as radiography or intravenous catheter placement can be fatal in patients with severe respiratory compromise. stabilization should always precede further diagnostic evaluation. in some cases, sedation may be required before performing any diagnostics, to prevent further stress. all patients should receive some form of supplemental oxygen, either by mask, cage, or flow-by techniques. in cases in which a severe pneumothorax or pleural effusion is suspected, perform therapeutic and diagnostic thoracocentesis bilaterally to allow lung re-expansion and alleviate respiratory distress, whenever possible. if thoracocentesis alone is not effective at maintaining lung re-expansion, place a thoracostomy tube (particularly in cases of tension pneumothorax). if hypovolemic/ hemorrhagic shock is present, initiate treatment while stabilizing the respiratory system (see section on shock). if an animal is suspected of having an upper airway obstruction, reestablish airflow. in cases of laryngeal paralysis, tracheal collapse, and brachycephalic airway syndrome, sedation is often very useful in alleviating the distress of airway obstruction. in cases of laryngeal collapse, however, sedation may make the condition worse. if laryngeal edema is severe, administer a dose of short-acting glucocorticosteroids (dexamethasone sodium phosphate) to decrease laryngeal inflammation and edema. if a foreign body is lodged in the pharynx, perform the heimlich maneuver by thrusting bluntly several times on the patient's sternum. objects such as balls or bones may be small enough to enter the larynx but too large to be expelled, and will require rapid-acting general anesthesia to facilitate dislodgement and removal. if the obstruction cannot be removed, bypassing the obstruction with an endotracheal tube or temporary tracheostomy should be considered. in an emergency, a temporary transtracheal oxygen catheter can quickly be placed in the following manner. connect a 20-or 22-gauge needle to a length of intravenous extension tubing and a 3-ml syringe. place the male connector of the syringe into the female portion of the extension tubing. cut off the syringe plunger and connect the resulting blunt end to a length of flexible tubing attached to a humidified oxygen source. run the oxygen at 10 l/minute to provide adequate oxygenation until a tracheostomy can be performed. (see sections on oxygen supplementation and tracheostomy). once the animal's condition has been stabilized, specific diagnostic tests, including arterial blood gas analyses, thoracic radiographs, and/or transtracheal wash, can be performed, depending on the patient's condition and needs. specific therapies for management of upper airway obstruction, pleural space disease, and pulmonary disease are discussed next. upper airway obstruction can occur as a result of intraluminal or extraluminal mass lesions or foreign bodies in the oropharynx (abscess, neoplasia), laryngeal paralysis, trauma, and anatomic abnormalities. clinical signs of an upper airway obstruction are associated with an animal's extreme efforts to inhale air past the obstruction. marked negative pressure occurs in the extrathoracic airways and can cause worsening of clinical signs. mucosal edema and inflammation further worsen the obstruction. therapy for upper airway obstruction is aimed at breaking the cycle of anxiety and respiratory distress. administer the anxiolytic tranquilizer acepromazine (0.02-0.05 mg/kg iv, im, sq) to decrease patient anxiety. many animals develop hyperthermia from increased respiratory effort and extreme anxiety. implement cooling measures in the form of cool intravenous fluids and wet towels soaked in tepid water placed over the animal (see section on hyperthermia). administer supplemental oxygen in a manner that is least stressful for the animal. short-acting glucocorticosteroids can also be administered (dexamethasone sodium phosphate, 0.25 mg/kg iv, sq, im) to decrease edema and inflammation. if the airway obstruction is severe and there is no response to initial measures to alleviate anxiety and decrease inflammation, establish control of ventilation by placement of an endotracheal tube (see section on endotracheal intubation), tracheal oxygen catheter, or temporary tracheostomy. to obtain airway control, administer a rapid-acting anesthetic (propofol, 4-7 mg/kg iv to effect), and intubate with a temporary tracheostomy. an intratracheal oxygen catheter can be placed with sedation and/or a local anesthetic (see technique for transtracheal wash). laryngeal paralysis is a congenital or acquired condition that occurs primarily in largebreed dogs secondary to denervation of the arytenoid cartilages by the recurrent laryngeal nerve. congenital laryngeal paralysis occurs in the bouvier des flandres, siberian husky, and bull terrier. acquired laryngeal paralysis occurs in labrador retrievers, saint bernards, and irish setters. acquired laryngeal paralysis can be idiopathic, acquired secondary to trauma to the recurrent laryngeal nerve, or can be a component of systemic neuromuscular disease. although rare, this condition also occurs in cats. with dysfunction of the recurrent laryngeal nerve, the intrinsic laryngeal muscles atrophy and degenerate. as a result, the vocal folds and arytenoid cartilage move in a paramedian position within the airway and fail to abduct during inhalation, causing airway obstruction. laryngeal paralysis can be partial or complete, unilateral or bilateral. in many cases, a change in bark is noted prior to the development of clinical signs of respiratory distress or exercise intolerance. when a patient presents with severe inspiratory stridor (with or without hyperthermia) initiate stabilization with anxiolytic tranquilizers, supplemental oxygen, and cooling measures. once the patient's condition has been stabilized, definitive measures to accurately document and assess the patient's airway should be considered. place the patient under very heavy sedation with short-acting barbiturates or propofol (4-7 mg/kg iv) and observe the arytenoid cartilages closely in all phases of respiration. administer just enough drug to allow careful examination without getting bitten. if the arytenoid cartilages do not abduct during inhalation, administer dopram (doxapram hydrochloride, 1-5 mg/kg iv) to stimulate respiration. absent or paradoxical laryngeal motion (closed during inspiration and open during exhalation) is characteristic of laryngeal paralysis. correction of the defect involves documentation and treatment of any underlying disorder and surgical repair of the area to open the airway. partial laryngectomy, arytenoid lateralization ("tie-back" surgery), or removal of the vocal folds has been used with some success. aspiration pneumonitis is common following these procedures. brachycephalic airway syndrome is associated with a series of anatomic abnormalities that collectively increase resistance to airflow. affected animals typically have stenotic nares, an elongated soft palate, and a hypoplastic trachea. components of the syndrome can occur alone or in combination. in severe cases, laryngeal saccular edema and eversion, and eventual pharyngeal collapse, can occur secondary to the severe increase in intrathoracic airway pressure required to overcome the resistance of the upper airways. specific airway anomalies can be identified with general anesthesia and laryngoscopy. severe respiratory distress should be treated as discussed previously. treatment requires surgical correction of the anatomic abnormalities. in animals with laryngeal collapse, surgical correction may not be possible, and a permanent tracheostomy may be required. because an elongated soft palate and stenotic nares can be identified before the onset of clinical signs, surgical correction to improve airflow when the animal is young may decrease the negative intra-thoracic pressure necessary to move air past these obstructions. the chronic consequences of everted laryngeal saccules and laryngeal collapse potentially can be prevented. tracheal collapse is common in middle-aged and older toy and small-breed dogs. the owner typically reports a chronic cough that is readily induced by excitement or palpation of the trachea. the cough often sounds like a "goose honk." diagnostic confirmation is obtained by lateral radiography or fluoroscopy of the cervical and thoracic trachea during all phases of respiration. acute decompensation is uncommon but does occur, particularly with excitement, exercise, and increased environmental temperatures or ambient humidity. therapy of the patient with acute respiratory distress secondary to tracheal collapse includes sedation, administration of supplemental oxygen, and provision of cooling measures to treat hyperthermia. cough suppressants (hydrocodone bitartrate-homatropine methylbromide, 0.25 mg/kg po q8-12h, or butorphanol, 0.5 mg/kg po q6-12h) are useful. tracheal collapse is a dynamic process that usually involves both the upper and lower airways. because of this, bypassing the obstruction is often difficult. tracheal stents have been 256 1 emergency care 1 used with limited success in combination with treatment of chronic lower airway disease. crush or bite injuries to the neck can result in fractures or avulsion of the laryngeal or tracheal cartilages. bypassing the obstructed area may be necessary until the patient is stable and can undergo surgical correction of the injury. if there is avulsion of the cranial trachea, it may be difficult to intubate the patient. a long, rigid urinary catheter can be inserted past the area of avulsion into the distal segment, and an endotracheal tube passed over the rigid catheter, to establish a secure airway. neck injury can also result in damage to the recurrent laryngeal nerve and laryngeal paralysis. foreign bodies can lodge in the nasal cavity, pharynx, larynx, and distal trachea. signs of foreign bodies in the nares include acute sneezing and pawing at or rubbing the muzzle on the ground. if the object is not removed, sneezing continues and a chronic nasal discharge develops. respiratory distress is uncommon, but the foreign body is severely irritating. pharyngeal and tracheal foreign bodies can cause severe obstruction to airflow and respiratory distress. diagnosis of a foreign body is based on the patient history, physical examination findings, and thoracic or cervical radiographs. smaller foreign bodies lodged in the distal airways may not be apparent radiographically but can cause pulmonary atelectasis. foreign bodies of the nose or pharynx can often be removed with an alligator forceps with the patient under anesthesia. if removal is not possible with a forceps, flushing the nasal cavity from cranial to caudal (pack the back of the mouth with gauze to prevent aspiration) can sometimes dislodge the foreign material into the gauze packing. rhinoscopy may be necessary. if an endoscope is not available, an otoscope can be used. foreign objects lodged in the trachea can be small and function like a ball valve during inhalation and exhalation, causing episodic hypoxia and collapse. when attempting to remove these objects, suspend the patient with its head down. remove the object with an alligator forceps, using a laryngoscope to aid in visualization. foreign bodies lodged in the trachea or bronchi require removal with endoscopic assistance. nasopharyngeal polyps (in cats, tumors, obstructive laryngitis, granulomas, abscesses, and cysts) can cause upper airway obstruction. clinical signs are usually gradual in onset. the lesions can be identified through careful laryngoscopic examination performed with the patient under general anesthesia. the nasopharynx above the soft palpate should always be included in the examination. pedunculated masses and cysts are excised at the time of evaluation. biopsy of diffusely infiltrative masses is indicated for histologic examination and prognosis. it is impossible to distinguish obstructive laryngitis from neoplasia based on gross appearance alone. whenever possible, material should be collected from abscesses and granulomas for cytologic evaluation and bacterial culture. extraluminal masses impinge on and slowly compress the upper airways, resulting in slow progression of clinical signs. masses are usually identified by palpation of the neck. enlarged mandibular lymph nodes, thyroid tumors, and other neoplasms may be present. diagnosis is usually based on a combination of radiography and ultrasonography. ct and/or mri are helpful in identifying the full extent and invasiveness of the lesion. definitive diagnosis is made with a fine-needle aspirate or biopsy. many thyroid tumors bleed excessively. the inside of each side of the hemithorax is covered in parietal pleura. the lung lobes are covered in visceral pleura. the two surfaces are in close contact with each other, and are contiguous at the hilum under normal circumstances. pneumothorax refers to free air within the pleural space, accumulating in between the parietal and visceral pleura. the term pleural effusion refers to fluid accumulation in that area but does not reflect the amount or type of fluid present. the mediastinal reflections of the pleura typically are thin in dogs and cats, and usually, but not always, connect. bilateral involvement of pneumothorax or pleural effusion is common. both pneumothorax and pleural effusion compromise the lungs' ability to expand and result in hypoxia and respiratory distress. pneumothorax can be classified as open versus closed, simple versus complicated, and tension. an open pneumothorax communicates with the external environment through a rent in the thoracic wall. a closed pneumothorax results from tears in the visceral pleura but does not communicate with the outside. a tension pneumothorax occurs as a result of a tear in the lung or chest wall that creates a flap valve, such that air is allowed to leave the lung and accumulate in the pleural space during inhalation, and closes to seal off exit of air from the pleural space during exhalation. tension pneumothorax can cause rapid decline in cardiopulmonary status and death if not recognized and treated immediately. a simple pneumothorax is one that can be controlled with a simple thoracocentesis. complicated pneumothorax involves repeated accumulation of air, requiring placement of a thoracic drainage catheter. in many cases, pneumothorax develops as a result of trauma. spontaneous pneumothorax occurs with rupture of cavitary lesions of the lung that may be congenital or acquired as a result of prior trauma, heartworm disease, airway disease (emphysema), paragonimiasis, neoplasia, or lung abscess. pneumothorax also rarely occurs as a result of esophageal tears or esophageal foreign bodies. rapid circulatory and respiratory compromise following traumatic pneumothorax can develop as a result of open or tension pneumothorax, rib fractures, airway obstruction, pulmonary contusions, hemothorax, cardiac dysrhythmias, cardiac tamponade, and hypovolemic shock. any patient that is rapidly decompensating after a traumatic episode must be quickly assessed, and emergency therapy initiated (see section on immediate management of trauma, a crash plan). diagnosis of pneumothorax is usually made based on a history of trauma, a rapid, shallow, restrictive respiratory pattern, and muffled heart and lung sounds on thoracic auscultation. the clinical signs and history alone should prompt the clinician to perform a bilateral diagnostic and therapeutic thoracocentesis before taking thoracic radiographs (see section on thoracocentesis). the stress of handling the patient for radiography can be deadly in severe cases of pneumothorax. although the mediastinum on both sides of the thorax connects, it is necessary to perform thoracocentesis on both sides to ensure maximal removal of free air in the pleural space and allow maximal lung expansion. if negative pressure cannot be obtained, or if the patient rapidly reaccumulates air, place a thoracostomy tube connected to continuous suction. (see section on thoracostomy tube placement). treat all penetrating wounds to the thorax as open sucking chest wounds unless proved otherwise. to "close" an open sucking chest wound, clip the fur around the wound as quickly as possible, and place sterile lubricant jelly or antimicrobial ointment circumferentially around the wound. cut a sterile glove to provide a covering. place the covering over the wound, making sure to cover all of the sterile lubricant, thus creating a seal to close the wound temporarily from the external environment. evaluate the patient's thorax via thoracocentesis while placing a thoracostomy tube. once the patient is stable, the open chest wound can be surgically explored, lavaged, and definitively corrected. all animals with open chest wounds should receive antibiotics (first-generation cephalosporin) to prevent infection. following stabilization, radiographs can be taken and evaluated. pneumothorax is confirmed by evidence of elevation of the cardiac silhouette above the sternum, increased density of the pulmonary parenchymal tissue, free air in between the parietal and visceral 1 pleura (making the outline of the lungs visible), and absence of pulmonary vascular structures in the periphery. parenchymal lesions within the lungs are best identified after as much air as possible has been removed from the thorax. obtain left and right lateral and ventrodorsal or dorsoventral views. a standing lateral view may reveal air-or fluid-filled cavitary masses. if underlying pulmonary disease is suspected as a cause of spontaneous pneumothorax, a transtracheal wash, fecal flotation, and heartworm test may be indicated. treatment of pneumothorax includes immediate bilateral thoracocentesis, covering of any open chest wounds, administration of supplemental oxygen, and placement of a thoracostomy tube if negative pressure cannot be obtained or if air rapidly reaccumulates. serial radiography, ct, or mri should be performed in dogs with spontaneous pneumothorax, because the condition can be associated with generalized pulmonary parenchymal disease. strict cage rest is required until air stops accumulating and the thoracostomy tube can be removed. the patient's chest tube should be aspirated every 4 hours after discontinuing continuous suction. if no air reaccumulates after 24 hours, the chest tube can be removed. exercise restriction is indicated for a minimum of 1 week. if bullae or mass lesions are present, exploratory thoracotomy should be considered as a diagnostic and potentially therapeutic option for long-term management in prevention of recurrence. pleural fluid cytologic analysis is indicated for all patients with pleural effusion before administration of antibiotics. the general term pleural effusion means a collection of fluid in the space between the parietal and visceral pleura but does not indicate what kind or how much fluid is present. clinical signs associated with pleural effusion depend on how much fluid is present, and how rapidly the fluid has accumulated. clinical signs associated with pleural effusion include respiratory distress, reluctance to lie down, labored breathing with an abdominal component on exhalation, cough, and lethargy. auscultation of the thorax may reveal muffled heart and lung sounds ventrally and increased lung sounds dorsally, although pockets of fluid may be present, depending on the chronicity of the effusion. percussion of the thorax may reveal decreased resonance. in stable patients, the presence of pleural effusion can be confirmed radiographically. radiographic confirmation of the pleural effusion should include right and left lateral and dorsoventral or ventrodorsal views. a handling or standing lateral view should be obtained if an anterior mediastinal mass is suspected. the standing lateral view will allow the fluid to collect in the costophrenic recess. in patients with respiratory distress, muffled heart and lung sounds, and suspicion of pleural effusion, thoracocentesis should be performed immediately. thoracocentesis can be both therapeutic and diagnostic. radiography is contraindicated because the procedure can cause undue stress and exacerbation of clinical signs in an unstable patient. pleural effusion can cause severe respiratory distress, and can be the result of a number of factors that must be considered when implementing an appropriate treatment plan. pathology of the pleura is almost always a secondary process except for primary bacterial pleuritis and pleural mesotheliomas. causes of pleural effusion in the cat and dog include pyothorax, feline infectious peritonitis, congestive heart failure, chylothorax, heartworm disease, hemothorax, hypoalbuminemia, lung lobe torsions, neoplasia, diaphragmatic hernia, and pancreatitis (box 1-62). in stable animals, diagnosis of pleural effusion can be made based â�¢ imbalance of transpleural or hydrostatic or protein osmotic forces â�¢ change in membrane permeability â�¢ decrease in rate of fluid reabsorption â�¢ combination of foregoing mechanisms on thoracic radiography or ultrasound. thoracic radiographs can show whether the pleural effusion is unilateral or bilateral. effusions in dogs and cats are usually bilateral. the lung parenchyma and the cardiac silhouette cannot be fully evaluated until most of the fluid has been evacuated from the pleural cavity. following thoracocentesis, radiography should be performed with left and right lateral and ventrodorsal or dorsoventral views. in cases of suspected heart failure, echocardiography also is necessary. pleural fluid cytologic analysis is indicated for all patients with pleural effusion. collect specimens before administering antibiotics, whenever possible, because treatment with antibiotics can make a septic condition (pyothorax) appear nonseptic. the remainder of the diagnostic workup and treatment is based on the type of fluid present (table 1 -52). the fluid may be a transudate, nonseptic exudate, septic exudate, chylous, hemorrhagic, or neoplastic. ultrasonographic evaluation of the thorax can be helpful in identifying intrathoracic masses, diaphragmatic hernias, lung lobe torsions, and cardiac abnormalities. unlike radiography, ultrasonography is facilitated by the presence of fluid in the pleural space. pyothorax refers to a septic effusion of the pleural cavity. the infection is generally the result of a combination of aerobic and anaerobic bacteria. rarely, fungal organisms are present. the source of the underlying organisms is rarely identified, particularly in cats, but can be caused by penetrating wounds through the chest wall, esophagus, migrating foreign bodies (especially grass awns), or primary lung infections. the most common organisms associated with pyothorax in the cat are pasteurella, bacteroides, and fusobacterium. fever is often present in addition to clinical signs of pleural effusion. septic shock is ununcommon. diagnosis of pyothorax is made based on cytologic analysis and the demonstration of intracellular and extracellular bacteria, toxin neutrophils and macrophages, and sometimes the presence of sulfur granules. gram stains of the fluid can assist in the initial identification of some organisms. bacterial cultures are indicated for bacteria identification and antibiotic susceptibility testing. administration of antibiotics before cytologic evaluation can cause a septic effusion to appear nonseptic. emergency treatment for pyothorax involves placement of an intravenous catheter, intravenous fluids to treat hypovolemic shock, and broad-spectrum antibiotics (ampicillin, 22 mg/kg iv q6h, and enrofloxacin, 10 mg/kg iv q24h). chloramphenicol also is an appropriate antibiotic to use for penetration into pockets of fluid. administration of a beta-lactam antibiotic (ampicillin or amoxicillin) with a beta-lactamase inhibitor (amoxicillin clavulanate or ampicillin sulbactam) is helpful in achieving better coverage of bacteroides spp. treatment of pyothorax differs in the cat and dog. in the cat, placement of one or two thoracic drainage catheters is recommended to allow continuous drainage of the intrathoracic abscess. inadequate drainage can result in treatment failure. fluid should be evaluated and the pleural cavity lavaged with 10 ml/kg of warmed 0.9% saline or lactated ringer's solution every 8 hours. approximately 75% of the infused volume should be recovered after each lavage. in dogs, or in cats with refractory pyothorax, perform an exploratory thoracotomy to remove any nidus of infection. rarely a foreign body is visible that can be removed at the time of surgery, but this finding is rare. antibiotics are indicated for a minimum of 6 to 8 weeks after removal of the thoracostomy tube. early diagnosis and aggressive treatment result in a good prognosis in the majority of patients with pyothorax. in cats, clinical signs of ptyalism and hypothermia at the time of presentation worsen the prognosis. chylothorax refers to the abnormal accumulation of chyle (lymphatic fluid) in the pleural cavity. the cisterna chili is the dilated collection pool of lymphatic ducts in the abdomen that accumulate chyle prior to entry into the thoracic duct located within the thoracic cavity. the thoracic duct enters the thorax at the aortic hiatus. numerous tributaries or collateral ducts exist. the functions of the lymphatic vessels collectively serve to deliver triglycerides and fat-soluble vitamins into the peripheral vascular circulation. damage of the thoracic duct or lymphatic system or obstruction to lymphatic flow can result in the development of chylous effusion in the pleural or peritoneal space. it is difficult to identify chylous effusions based on their milky appearance alone. to identify a chylous effusion versus a pseudochylous effusion, the triglyceride and cholesterol levels of the fluid must be compared with those of peripheral blood. chylous effusions have a higher triglyceride and lower cholesterol levels than peripheral blood. pseudochylous effusions have a higher cholesterol and lower triglyceride levels than peripheral blood. disease processes that can result in chylous effusions are listed in the box 1-63. clinical signs associated with chylous effusion are typical of any pleural effusion and of the disease process that caused the effusion. weight loss may be evident, depending on the chronicity of the process. the diagnosis is made based on thoracocentesis, cytology, and biochemical evaluation of the fluid (i.e., triglyceride and cholesterol levels). the fluid often appears milky or bloodtinged but can be clear if the patient has significant anorexia. typical cytologic characteristics are listed in table 1 -52. lymphangiography can be used to confirm trauma to the thoracic duct, but this is usually not necessary unless surgical ligation is going to be attempted. the diagnostic evaluation must also attempt to identify an underlying cause. therapy for chylothorax is difficult and primarily involves documentation and treatment of the underlying cause. if an underlying cause is not found, treatment is largely supportive and consists of intermittent thoracocentesis to drain the fluid as it accumulates and causes respiratory dysfunction, nutritional support, and maintenance of fluid balance. a variety of surgical techniques, including ligation of the thoracic duct, pleural-peritoneal shunts, and pleurodesis, have been attempted but have had limited success. most recently, the combination of thoracic duct ligation with subtotal pericardectomy has been shown to improve surgical success rates in the treatment of chylothorax. rutin, a bioflavinoid, has been used with limited success in the treatment of idiopathic chylothorax in cats. prognosis in many cases of chylothorax is guarded. extensive hemorrhage into the pleural cavity can cause fulminant respiratory distress due to sudden hypovolemia and anemia and interference with lung expansion. hemothorax typically is associated with trauma, systemic coagulopathy, lung lobe torsions, and erosive lesions within the thorax (usually neoplasia). diagnosis of hemothorax involves obtaining a fluid sample via thoracocentesis. hemorrhagic effusion must be differentiated from systemic blood inadvertently collected during the thoracocentesis procedure. unless the hemorrhage is peracute, fluid in cases of hemothorax is rapidly defibrinated and will not clot, has a packed cell volume less than that of venous blood, contains rbcs and macrophages. hemorrhagic effusions also usually contain a disproportionately higher number of white blood cells compared with peripheral blood. hemothorax commonly is the sole clinical sign observed in animals with vitamin k antagonist rodenticide intoxication and systemic coagulopathy. whenever an animal presents with signs of a hemorrhagic pleural effusion, perform coagulation testing immediately to determine whether a coagulopathy exists. the prothrombin time test is fast and can be performed as a cage-side test (see section on coagulopathy). therapy for hemorrhagic pleural effusions should address the blood and fluid loss. administer intravenous crystalloid fluids and rbc products (see section on transfusion therapy). when necessary, administer coagulation factors in the form of fresh whole blood or fresh frozen plasma, along with vitamin k 1 (5 mg/kg sq in multiple sites with a 25-gauge needle). if severe respiratory distress is present, evacuate the blood within the pleural space via thoracocentesis until clinical signs of respiratory distress resolve. fluid that remains aids in the recovery of the patient, because rbcs and proteins eventually will be reabsorbed. autotransfusion can be performed to salvage blood and reinfuse it into the anemic patient. in cases of neoplastic or traumatic uncontrollable hemorrhagic effusions, surgical exploration of the thorax is warranted. diaphragmatic hernia, or a rent in the diaphragm, can result in the protrusion of abdominal organs into the thoracic cavity and impair pulmonary expansion. organs that are commonly herniated into the thorax include the liver, stomach, and small intestines. diaphragmatic hernia usually is secondary to trauma but can occur as a congenital anomaly. in cases of trauma, rib fractures, pulmonary contusions, traumatic myocarditis, hemothorax, and shock are also often present concurrently with diaphragmatic hernia. respiratory distress can be caused by any one or a combination of the above lesions. animals with prior or chronic diaphragmatic hernias may have minimal clinical signs despite the presence of abdominal organs within the thorax. clinical signs of acute or severe diaphragmatic hernia include respiratory distress, cyanosis, and shock. a diagnosis of diaphragmatic hernia is made based on the patient's history (traumatic event), clinical signs, and radiographs. in some cases, ultrasonography or contrast peritoneography is necessary to confirm the diagnosis. contrast radiographs may show the presence of the stomach or intestines within the thorax following oral administration of barium. never administer barium directly into the peritoneal cavity or in cases of suspected gastrointestinal rupture. treatment of a patient with a diaphragmatic hernia includes cardiovascular and respiratory system stabilization before attempting surgical repair of the diaphragm. if the stomach is within the thorax, or if the patient's respiratory distress cannot be alleviated with medical management alone, immediate surgery is necessary. if the respiratory distress is minimal and the stomach is not located within the thorax, surgery can be postponed until the patient is a more stable anesthetic candidate. at the time of surgery, the abdominal organs are replaced into the abdominal cavity, and the rent in the diaphragm is closed. air must be evacuated from the thorax following closure of the diaphragm. if chronic diaphragmatic hernia is repaired, the complication of reexpansion pulmonary edema can occur. cardiac injury is a common complication secondary to blunt thoracic trauma. in most cases, cardiac injury is manifested as arrhythmias, including multiple premature ventricular contractions, ventricular tachycardia, st segment depression or elevation secondary to myocardial hypoxemia, and atrial fibrillation (see section on cardiac emergencies). myocardial infarction and cardiac failure can occur. careful and repeated assessments of the patient's blood pressure and ecg tracing should be a part of any diagnostic work-up for a patient that has sustained blunt thoracic trauma. rib fractures are associated with localized pain and painful respiratory movements. radiographs are helpful to confirm the diagnosis. careful palpation may reveal crepitus and instability of the fractured ribs. common problems associated with rib fractures 264 1 emergency care include pulmonary contusions, pericardial laceration, traumatic myocarditis, diaphragmatic hernia, and splenic laceration or rupture. a flail segment results from rib fractures of more than three adjacent ribs that produce a "floating segment" of the chest wall. the flail segment moves paradoxically with respiration-that is, it moves inward during inhalation and outward during exhalation. respiratory distress is associated with the pain caused by the fractures and the presence of traumatic underlying pulmonary pathology. therapy for rib fractures and flail chest includes administration of supplemental oxygen, treatment of pneumothorax or diaphragmatic hernia, and administration of systemic and local anesthesia to alleviate the discomfort associated with the fractures. although controversial, positioning the patient with the flail segment up may reduce pain and improve ventilation. avoid the use of chest wraps, which do nothing to stabilize the flail segment and can further impair respiratory excursions. following administration of a systemic analgesic, administer a local anesthetic at the dorsocaudal and ventrocaudal segment of each fractured rib, and in one rib in front of and behind the flail segment. often, pulmonary function will improve once the pain associated with rib fractures has been adequately treated. in rare cases in which the flail segment involves five or more ribs, surgical stabilization may be necessary. single rib fractures or smaller flail segments are allowed to heal on their own. feline bronchitis has a variety of names (bronchial asthma, asthma, acute bronchitis, allergic bronchitis, chronic asthmatic bronchitis, feline lower airway disease) and refers to the acute onset of respiratory distress secondary to narrowing of the bronchi. cats may present with an acute onset of severe restrictive respiratory pattern associated with lower airway obstruction. acute bronchitis in cats typically has an inflammatory component in the lower airways, resulting in acute bronchoconstriction, excessive mucus production, and inflammatory exudates. in cats with chronic bronchitis, there may be damage of the bronchial epithelium and fibrosis of the airways. these patients often have a history if intermittent exacerbation of clinical signs, intermittent cough, and periods of normality throughout the year. because there appears to be an allergic or inflammatory component in feline bronchitis, clinical signs can be acutely exacerbated by stress and the presence of aerosolized particles such as perfume, smoke, and carpet powders. causes of feline bronchitis include heartworm disease, parasitic infestation (lungworms), and (rarely) bacterial infection. on presentation, the patient should be placed in an oxygen cage and allowed to rest while being observed from a distance. postpone performing stressful diagnostic procedures until the patient's respiratory status has been stabilized. after careful thoracic auscultation, administer a short-acting bronchodilator (terbutaline, 0.01 mg/kg sq or im) along with a glucocorticosteroid (dexamethasone sodium phosphate 1 mg/kg im, sq, iv) to alleviate immediate bronchospasm and airway inflammation. clinical signs of feline bronchitis are characterized by a short, rapid respiratory pattern with prolonged expiration with an abdominal push. wheezes may be heard on thoracic auscultation. in some cases, no abnormalities are found on auscultation, but become acutely worse when the patient is stimulated to cough by tracheal palpation. radiographs may reveal a hyperinflated lung field with bronchial markings and caudal displacement of the diaphragm. in some cases, consolidation of the right middle lung lobe is present. a complete blood count and serum biochemistry profile can be performed, but results usually are unrewarding. in endemic areas, a heartworm test is warranted. fecal examination 1 by flotation and the baermann technique is helpful in ruling out lungworms and other parasites. bronchoalveolar lavage or transtracheal wash is useful for cytologic and bacterial examination. long-term management of feline bronchitis includes isolation from environmental exposure to potential allergens (litter dust, perfumes, smoke, incense, carpet powders) and treatment of bronchoconstriction and inflammation with a combination of oral and inhaled glucocorticosteroids and bronchodilators (table 1 -53). antibiotic therapy is contraindicated unless a pure culture of a pathogen is documented. oral therapy with steroids and bronchodilators should be used for a minimum of 4 weeks after an acute exacerbation and then gradually decreased to the lowest dose possible to alleviate clinical signs. metered dose inhalers are now available (aerokat.com) for administration of inhaled bronchodilators and steroids. fluticasone (flovent, 100 mcg/puff ) can be administered initially every 12 hours for 1 week and then decreased to once daily, in most cases. inhaled glucocorticosteroids are not absorbed systemically, and therefore patients do not develop the adverse side effects sometimes documented with oral glucocorticosteroid administration. because it takes time for glucocorticosteroids to reach peak effects in the lungs, administration of inhaled glucocorticosteroids should overlap with oral prednisolone administration for 5 to 7 days. treatment of pulmonary contusions is supportive. administer supplemental oxygen in a manner that is least stressful for the animal. arterial blood gas analysis or pulse oximetry can determine the degree of hypoxemia and monitor the response to therapy. intravenous fluids should be administered with caution to avoid exacerbating pulmonary hemorrhage or fluid accumulation in the alveoli. treat other conditions associated with the traumatic event. possible complications of pulmonary contusions are rare but include bacterial infection, abscessation, lung lobe consolidation, and the development of cavitary lesions. the routine use of antibiotics or steroids in cases of pulmonary contusions is contraindicated unless external wounds are present. empiric antibiotic use without evidence of external injury or known infection can potentially increase the risk of a resistant bacterial infection. steroids have been shown to decrease pulmonary alveolar macrophage function and impair wound healing and are contraindicated. aspiration pneumonia can occur in animals as a result of abnormal laryngeal or pharyngeal protective mechanisms or can be secondary to vomiting during states of altered mentation, including anesthesia, recovery from anesthesia, and sleep. megaesophagus, systemic polyneuropathy, myasthenia gravis, and localized oropharyngeal defects such as cleft palate can increase the risk of developing aspiration pneumonitis. iatrogenic causes of aspiration pneumonia include improper placement of nasogastric feeding tubes, overly aggressive force-feeding, and oral administration of drugs. aspiration of contents into the airways can cause mechanical airway obstruction, bronchoconstriction, chemical damage to the alveoli, and infection. severe inflammation and airway edema are common. pulmonary hemorrhage and necrosis can occur. diagnosis of aspiration pneumonia is based on clinical signs of pulmonary parenchymal disease, a history consistent with vomiting or other predisposing causes, and thoracic radiographs demonstrating a bronchointerstitial to alveolar pulmonary infiltrate. the most common site is the right middle lung lobe, although the pneumonia can occur anywhere, depending on the position of the patient at the time of aspiration. a transtracheal wash or bronchoalveolar lavage is useful for bacterial culture and susceptibility testing. treatment of aspiration pneumonia includes antibiotic therapy for the infection, administration of supplemental oxygen, and loosening the debris in the airways. administer intravenous fluids to maintain hydration. nebulization with sterile saline and chest physiotherapy (coupage) should be performed at least every 8 hours. antibiotics to consider in the treatment of aspiration pneumonia include ampicillin/enrofloxacin, amoxicillinclavulanate, ampicillin-sulbactam, trimethoprim sulfa, and chloramphenicol. the use of glucocorticosteroids is absolutely contraindicated. continue antibiotic therapy for a minimum of 2 weeks after the resolution of radiographic signs of pneumonia. pulmonary edema arises from the accumulation of fluid in the pulmonary interstitial alveolar spaces, and airways. ventilation-perfusion abnormalities result in hypoxia. pulmonary edema can be caused by increased pulmonary vasculature hydrostatic pressure, decreased pulmonary oncotic pressure, obstruction of lymphatic drainage, or increased capillary permeability. multiple factors can occur simultaneously. the most common cause of edema is increased pulmonary hydrostatic pressure resulting from left-sided congestive heart failure. decreased plasma oncotic pressure with albumin <1.5 g/dl can also result in accumulation of fluid in the pulmonary parenchyma. overzealous intravenous crystalloid fluid administration can result in dilution of serum oncotic pressure and vascular overload. obstruction of lymphatic drainage is usually caused by neoplasia. other causes of pulmonary edema include pulmonary thromboembolic disease, severe upper airway obstruction (noncardiogenic pulmonary edema), seizures, and head trauma. increased capillary permeability is associated with a variety of diseases that cause severe inflammation (systemic inflammatory response syndrome). the resultant pulmonary edema contains a high amount of protein and is known as acute respiratory 1 distress syndrome (ards). ards can be associated with pulmonary or extrapulmonary causes, including direct lung injury from trauma, aspiration pneumonia, sepsis, pancreatitis, smoke inhalation, oxygen toxicity, electrocution, and immune-mediated hemolytic anemia with disseminated intravascular coagulation. diagnosis of pulmonary edema is made based on clinical signs of respiratory distress and the presence of crackles on thoracic auscultation. in severe cases, cyanosis and fulminant blood-tinged frothy edema fluid may be present in the mouth and nostrils. immediate management includes administration of furosemide (4-8 mg/kg iv, im) and supplemental oxygen. sedation with low-dose morphine sulfate (0.025-0.1 mg/kg iv) is helpful in dilating the splanchnic capacitance vasculature and relieving anxiety for the patient. if fluid overload is suspected secondary to intravenous fluid administration, fluids should be discontinued. severely hypoalbuminemic patients should receive concentrated human albumin (2 ml/kg of a 25% solution) or fresh frozen plasma. furosemide as a constant rate infusion (0.66-0.1 mg/kg/hour) also can dilate the pulmonary vasculature and decrease fluid accumulation in cases of ards. following initial stabilization of the patient, thoracic radiographs and an echocardiogram should be assessed to determine cardiac side, pulmonary vascular size, and cardiac contractility. further diagnostic testing may be required to determine other underlying causes of pulmonary edema. heart failure is managed with vasodilators, diuretics, oxygen, and sometimes positive inotropes. treatment ultimately consists of administration of supplemental oxygen, minimal stress and patient handling, and judicious use of diuretics. in cases of cardiogenic pulmonary edema, administer furosemide (4-8 mg/kg iv, im) every 30 to 60 minutes until the patient loses 7% of its body weight. positive inotropic and antiarrhythmic therapy may be necessary to improve cardiac contractility and control dysrhythmias. the clinician should determine whether the cause of the pulmonary edema is secondary to congestive heart failure with pulmonary vascular overload, volume overload, hypoalbuminemia, or increased permeability (ards). pulmonary edema secondary to ards typically is refractory to supplemental oxygen and diuretic therapy. in many cases, mechanical ventilation should be considered. a diagnosis of pulmonary thromboembolism (pte) is difficult to make and is based on clinical signs of respiratory distress consistent with pte, lack of other causes of hypoxemia, a high index of suspicion in susceptible animals, the presence of a condition associated with pte, and radiographic findings. virchow's triad consists of vascular endothelial injury, sluggish blood flow with increased vascular stasis, and a hypercoagulable state as predisposing factors for thromboembolic disease. clinical conditions that predispose an animal to pte include hyperadrenocorticism, disseminated intravascular coagulation (dic), catheterization of blood vessels, bacterial endocarditis, protein-losing nephropathy or enteropathy, hyperviscosity syndromes, heat-induced illness, pancreatitis, diabetes mellitus, inflammatory bowel disease, and immune-mediated hemolytic anemia. definitive diagnosis requires angiography or a lung perfusion scan. clinical signs associated with pte include an acute onset of tachypnea, tachycardia, orthopnea, and cyanosis. if the embolism is large, the patient may respond poorly to supplemental oxygen administration. pulmonary hypertension can cause a split second heart sound on cardiac auscultation. in some cases, a normal thoracic radiograph is present in the face of severe respiratory distress. this is a classic finding in cases of pte. potential radiographic abnormalities include dilated, tortuous, or blunted pulmonary arteries; wedge-shaped opacities in the lungs distal to an obstructed artery; and interstitial to alveolar infiltrates. the right heart may be enlarged. echocardiography can show right heart enlargement, tricuspid regurgitation, pulmonary hypertension, and evidence of underlying cardiac disease, possibly with clots in the atria. measurement of antithrombin (at) and d-dimer levels can be useful in the identification of hypercoagulable states, including dic. treatment of any patient with at deficiency or dic includes replenishment of at and clotting factors in the form of fresh frozen plasma. treatment of pte includes therapy for cardiovascular shock, oxygen supplementation, and thrombolytic therapy (see section on thromboembolic therapy). for short-term treatment, administer heparin (heparin sodium, 200-300 units/kg sq once, followed by 100 units/kg q8h of unfractionated heparin; or fractionated heparin). thrombolytic therapy may include tissue plasminogen activator, streptokinase, or urokinase. long-term therapy with low molecular weight heparin or warfarin may be required to prevent further thromboembolic events. ideally, management should include treatment and elimination of the underlying disease. smoke inhalation commonly occurs when an animal is trapped in a burning building. the most severe respiratory complications of smoke inhalation are seen in animals that are close enough to the flames to also sustain burn injuries (see section on burn injury). at the scene, many animals are unconscious from the effects of hypoxia, hypercapnia, carbon monoxide intoxication, and hydrogen cyanide gases that accumulate in a fire. carbon monoxide produces hypoxia by avidly binding to and displacing oxygen binding to hemoglobin, resulting in severe impairment of oxygen-carrying capacity. the percentage of carboxyhemoglobin in peripheral blood depends on the amount or carbon monoxide in inhaled gases and the length of time of exposure. clinical signs of carbon monoxide intoxication include cyanosis, nausea, vomiting, collapse, respiratory failure, loss of consciousness, and death. smoke inhalation of superheated particles also causes damage to the upper airways and respiratory tree. the larynx can become severely edematous and obstruct inspiration. emergency endotracheal intubation, tracheal oxygen, or tracheostomy tube may be required in the initial resuscitation of the patient, depending on the extent of airway edema. inhalation of noxious gases and particles can cause damage to the terminal respiratory bronchioles. specific noxious gases that can cause alveolar damage include combustible particles from plastic, rubber, and other synthetic products. pulmonary edema, bacterial infection, and ards can result. in any case of smoke inhalation, the first and foremost treatment is to get the animal away from the source of the flames and smoke and administer supplemental oxygen at the scene. at the time of presentation, carefully examine the animal's eyes, mouth, and oropharynx suction soot and debris from the mouth and upper airways. evaluate the patient's respiratory rate, rhythm, and pulmonary sounds. arterial blood gases should be analyzed with co-oximetry to evaluate the pao 2 and carboxyhemoglobin concentrations. evaluation of sao 2 by pulse oximetry is not accurate in cases of smoke inhalation, as the pao 2 may appear normal, even when large quantities of carboxyhemoglobin are present. radiographs are helpful in determining the extent of pulmonary involvement, although radiographic signs may lag behind the appearance of clinical respiratory abnormalities by 16 to 24 hours. bronchoscopy and bronchoalveolar lavage provide a more thorough and accurate evaluation of the respiratory tree; however, these procedures should be performed only in patients whose cardiovascular and respiratory status is stable. management of the patient with smoke inhalation includes maintaining a patent airway, administration of supplemental oxygen, correction of hypoxemia and acid-base abnormalities, preventing infection, and treating thermal burns (see section on burn injury). if severe laryngeal edema is present, a temporary tracheostomy may be necessary to allow adequate oxygenation and ventilation. glucocorticosteroids should not be empirically used in the treatment of smoke inhalation, because of the risk of decreasing pulmonary alveolar macrophage function and increasing the potential for infection. in cases of severe laryngeal edema, however, glucocorticosteroids may be necessary to decrease edema and inflammation. the use of empiric antibiotics is contraindicated unless clinical signs of deterioration and bacterial pneumonia develop. epistaxis can be caused by facial trauma, a foreign body, bacterial or fungal rhinitis, neoplasia, coagulopathies, and systemic hypertension. acute, severe bilateral hemorrhage without wounds have been classified in several ways according their degree of tissue integrity, etiologic force, degree of contamination and duration, and degree of contamination and infection (table 1 -54) . there are also unique causes of wounds such as burns, psychogenic dermatoses, frostbite, decubital ulcers, and snake bite. the animal should be transported to the nearest veterinary facility for definitive care. the wound should be covered or packed with dry gauze or clean linen to protect the wound, and to prevent further hemorrhage and contamination. if an open fracture is present, the limb should be splinted without placing the exposed bone back into the wound. replacing the exposed bone fragment back through the skin wound can cause further damage to underlying soft tissue structures and increase the degree of contamination of deeper tissues. if a spinal fracture is suspected, the patient should be transported on a stable flat surface to prevent further spinal mobilization and neurologic injury. at the time of presentation, first refer to the abcs of trauma, taking care to evaluate and stabilize the patient's cardiovascular and respiratory status. after a complete physical examination and history, ancillary diagnostic techniques can be performed if the patient is hemodynamically stable (see section on triage, assessment, and treatment of emergencies). initially, every patient with superficial wound should receive some degree of analgesia and an injection of a first-generation cephalosporin, preferably within 3 hours of the injury. evaluate the wound after the patient's cardiovascular and respiratory status have been stabilized. always cover an open wound before taking an animal to the hospital to prevent a nosocomial infection. evaluate limb wounds for neural, vascular, and orthopedic abnormalities. carefully examine the structures deep to the superficial wounds. when there has been a delay in assessment of the wound, obtain samples for culture and antimicrobial susceptibility testing. if the wound is older and obviously infected, a gram stain can help guide appropriate antimicrobial therapy pending results of culture 1 and susceptibility testing. place a support bandage saturated with a water-soluble antibiotic ointment or nonirritating antimicrobial solution (e.g., 0.05% chlorhexidine, if bone or joint tissue is not exposed) around the wound. in addition to a first-generation cephalosporin, other appropriate antibiotic choices include amoxicillin-clavulanate, trimethoprim-sulfadiazine, amoxicillin, and ampicillin. if gram-negative flora are present, administer enrofloxacin. administer the antibiotics of choice for a minimum of 7 days unless a change of antibiotic therapy is indicated. at the time of wound cleansing or definitive wound repair, the patient should be placed under general anesthesia with endotracheal intubation, unless the procedure will be brief (i.e., less than 10 minutes). in such cases, a short-acting anesthetic combination open lacerations or skin loss closed crushing injuries and contusions etiologic force abrasion loss of epidermis and portions of dermis, usually caused by shearing between two compressive surfaces avulsion tearing of tissue from its attachment because of forces similar to those causing abrasion but of a greater magnitude incision wound created by a sharp object; wound edges are smooth and there is minimal trauma in the surrounding tissues laceration irregular wound caused by tearing of tissue with variable damage to the superficial and underlying tissue puncture penetrating wound caused by a missile or sharp object; superficial damage may be minimal; damage to deeper structures may be considerable; contamination by fur and bacteria with subsequent infection is common class i 0-6 hours with minimal contamination class ii 6-12 hours with significant contamination class iii >12 hours with gross contamination (analgesia + propofol, analgesia + ketamine/diazepam) can be administered to effect. heavy sedation with infiltration of a local anesthetic may also be appropriate for very small wounds, depending on the location of the wound and temperament of the patient. protect the wound by packing it with sterile gauze sponges soaked in sterile saline, or with watersoluble lubricating gel such as k-y jelly. clip the fur surrounding the wound, moving from the inner edge of the wound outward, to help prevent wound contamination with fur or other debris. scrub the wound and surrounding skin with an antimicrobial soap and solution such as dilute chlorhexidine until the area is free of all gross debris. gross debris within the wound itself can be flushed using a 30-ml syringe filled with sterile saline or lactated ringer's solution and an 18-gauge needle. pressure-lavage systems are also available for use, if desired. grossly contaminated wounds can be rinsed first with warm tap water to eliminate gross contamination, and then prepared as just described. debride the wound, removing skin and other soft tissue that is not obviously viable. obviously viable and questionable tissue should remain, and the wound left open for frequent reassessment on a daily basis. remove any dark or white segments of skin. questionable skin edges may or not regain viability and should be left in place for 48 hours, so the wound can fully reveal itself. excise grossly contaminated areas of fat and underlying fascia. blood vessels that are actively bleeding should be ligated to control hemorrhage, if collateral circulation is present. if nerve bundles are ligated cleanly in a clean wound, the nerve edges should be reapposed and anastomosed. if gross contamination is present, however, definitive neurologic repair should be delayed until healthy tissue is present. excise contaminated muscle until healthy bleeding tissue is present. anastamoe tendon lacerations if the wound is clean and not grossly contaminated. if gross contamination is present, the tendon can be temporarily anastomosed and a splint placed on the limb until definitive repair of healthy tissue is possible. thoroughly lavage open wounds to a joint with sterile saline or lactated ringer's solution. infusion of chlorhexidine or povidone-iodine solution into the joint can cause a decrease in cartilage repair and is contraindicated. smooth sharp edges and remove any obvious fragments. whenever possible, the joint capsule and ligaments should be partially or completely closed. after removing bullets and metal fragments, the subcutaneous tissue and skin should be left open to heal by second intention, or should be partially closed with a drain. the joint should then be immobilized. injuries and exposed bone should be carefully lavaged, taking care to remove any gross debris without pushing the debris further into the bone and wound. the bone should be covered with a moist dressing and stabilized until definitive fracture repair can be made. this type of injury typically is seen with shearing injuries of the distal extremities caused by interaction with slow-moving vehicles. perform wet-to-dry or enzymatic debridement until a healthy granulation bed is present. if large areas of contamination are present (e.g., necrotizing fasciitis), en bloc debridement may be necessary. en bloc debridement consists of complete excision of badly infected wounds without entering the wound cavity, to prevent systemic infection. this technique should be used only if there is sufficient skin and soft tissue to allow later closure and it can be performed without damaging any major nerves, tendons, or blood vessels. open wounds often are managed by second intention healing, delayed primary closure, or secondary closure. see section on wound management and bandaging for a more complete discussion on the use of various bandaging materials in the treatment of open wounds. if an animal is presented very shortly after a wound has occurred and there is minimal contamination and trauma, the wound can be closed after induction of anesthesia and 1 careful preparation of the wound and surrounding tissues. close any dead space under the skin with absorbable suture material in an interrupted suture pattern. avoid incising major blood vessels or nerves. close the subcutaneous tissues with absorbable suture material in an interrupted or continuous suture pattern. take care that there is not too much tension on the wound, or else surgical dehiscence will occur with patient movement. close the skin with nonabsorbable suture or surgical staples (2-0 to 4-0) . if there is any doubt at the time of repair about tissue status or inability to close all dead space, place a passive drain (penrose drain) so that the proximal end of the drain is anchored in the proximal aspect of the wound with a suture(s). leave the ends long so that the suture can be accurately identified at the time of drain removal. pass the suture through the skin, through the drain, and out the other side of the skin. place the rest of the drain into the wound and then secure it at the most ventral portion of the wound or exit hole in the most dependent area of the body, to allow drainage and prevent seroma formation. close the subcutaneous tissue over the drain before skin closure. during wound closure, be sure to not incorporate the subcutaneous or skin sutures into the drain, or it will not be possible to remove the drain without reopening the wound. bandage the area to prevent contamination. the drain can be removed once drainage is minimal (usually 3 to 5 days). active drains can be constructed or purchased; their use is indicated in wounds that are free of material that can plug the drain. to construct a small suction drain, remove the female portion or catheter hub at the end of a butterfly catheter. fenestrate the tubing so that there are multiple side holes, taking care to avoid making the holes larger than 50% of the circumference of the tubing. place the tubing into the wound via a small stab incision distal to the wound. use a purse-string suture around the tubing to facilitate a tight seal and prevent the tubing from exiting the wound. following wound closure, insert the butterfly needle into a 5-to 10-ml evacuated blood collection tube to allow fluid to drain into the tube. incorporate the tube into the bandage, and replace it when it becomes full. alternatively, the butterfly portion of the system can be removed and the tube fenestrated as described previously. place the tube into the wound and suture it in place to create a tight seal. secure the catheter hub to a syringe in which the plunger has been drawn back slightly to create suction. insert a metal pin or 16-to 18-gauge needle through the plunger at the top of the barrel to hold it at the desired level. incorporate the suction apparatus into the bandage and replace it when it becomes full. delayed primary closure should be considered when there is heavy contamination, purulent exudate, residual necrotic debris, skin tension, edema and erythema, and lymphangitis. delayed primary closure usually is made 3 to 5 days after the initial wound infliction and open wound management has been performed. once healthy tissue is observed, the skin edges should be debrided and the wound closed as with primary closure. secondary wound closure should be considered when infection and tissue trauma necessitate open wound management for more than 5 days. secondary wound closure is performed after the development of a healthy granulation bed. this technique also is useful when a wound has dehisced and has formed granulation tissue. if the wound edges can be manipulated into apposition and if epithelialization has not begun, the wound can be cleansed and the wound edges apposed and sutured. this is known as early secondary closure. late secondary closure should be performed whenever there is a considerable amount of granulation tissue, the edges of the wound cannot be manipulated into position, and epithelialization has already started. in such cases, the wound should be cleaned, and the skin edges debrided to remove the epithelium. the remaining wound edges are then sutured over the granulation tissue ( shock is defined as a state of inadequate circulating volume and inability to meet cellular oxygen demands. there are three types of shock: hypovolemic, cardiogenic, and septic. early recognition of the type of shock present is crucial in the successful clinical management of shock syndrome. tissue oxygen delivery is based on cardiac output and arterial oxygen concentration. knowledge of the components of normal oxygen delivery is essential to the treatment of shock in the critical patient. improper handling of animal during further tissue and neurologic damage may occur transport (e.g., improper limb or spine immobilization). inadequate assessment of animal's animal's condition may worsen or animal may general condition or wounded tissues succumb; tissue injuries may be overlooked. inadequate wound protection during further wound contamination may occur at assessment, resuscitation, or veterinary facility. stabilization procedures inadequate wound protection while further wound contamination with fur and preparing the surrounding area debris may occur. insufficient wound lavage wound infection may occur. hydrogen peroxide wound lavage lavage offers little bactericidal activity and contributes to irritation of tissues and delayed healing. lavage has short residual activity and absorption with large wound. overly aggressive initial layered debridement may result in the removal of viable debridement tissue. en bloc debridement debridement results in removal of large amounts of tissue and a large defect for closure. use of drains potential exists for bacteria to ascend along the drain, for drain removal by the animal or breakage of the drain, and for possible tissue emphysema with air being sucked under the skin with patient movement. tube-type drains drains may cause postoperative discomfort; fenestrations may become occluded to stop intraluminal drainage. deeply placed sutures in the presence drain may be incorporated into the repair and of a drain prevent drain removal. active drains high negative pressure may cause tissue injury; highly productive wounds may necessitate changing the evacuated blood tubes several times a day with constructed drains. oxygen delivery (do 2 ) = cardiac output (q) ã� arterial oxygen content (cao 2 ) where q = heart rate ã� stroke volume. stroke volume is affected by preload, afterload, and cardiac contractility. where hb = hemoglobin concentration, sao 2 = oxygen saturation, and pao 2 = arterial partial pressure of oxygen in mm hg. thus, factors that can adversely affect oxygen delivery include inadequate preload or loss of circulating volume, severe peripheral vasoconstriction and increased afterload, depressed cardiac contractility, tachycardia and decreased diastolic filling, cardiac dysrhythmias, inadequate circulating hemoglobin, and inadequate oxygen saturation of hemoglobin. during septic shock, enzymatic dysfunction and decreased cellular uptake and utilization of oxygen also contribute to anaerobic glycolysis. an inadequate circulating volume may develop secondary to maldistribution of available blood volume (traumatic, septic, and cardiogenic origin) or as a result of absolute hypovolemia (whole blood or loss of extracellular fluid). normally, the animal compensates by (1) splenic and vascular constriction to translocated blood from venous capacitance vessels to central arterial circulation, (2) arteriolar constriction to help maintain diastolic blood pressure and tissue perfusion, and (3) an increase in heart rate to help maintain cardiac output. arteriolar vasoconstrictions support perfusion to the brain and heart at the expense of other visceral organs. if vasoconstriction is severe enough to interfere with delivery of adequate tissue oxygen for a sufficient period of time, the animal may die. hypovolemic shock can result from acute hemorrhage or from severe fluid loss from vomiting, diarrhea, or third spacing of fluids. early in shock, baroreceptors in the carotid body and aortic arch sense a decrease in wall stretch from a decrease in circulating fluid volume. tonic inhibition of sympathetic tone via vagal stimulation is diminished, and heart rate and contractility increase and peripheral vessels constrict to compensate for the decrease in cardiac output. the compensatory mechanisms protect and support blood supply to the brain and heart at the expense of peripheral organ perfusion. this is called early compensatory shock. early compensatory shock is characterized by tachycardia, normal to fast capillary refill time, tachypnea, and normothermia. as shock progresses, the body loses its ability to compensate for ongoing fluid losses. early decompensatory shock is characterized by tachycardia, tachypnea, delayed capillary refill time, normotension to hypotension, and a fall in body temperature. end-stage decompensatory shock is characterized by bradycardia, markedly prolonged capillary refill time, hypothermia, and hypotension. aggressive treatment is necessary for any hope of a favorable outcome. septic shock should be considered in any patient with a known infection, recent instrumentation that could potentially introduce infection (indwelling intravenous or urinary catheter, surgery or penetrating injury), disorders or medical therapy that can compromise immune function (diabetes mellitus, immunodeficiency virus, parvovirus or feline panleukopenia virus infection, stress, malnutrition, glucocorticoids, chemotherapy). the presence of bacteria, viruses or rickettsiae, protozoa, or fungal organisms in the blood constitutes septicemia. septic shock is characterized by the presence of sepsis and refractory hypotension that is unresponsive to standard aggressive fluid therapy and inotropic or pressor support. septic shock and other causes of inflammation can lead to systemic inflammatory response syndrome (sirs). in animals, the presence of two or more of the criteria in table 1 -56 in the presence of suspected inflammation or sepsis constitutes sirs (table 1 -56). clinical signs associated with sepsis may be vague and nonspecific, including weakness, lethargy, vomiting, and diarrhea. cough and pulmonary crackles may be associated with pneumonia. decreased lung sounds may be associated with pyothorax. abdominal pain and fluid may be associated with septic peritonitis. vaginal discharge may or may not be present in patients with pyometra. diagnostic tests should include a white blood cell count, serum biochemical profile, coagulation tests, thoracic and abdominal radiographs, and urinalysis. the white blood cell count in a septic patient that is appropriately responding to the infection will be elevated with a left-shifted neutrophilia and leukocytosis. a degenerative left shift, in which leukopenia with elevated band neutrophils suggests an overwhelming infection. biochemical analyses may demonstrate hypoglycemia and nonspecific hepatocellular and cholestatic enzyme elevations. in the most severe cases, metabolic (lactic) acidosis, coagulopathies, and end-organ failure, including anuria and ards, may be present. cardiogenic shock occurs as a result of cardiac output inadequate to meet cellular oxygen demands. cardiogenic shock is associated with primary cardiomyopathies, cardiac dysrhythmias, pericardial fluid, and pericardial fibrosis. abnormalities seen on physical examination often are similar to those seen in other categories of shock, but they can also include cardiac murmurs, dysrhythmias, pulmonary rales, bloody frothy pulmonary edema fluid from the nares or mouth, orthopnea, and cyanosis. it is important to distinguish the primary cause of shock before implementing treatment (table 1-57) , whenever possible, because treatment for a suspected ruptured hemangiosarcoma differs markedly from the treatment for end-stage dilatative cardiomyopathy. the patient's clinical signs may be similar and include a peritoneal fluid wave, but the treatment for hypovolemia can dramatically worsen the congestive heart failure secondary to dilatative cardiomyopathy. when a patient presents with some form of shock, immediate vascular access is of paramount importance. place a large-bore peripheral or central venous catheter for the infusion of crystalloid or colloid fluids, blood component therapy, and drugs. monitor the patient's cardiopulmonary status (by ecg), blood pressure, oxygen saturation (as determined by pulse oximetry or arterial blood gas analyses), hematocrit, bun, and glucose. ancillary diagnostics, including thoracic and abdominal radiography, urinalysis, serum biochemistry profile, coagulation tests, complete blood count, abdominal ultrasound, and echocardiography, should be performed as determined by the individual patient's needs and the type of shock. the following list, called the "rule of twenty," is a guideline for case management of the shock patient. consideration of each aspect of the rule of twenty on a daily basis ensures temperature <100â°f or >103.5â°f <100â°f or >103.5â°f heart rate >120 beats/minute in dogs <140 or >250 beats/minute in cats respiratory rate >20 breaths/minute or paco 2 >40 breaths/minute or paco 2 <32 mm hg <32 mm hg white blood cell >18,000 cells/âµl 19,000 cells/âµl count or <4000 cells/âµl o r <5000 cells/ml or >10% bands or >10% bands 1 that major organ systems are not overlooked. the list also provides a means to integrate and relate changes in different organ systems functions with one another.* the treatment of hypovolemic and septic shock requires the placement of large-bore intravenous catheters in peripheral and central veins. if vascular access cannot be obtained percutaneously or by cutdown methods, intraosseous catheterization should be considered. once vascular access is achieved, rapidly administer large volumes of crystalloid or colloid fluids. as a rule of thumb, administer 1 /4 of a calculated shock dose of fluids-that is, 1 /4 ã� (90 ml/kg/hour) in dogs and 1 /4 ã� (44 ml/kg/hour) in cats) of a balanced crystalloid fluid ( normosol-r, plasmalyte-m, lactated ringer's solution, or 0.9% sterile saline). reassess the patient's perfusion parameters (heart rate, capillary refill time, blood pressure, urine output) on a continual basis to direct further fluid therapy. synthetic colloid fluids (hetastarch, dextran 70, or oxyglobin) can also be administered in the initial resuscitation from shock. a guideline is to administer 5 to 10 ml/kg of hetastarch or dextran as a bolus over 10 to 15 minutes and then reassess perfusion parameters. hypertonic saline (0.7% nacl, 4 ml/kg) can be used in cases of hemorrhagic shock to temporarily restore intravascular fluid volume by drawing fluid from the interstitial space. because this type of fluid resuscitation is short-lived, hypertonic saline should always be used with another crystalloid or colloid fluid, and it should not be used in patients with interstitial dehydration. if hemorrhagic shock is present, the goal should be to return a patient's blood pressure to normal (not supraphysiologic) levels (i.e., systolic pressure 90-100 mm hg, diastolic pressure >40 mm hg, and mean arterial pressure â�¥60 mm hg) to avoid iatrogenically causing clots to fall off and hemorrhage to re-start. in critically ill patients, fluid loss can be measured in the form of urine, vomit, diarrhea, body cavity effusions, and wound exudates. additionally, insensible losses (those that cannot be readily measured from sweat, panting, and cellular metabolism) constitute 20 ml/kg/ day. measurement of fluid "ins and outs" in conjunction with the patient's central venous pressure, hematocrit, albumin, and colloid oncotic pressure can help guide fluid therapy (see also section on fluid therapy). maintenance of normotension is necessary for adequate oxygen delivery to meet cellular energy demands. blood pressure can be measured using direct arterial catheterization, or through indirect means such as doppler plesthymography or oscillometric methods. the systolic pressure should remain at or greater than 90-100 mm hg at all times. the diastolic pressure is very important, too, as it constitutes two thirds of the mean arterial pressure; it must be greater than 40 mm hg for coronary artery perfusion. the mean arterial pressure should be greater than 60 mm hg for adequate tissue perfusion. if fluid resuscitation and pain management are not adequate in restoring blood pressure to normal, vasoactive drugs including positive inotropes and pressors should be considered (table 1 -58). in cases of cardiogenic shock, vasodilator drugs (table 1 -59) can be used to decrease vascular resistance and afterload. low-dose morphine (0.05 mg/kg, iv, im) dilates splanchnic vessels and helps reduce pulmonary edema. furosemide (1 mg/kg/hour) also can dilate pulmonary vasculature and potentially reduce edema fluid formation in cases of ards. cardiac output is a function of both heart rate and stroke volume. stroke volume or (the amount of blood that the ventricle pumps in 1 minute) is affected by preload, afterload, and contractility. during hypovolemic shock, there is a fall in cardiac preload due to a decrease in circulating blood volume. during septic and cardiogenic shock, there is a decrease in contractility secondary to inherent defects of the myocardium or due to the negative inotropic effects of inflammatory cytokines such as tnf-alpha, myocardial depressant factor, il-1, and il-10 released during sepsis and systemic inflammation. afterload also may be increased because of the compensatory mechanisms and neurohumoral activation of the renin-angiotensin-aldosterone axis in hypovolemic or cardiogenic shock. as heart rate increases to compensate for a decline in cardiac output, myocardial oxygen demand increases and diastolic filling time becomes shorter. because the coronary arteries are perfused during diastole, coronary perfusion can be impaired, and myocardial lactic acidosis can develop, causing a further decline in contractility. in addition to lactic acidosis, acid-base and electrolyte abnormalities, inflammatory cytokines, direct bruising of the myocardium from trauma, and areas of ischemia can further predispose the patient to ventricular or atrial dysrhythmias. cardiac dysrhythmias should be controlled whenever possible. treatment of bradycardia should be directed at treating the underlying cause. administer anticholinergic drugs such as atropine (0.04 mg/kg im) or glycopyrrolate (0.02 mg/kg im) as necessary. in cases of third-degree or complete atrioventricular (av) block, administer a pure betaagonist such as isoproterenol (0.04-0.08 âµg/kg/minute iv cri, or 0.4 mg in 250 ml of 5% dextrose in water iv slowly). perform passive rewarming if the patient is hypothermic. receptor activity dosage (iv) dopamine da 1 , da 2 , î± +++ , 5-25 âµg/kg/minute (blood pressure support)* î² +++ 1-5 âµg/kg/minute (renal afferent diuresis) dobutamine î± + , î² +++ 3-20 âµg/kg/minute* (blood pressure support, positive inotrope) norepinephrine î± +++ , î² + 0.05-0.3 mg/kg/minute; 0.01-0.02 mg/kg phenylephrine î± +++ , î² 0 0.05-0.2 mg/kg epinephrine î± +++ , î² +++ 0.02-0.5 mg/kg, 0.05-0.2 mg/kg/minute +++, strong receptor activity; 0, no receptor activity; +, weak receptor activity. *monitor for tachyarrhythmias at higher doses. correct any underlying electrolyte abnormalities such as hyperkalemia and hypo-and hypermagnesemia. treat ventricular dysrhythmias such as multifocal premature ventricular contractions (pvcs), sustained ventricular tachycardia >160 beats per minute, and r on t phenomenon (the t wave of the preceding beat occurs superimposed on the qrs complex of the next beat, and there is no return to isoelectric shelf), or if runs of ventricular tachycardia cause a drop in blood pressure. intravenous lidocaine and procainamide are the first drugs of choice for ventricular dysrhythmias. supraventricular tachycardia can impair cardiac output by impairing diastolic filling time. control supraventricular dysrhythmias with calcium channel blockers, beta-adrenergic blockers, or quinidine (table 1-60) . (disorientation); is 1 minute; 2 minutes) light sensitive and must be covered in foil and not kept for longer than 4 hours 1 albumin can decrease as a result of loss from the gastrointestinal tract, urinary system, and wound exudates, or into body cavity effusions. albumin synthesis can decrease during various forms of shock due to a preferential increase in hepatic acute phase protein synthesis. serum albumin contributes 80% of the colloid oncotic pressure of blood, in addition to its important roles as a free radical scavenger at sites of inflammation and as a drug and hormone carrier. albumin levels <2.0 g/dl have been associated with an increase in morbidity and mortality in human and veterinary patients. administer fresh frozen plasma (20 ml/kg) or concentrated human albumin (2 ml/kg of 25% solution) to maintain serum albumin â�¥2.0 g/dl. additional oncotic support can be in the form of synthetic colloids, as indicated. colloid oncotic pressure within the intravascular and interstitial spaces contributes to fluid flux. oncotic pressure can be measured with a colloid osmometer. normal oncotic pressure is 15 mm hg. in cases of sepsis and sirs, increased vascular permeability increases the tendency for leakage of fluids into the interstitial spaces. colloids that can be administered until the source of albumin loss resolves include the synthetic colloids hetastarch and dextran 70 (20-30 ml/kg/day), synthetic hemoglobin-based oxygen carriers (oxyglobin, 3-7 ml/kg/day), concentrated human albumin (25% albumin, 2 ml/kg), and plasma (20 ml/kg). oxygenation and ventilation can be evaluated by arterial blood gas analysis or by the noninvasive means of pulse oximetry and capnometry (see sections on pulse oximetry and capnometry). oxygen delivery can be impaired in cases of hypovolemic shock because of hemorrhage and anemia, and thus a decrease in functional capacity to carry oxygen, and is not to be used for more than 2 weeks due to idiosyncratic blindness. in cases of cardiogenic shock as a result of impaired ability to saturate hemoglobin due to pulmonary edema in the lungs, or decrease in cardiac output. in septic shock, decreases in cardiac output due to inflammatory cytokines and a decrease in cellular oxygen extraction can lead to lactic acidosis. increased cellular metabolism and decreases in respiratory function can lead to respiratory acidosis as co 2 increases. administer supplemental oxygen as flow-by, nasal or nasopharyngeal catheter, oxygen hood, or oxygen cage. supplemental oxygen should be humidified, and delivered at 50-100 ml/kg/minute. if oxygenation and ventilation are so impaired that the pao 2 remains <60 mm hg with the patient on supplemental oxygen, a paco 2 >60 mm hg, or severe respiratory fatigue, develops, and mechanical ventilation should be considered. glucose is a necessary fuel source for red blood cells and neuronal tissues, and serum glucose should be maintained within normal reference ranges. glucose supplementation can be administered as 2.5-5% solutions in crystalloid fluids, or in parenteral and enteral nutrition products. arterial and venous ph can be measured by performing blood gas analyses. decrease in tissue perfusion, impaired oxygen delivery, and decreased oxygen extraction in the various forms of shock can lead to anaerobic metabolism and metabolic acidosis. in most cases, improving tissue perfusion and oxygen delivery with crystalloid and colloid fluids, supplemental oxygen, and inotropic drugs will help normalize metabolic acidosis. serial measurements of serum lactate (normal, <2.5 mmol/l) can be used as a guide to evaluate the tissue response to fluid resuscitative efforts. serum electrolytes often become severely deranged in shock states. serum potassium, magnesium, sodium, chloride, and total and ionized calcium should be maintained within normal reference ranges. if metabolic acidosis is severe, sodium bicarbonate can be administered by calculating the formula base deficit ã� 0.3 ã� body weight in kg = meq bicarbonate to administer because iatrogenic metabolic alkalosis can occur, a conservative approach is to administer 1 /4 of the calculated dose and then recheck the patient's ph and bicarbonate levels. if the base excess is unknown, sodium bicarbonate can be administered in incremental doses of 1 meq/kg until the ph is above 7.2. complications associated with bicarbonate therapy include iatrogenic hypocalcemia, metabolic alkalosis, paradoxical cerebrospinal fluid acidosis, hypotension, restlessness, and death. massive trauma, neoplasia, sepsis, and systemic inflammation can all lead to coagulation abnormalities, including disseminated intravascular coagulation (dic). cage-side coagulation monitors are available for daily measurement of prothrombin time (pt), activated partial thromboplastin time (aptt), and platelet counts. fibrin degradation products (fibrin split products) become elevated in dic, trauma, hepatic disease, and surgery. coagulation proteins (clotting factors) and antithrombin often are lost with other proteins in hypoproteinemia or are consumed when microclots are formed and then dissolved. antithrombin levels can be measured by commercial laboratories. antithrombin and clotting factors can be replenished in the form of fresh frozen plasma transfusions. a more sensitive and specific test for dic is the detection of d-dimers, which can be measured by commercial laboratories. treatment for dic involves treatment and resolution of the underlying disease and administration of antithrombin and clotting factors in the form of fresh frozen plasma (20 ml/kg) and heparin (unfractionated, 50-100 units/kg sq tid; fractionated [lovenox], 1 mg/kg sq bid). monitor the patient for changes in mental status, including stupor, coma, decreased ability to swallow and protect the airway, and seizures. elevation of the patient's head can help to protect the airway and decrease the risk of increased intracranial pressure. serum glucose should be maintained within normal levels to prevent hypoglycemia-induced seizures. one of the major components of oxygen delivery is the binding to hemoglobin. packed cell volume must be kept above 20-30% for adequate cellular oxygen delivery. acid-base status can adversely affect oxygen offloading at the tissue level if metabolic or respiratory alkalosis is present. oxygen-carrying capacity and hemoglobin levels can be increased with administration of rbc component therapy or with hemoglobin-based oxygen carriers. monitoring of renal function includes daily measurement of bun, creatinine, and urine output. normal urine output in a hydrated euvolemic patient is 1-2 ml/kg/hour. fluid ins and outs should be measured in cases of suspected oliguria or anuria. in patients with oliguria or anuria, furosemide can be administered as a bolus (4-8 mg/kg) or by constant rate infusion (cri)(0.66-1 mg/kg/hour). mannitol should also be administered (0.5-1 g/kg over 10 to 15 minutes). dopamine (1-5 âµg/kg/minute cri) can be administered to dilate renal afferent vessels and improve urine output. the patient's white blood cell count may be elevated, normal, or decreased, depending on the type of shock. the decision to administer antibiotics should be made on a daily basis. superficial or deep staphylococcus or streptococcus infection usually can be treated with a first-generation cephalosporin (cefazolin, 22 mg/kg iv tid). if a known source of infection is present, administer a broad-spectrum antibiotic (cefoxitin, 22 mg/kg iv tid; ampicillin, 22 mg/kg qid, or enrofloxacin, 5-10 mg/kg once daily) pending results of culture and susceptibility testing. if broader anaerobic coverage is required, metronidazole (10 mg/kg iv tid) should be considered. gentamicin (3-5 mg/kg iv once daily) is a good choice for gram-negative sepsis, provided that the patient is well hydrated and has normal renal function. ideally, patients receiving any aminoglycoside antibiotic should have a daily urinalysis to check for renal tubular casts that signify renal damage. in dogs, the gut is the shock organ. impaired gastrointestinal motility and vomiting should aggressively be treated with antiemetics and promotility drugs (dolasetron, 0.6 mg/kg iv once daily, and metoclopramide, 1-2 mg/kg/day iv cri). metoclopramide is contraindicated in cases of suspected gastrointestinal obstruction. histamine-receptor blockers such as famotidine (0.5 mg/kg bid iv) and ranitidine (0.5 to 2 mg/kg iv bid, tid) or proton-pump inhibitors (omeprazole, 0.5-1 mg/kg po once daily) can be administered for esophagitis. administer sucralfate (0.25-1 g po tid) to treat gastric ulceration. if the gastrointestinal barrier function is diminished due to poor perfusion, infection, or inflammation, administer broad-spectrum antibiotics such as ampicillin (22 mg/kg iv qid) to prevent gastrointestinal bacterial translocation. the course of drug therapy should be reviewd daily and the patient should be monitored for potential drug interactions. for example, metoclopramide and dopamine, working at the same receptor, can effectively negate the effects of each other. cimetidine, a cytochrome p450 enzyme inhibitor, can decrease the metabolism of some drugs. drugs that are avidly protein-bound may have an increase in unbound fraction with concurrent hypoalbuminemia or when hypoalbuminemia is present. decreased renal function may impair the renal clearance of some drugs, requiring increased dosing interval or decreased dose. nutrition is of utmost importance in any critically ill patient. patients with septic shock may become hypermetabolic and require supraphysiologic nutrient caloric requirements, while others may actually become hypometabolic. enteral nutrition is preferred, whenever possible, because enterocytes undergo atrophy without luminal nutrient stimulation. a variety of enteral feeding tubes can be placed, depending on what portion of the gut is functional, to provide enteral nutrition in an inappetent patient. loss of gastrointestinal mucosal barrier function may predispose the patients to the development of bacterial translocation and may contribute to sepsis. if enteral nutrition is impossible because of protracted vomiting or gastrointestinal resection, glucose, lipid, and amino acid products are available that can be administered parenterally to meet nutrient needs until the gastrointestinal tract is functioning and the patient can be transitioned to enteral nutrition. assessment of pain in animals in shock can be challenging. pain can result in the release of catecholamines and glucocounterregulatory hormones that can impair nutrient assimilation and lead to negative nitrogen balance, impaired wound healing, and immunocompromise. in any animal determined to be in pain, analgesic drugs should be administered to control pain and discomfort at all times. opioids are cardiovascularly friendly, and their effects can easily be reversed with naloxone if adverse effects such as hypotension and hypoventilation occur. if the patient is nonambulatory, rotate the animal from side to side every 4 to 6 hours to prevent lung atelectasis. passive range-of-motion exercises and deep muscle massage should be performed to increase tissue perfusion, decrease dependent edema, and prevent disuse atrophy. animals should be kept completely dry on soft, padded bedding to prevent the development of decubital ulcers. all bandages, wound sites, and catheter sites should be checked daily for the presence of swelling, erythema, and pain. soiled bandages should be changed to prevent strike-through and contamination of the underlying catheter or wound. hospitalization can be a stressful experience for patient and client alike. allowing brief visits and walks outside in the fresh air can improve a patient's temperament and decrease stress. the preemptive use of analgesic drugs on a regular schedule (not prn) should be used to prevent pain before it occurs. pain decreases the patient's ability to sleep. lack of sleep can promote further stress and impaired wound healing. the use of glucocorticosteroids and antiprostaglandins in shock therapy remains a topic of wide controversy. although the use of these agents potentially may stabilize membranes, decrease the absorption of endotoxin, and decrease prostaglandin release, the routine use of glucocorticosteroids and antiprostaglandins can decrease renal perfusion and gastrointestinal blood flow, promoting gastrointestinal ulceration and impaired renal function. the administration of supraphysiologic levels of glucocorticosteroids in patients in any type of shock can increase sodium and water retention, depress cellular immune function, and impair wound healing. in clinical studies of small animal patients, the routine use of glucocorticosteroids and antiprostaglandins has not demonstrated definite improved survival. the risks of therapy do outweigh the anecdotal reported benefits, and therefore the empiric use of glucocorticosteroids and antiprostaglandins in any shock patient is urinary tract emergencies azotemia azotemia occurs when 75% or more of the nephrons are nonfunctional. the magnitude of the azotemia alone cannot be used to determine whether the azotemia is prerenal, renal, or postrenal in origin, or whether the disease process is acute or chronic, reversible or irreversible, progressive or nonprogressive. before beginning treatment for azotemia, the location or cause of the azotemia must be identified. take a thorough history and then perform a physical examination. obtain blood and urine samples before initiating fluid therapy, for accurate assessment of the location of the azotemia. for example, an azotemic animal with a history of vomiting and diarrhea that appears clinically dehydrated on physical examination, normally should have a concentrated urine specific gravity (>1.045) reflecting the attempt to conserve fluid. if this level is found, the azotemia is much less likely to be renal in origin, and the azotemia will likely resolve after rehydration. if, however, the urine specific gravity is isosthenuric or hyposthenuric (1.007-1.015) in the presence of azotemia and dehydration, primary intrinsic renal insufficiency is likely present. if the azotemia resolves with fluid therapy, the patient has prerenal and primary renal disease. if the azotemia does not resolve after rehydration, the patient has prerenal and primary renal failure. dogs with hypoadrenocorticism can have both prerenal and primary renal disease secondary to the lack of mineralocorticoid (aldosterone) influence on the renal collecting duct and renal interstitial medullary gradient. medullary washout can occur, causing isosthenuric urine in the presence of dehydration from vomiting and diarrhea. the patient often has azotemia due to fluid loss (dehydration and urinary loss) and gastric or intestinal hemorrhage (elevated bun). the prerenal component will resolve with treatment with glucocorticoids and crystalloid fluids, but the renal component may take several weeks to resolve, until the medullary concentration gradient is reestablished with the treatment and influence of mineralocorticoids. drugs such as corticosteroids and diuretics can influence renal tubular uptake and excretion of fluid, and cause a prerenal azotemia and isosthenuric urine in the absence of primary renal disease. treatment of azotemia includes calculation of the patient's dehydration estimate and maintenance fluid volumes, and administering that volume over the course of 24 hours. identify and treat underlying causes of prerenal azotemia (shock, vomiting, diarrhea). monitor urine output closely. once a patient is euvolemic, oliguria is defined as urine output <1-2 ml/kg/hour. urine output should return to normal in patients with prerenal azotemia as rehydration occurs. if a patient remains oliguric after rehydration, consider the possibility of oliguric acute intrinsic renal failure, and administer additional fluid therapy based on the patient's urine output, body weight, central venous pressure, and response to other medical therapies. prerenal azotemia is caused by conditions that decrease renal perfusion, including hypovolemic shock, severe dehydration, hypoadrenocorticism, congestive heart failure, cardiac tamponade, cardiac dysrhythmias, and hypotension. once renal perfusion is restored, the kidneys can resume normal function. glomerular filtration rate decreases when the mean arterial blood pressure falls to less than 80 mm hg in a patient with normal renal autoregulation. renal autoregulation can be impaired in some diseases. passive reabsorption of urea from the renal tubules can occur during states of low tubular flow (dehydration, hypotension) even if glomerular filtration is not decreased. if renal hypoperfusion is not quickly restored, the condition can progress from prerenal disease to acute intrinsic renal failure. prerenal and renal azotemia can coexist in animals with primary renal disease, as a result of vomiting and ongoing polyuria in the absence of any oral fluid intake. the treatment of prerenal azotemia consists of rehydration, antiemetic therapy, and treatment of the underlying cause of vomiting, diarrhea, or third spacing of fluids. acute intrinsic renal failure is characterized by an abrupt decline in renal function to the extent that azotemia and an inability to regulate solute and fluid balance. patients with acute intrinsic renal failure may be oliguric or polyuric, depending on the cause and state of renal failure. in small animals, the most common causes of acute intrinsic renal failure are renal ischemia and toxins. there are three phases of acute intrinsic renal failure: induction, maintenance, and recovery. during the induction phase, some insult (ischemia or toxin) to the kidneys occurs, leading to a defective concentrating mechanism, decreased renal clearance of nitrogenous waste (azotemia), and polyuria or oliguria. if treatment is initiated during the induction phase, progression to the maintenance phase potentially can be stopped. as the induction phase progresses, there is worsening of the urine-concentrating ability and azotemia. renal tubular epithelial cells and renal tubular casts can be seen on examination of the urine sediment. glucosuria may be present. the maintenance phase of acute intrinsic renal failure occurs after a critical amount of irreversible nephron injury. correction of the azotemia and removal of the cause of the problem do not result in return to normal function. in patients with oliguria, the extent of nephron damage is greater than that observed in patients with polyuria. the maintenance phase may last for several weeks to months. recovery of renal function may or may not occur, depending on the extent of injury. the most serious complications (overhydration and hyperkalemia) are observed in patients with oliguria. the recovery phase occurs with sufficient healing of damaged nephrons. azotemia may resolve, but concentrating defects may remain. if the patient was oliguric in the maintenance phase, a marked diuresis develops during the recovery phase that may be accompanied by fluid and electrolyte losses. this phase may last for weeks to months. treatment of acute intrinsic renal failure consists of determining the cause and ruling out obstruction or uroabdomen whenever possible. a careful history can sometimes determine whether there has been exposure to nephrotoxic drugs, chemicals, or food items. if ingestion or exposure to a toxic drug, chemical, or food occurred recently (within 2 to 4 hours), induce emesis with apomorphine (0.04 mg/kg iv). next, administer activated charcoal either orally or via stomach tube, to prevent further absorption of the toxin. obtain blood and urine samples for toxicologic analysis (e.g., ethylene glycol) and to determine whether azotemia or abnormalities in the urine sediment exist. (see section on ethylene glycol, grapes and raisins, and nonsteroidal antiinflammatory drugs). obtain a complete blood count, biochemical profile, and urinalysis to determine the presence of signs of chronic renal failure, including polyuria, polydipsia, and nonregenerative anemia. radiographs and abdominal ultrasound can help in determining the chronicity of renal failure. normal renal size is 2.5-3.5 times the length of l2 in dogs and 2.4-3.0 times the length of l2 in cats. monitor the patient's body weight at least twice a day to avoid overhydration. also monitor urine output; normal output is 1-2 ml/kg/hour. in cases of polyuric renal failure, massive fluid and electrolyte losses can occur. place a urinary catheter for patient cleanliness and to facilitate urine quantitation. measure fluid ins and outs (see section on fluid therapy). after the patient has been rehydrated, the amount of fluids administered should equal maintenance and insensible needs plus the volume of urine produced each day. if a urinary catheter cannot be placed or maintained, serial body weight measurements and central venous pressure should be used to monitor the patient's fluid balance and prevent overhydration. if the patient is oliguric (urine output <1-2 ml/kg/hour), pharmacologic intervention is necessary to increase urine output. first, administer furosemide (2-4 mg/kg or 0.66 mg/kg/hour iv cri). repeat bolus doses of furosemide if there is no response to initial treatment. if necessary, administer low-dose dopamine (3-5 âµg/kg/minute iv cri) to increase renal afferent dilatation and renal perfusion. dopamine and furosemide may be synergistic if administered together. if dopamine and furosemide therapy is ineffective, administer mannitol (0.25-0.5 g/kg iv) once only. if polyuria is present, management is 1 simplified because of the decreased risk of overhydration. if oliguria cannot be reversed, monitor the central venous pessure, body weight, and respiratory rate and effort, auscultate for crackles, and examine the patient carefully for signs of chemosis and the presence of serous nasal discharge. correct hyperkalemia with sodium bicarbonate (0.25-1.0 meq/kg iv) or with insulin (0.25 units/kg) plus dextrose (1 g/unit of insulin iv, followed by 2.5% dextrose iv cri). treat severe metabolic acidosis (ph <7.2 or hco 3 â�� <12 meq/l) with sodium bicarbonate. if anuria develops or oliguria is irreversible despite this therapy, begin peritoneal dialysis. obtain a renal biopsy to establish a diagnosis and prognosis (see section on renal biopsy). administer gastroprotectant drugs and antiemetics to control nausea and vomiting. if possible, avoid the use of nephrotoxic drugs and general anesthesia. initiate nutritional support in the form of an enteral feeding tube or parenteral nutrition as early as possible. once the patient enters the recovery phase, diuresis may occur that can lead to dehydration and electrolyte imbalances (hyponatremia, hypokalemia). dehydration and electrolyte imbalances can be treated with parenteral fluid and electrolyte supplementation. postrenal azotemia is primarily caused by urethral obstruction or leakage from the urinary tract into the abdomen (uroabdomen). complete urinary tract obstruction and uroabdomen are both ultimately fatal within 3 to 5 days if left untreated. in dogs, the most common causes of urethral obstruction are urinary (urethral) calculi or tumors of the urinary bladder or urethra. in male cats, feline urologic syndrome (fus) is the most common cause of urethral obstruction, although there has been an increased incidence of urethral calculi observed in recent years. a ruptured urinary bladder is the most common cause of uroabdomen and is usually secondary to blunt trauma. clinical signs of urinary tract obstruction include dysuria, hematuria, inability to urinate or initiate an adequate stream of urine, and a distended painful urinary bladder. late in the course of obstructive disease, clinical signs referable to uremia and azotemia (vomiting, oral ulcers, hematemesis, dehydration, lethargy, and anorexia) occur. the initial goal of treatment of urinary tract obstruction is to relieve the obstruction. in male dogs, a lubricated catheter can be inserted past the area of obstruction with the animal under heavy sedation or general anesthesia (see section on urohydropulsion). depending on the chronicity of the obstruction, serum electrolytes should be measured;an ecg should be obtained before administering any anesthetic drugs, because of the cardiotoxic effects of hyperkalemia (see section on atrial standstill). correct fluid, electrolyte, and acid-base abnormalities. if a urinary catheter cannot be placed, perform cystocentesis only as a last resort, because of the risk of urinary bladder rupture. definitive treatment includes identification and treatment of the underlying cause (tumor versus urinary calculi). in most cases, surgical intervention is necessary. if an unresectable tumor is present, a low-profile permanent cystostomy tube can be placed, if the owner desires. administration of piroxicam (feldene, 0.3 mg/kg po q24-48h) with or without chemotherapy may shrink the tumor mass and delay the progression of clinical signs. a complete discussion of this disorder is beyond the scope of this text (see additional reading for other sources of information). feline lower urinary tract disease can cause urethral obstruction, particularly in male cats. clinical signs include stranguria, dribbling of small amounts of urine, lethargy, inappetence, and vomiting. often, owners call with the primary complaint of constipation, because the cat is making frequent trips to the litterbox and straining. cases with a duration of obstruction <36 hours are considered uncomplicated; those with a duration >36 hours are complicated. treatment of urethral obstruction includes stabilizing and normalizing the patient's electrolyte status, induction of sedation or general anesthesia, and relieving the obstruction. obtain blood samples for analysis of electrolyte abnormalities. treat hyperkalemia (k + > 6.0 meq/l) with sodium bicarbonate (0.25-1.0 meq/kg iv), regular insulin (0.25 unit/ kg iv) plus dextrose (1 g//unit of insulin iv), followed by 2.5% dextrose iv cri to prevent hypoglycemia; or calcium gluconate (0.2 ml/kg 10% iv slowly). administer non-potassiumcontaining intravenous fluids in 0.9% saline solution. obtain an ecg to detect atrial standstill (see section on atrial standstill). in some cases, a urethral plug is visible at the tip of the penis. the urethral plug can sometimes be manually extracted or massaged from the penis, and the obstruction temporarily relieved. in such cases, it is still necessary to pass a urethral catheter to flush sediment from the urethra and urinary bladder. unless a patient is obtunded, administer an anesthetic such as ketamine, atropine, or propofol (4-7 mg/kg iv) with diazepam iv for patient comfort and muscle relaxation. once the patient is under anesthesia or heavily sedated, urinary catheterization should be performed. in some cases, it will be difficult to advance the catheter. lubricate a closedended tomcat catheter and pass the tip into the distal urethra. fill a 12-ml syringe with sterile saline and sterile lubricant and connect the syringe to the hub of the catheter. pulse the fluid into the catheter as you gently move the catheter tip back and forth against the urethral obstruction. when the catheter has been passed into the urinary bladder, obtain a urine sample for urinalysis. drain the bladder and flush with sterile saline solution until the urine efflux appears clear. remove the tomcat catheter and insert a 3-5 fr red rubber tube or argyle infant feeding catheter into the urethra for urine collection and quantitation. secure the urinary catheter to prepuce with a butterfly strip of 1-inch adhesive tape secured around the catheter and then sutured to either side of the prepuce. the catheter should be connected to a closed urinary collection system for cleanliness and to reduce the risk of ascending bacterial infection. an elizabethan collar should be placed at all times to prevent the patient from damaging or removing the catheter. when the urethral obstruction has been relieved and the catheter placed, continue intravenous fluid diuresis to alleviate postrenal azotemia. monitor the urine for bacteria and other sediment. in some cases, postobstructive diuresis can be severe. carefully monitor fluid ins and outs, along with body weight, to maintain adequate hydration and perfusion. remove the urinary catheter can be removed after 24 to 48 hours. palpate the bladder frequently to make sure that the patient is voiding normally and to detect the recurrence of obstruction. in patients with severe penile or urethral trauma or edema, administer a short-acting steroid (dexamethasone sodium phosphate, 0.25 mg/kg iv, im, sq). at the time of initial diagnosis and again at the time of discharge, the clients need to be instructed about the long-term management of feline lower urinary tract disease at home, and informed of the risks and consequences of recurrence. uroabdomen can occur from trauma or leakage from the kidneys, ureter, or urinary bladder. clinical signs of uroabdomen (azotemia, uremia, hyperkalemia) can also occur secondary to third spacing of urine and leakage into muscular tissue from a ruptured urethra. in most cases, urinary bladder trauma and rupture are secondary to blunt trauma. abdominocentesis should be performed in any animal with suspected blunt abdominal trauma, and any fluid obtained should be analyzed for creatinine or potassium and compared with the patient's serum levels. an abdominal effusion that has a low packed cell volume and a potassium or creatinine level greater than that of the patient's serum is consistent with the diagnosis of uroabdomen. uroabdomen is not a surgical emergency. however, medical management consists of placement of a temporary abdominal drainage catheter into the abdomen, to facilitate removal of urine from the peritoneal cavity. to place the catheter, position the patient in dorsal or lateral recumbency, shave the ventral abdomen, as for any exploratory laparotomy. aseptically scrub the clipped area, and instill a local anesthestic (lidocaine, 1-2 mg/kg) caudal and to the right of the umbilicus, through the skin, subcutaneous tissues, and rectus 290 1 emergency care clinical differentiation of acute necrotizing from chronic nonsuppurative pancreatitis in cats: 63 cases acute pancreatitis in dogs mesenteric volvulus in the dog: a retrospective study of 12 cases incidence and prognostic value of low plasma ionized calcium concentration in cats with pancreatitis: 46 cases (1996-1998) review of feline pancreatitis. part 2: clinical signs, diagnosis and treatment gastric dilatation-volvulus syndrome in dogs diagnostic approach to acute pancreatitis pathophysiology of organ failure in severe acute pancreatitis in dogs washabau rj: gastrointestinal motility disorders and gastrointestinal prokinetic therapy watson pt: exocrine pancreatic insufficiency as an end-stage of pancreatitis in 4 dogs clinical signs, underlying cause, and outcome in cats with seizures: 17 cases fibrocartilaginous embolism in 75 dogs: clinical findings and factors influencing the recovery rate kirk's current veterinary therapy xiii intervertebral disc extrusion in six cats medical management of acute spinal cord disease risk factors for recurrence of clinical signs associated with thoracolumbar intervertebral disk herniation in dogs: 229 cases intervertebral disk disease in 10 cats long-term functional outcome of dogs with severe injuries of the thoracolumbar spinal cord: 87 cases canine status epilepticus: a retrospective study of 50 cases risk factors for development of status epilepticus in dogs with idiopathic epilepsy and effects of status epilepticus on outcome and survival time: 32 cases (1990-1996) skills laboratory part i: performing a neurologic examination skills laboratory part ii: interpreting the results of the neurologic examination accuracy of localization of cervical intervertebral disk extrusion or protrusion using survey radiography in dogs medical and surgical management of the glaucoma patient the feline glaucomas: 82 cases (1995-1999) the canine glaucomas traumatic ocular protrusion in dogs and cats: 84 cases traumatic glaucoma in a dog ocular and orbital porcupine quills in the dog: a review and case series hyphema: pathophysiologic considerations. comp cont educ pract vet van der woerdt a: the treatment of acute glaucoma in dogs and cats administer crystalloid intravenous fluids at maintenance rates using a balanced electrolyte solution perform urinary catheterization and collection to monitor urine output monitor serum urea nitrogen and creatinine every 12 hours treat oliguria, defined as a drop in urine output to less than 1 ml/kg/hour ml/kg) bolus start dopamine at 3 to 5 âµg/kg/minute if no response to crystalloid/colloid bolus occurs within 30 minutes consider mannitol (0.5 to 1 g/kg iv) administration if no response to dopamine occurs within 30 minutes consider furosemide (4 to 8 mg/kg iv, or 0.66 to 1 mg/kg/hour iv cri) if no response to dopamine or mannitol occurs in 30 to 60 minutes if no response to furosemide, peritoneal dialysis or hemodialysis is indicated immediately, particularly if anuria is present administered with caution, because of the risk of exacerbating increased capillary permeability and causing pulmonary edema. animal patients. chlorphenoxy derivatives exert their toxic effects by an unknown mechanism, and cause clinical signs of gastroenteritis and muscle rigidity severe anemia should be treated with packed rbcs or hemoglobin-based oxygen carriers handbook of small animal toxicology and poisonings macadamia nut toxicosis in dogs the recognition and treatment of the intermediate syndrome of organophosphate poisoning in a dog acute renal failure in four dogs after raisin or grape ingestion pleural effusion in cats pulmonary function, ventilator management, and outcome of dogs with thoracic trauma and pulmonary contusions: 10 cases (1994-1998) acute lung injury and acute respiratory distress syndrome smoke exposure in cats: 22 cases (1986-1997) smoke exposure in dogs: 27 cases (1988-1997) thoracic duct ligation and pericardectomy for treatment of idiopathic chylothorax use of intraluminal nitinol stents in the treatment of tracheal collapse in a dog clinical approach to epistaxis the veterinary icu book. teton newmedia radiographic diagnosis of diaphragmatic hernia: review of 60 cases in dogs and cats tracheal collapse: diagnosis and medical and surgical management acute respiratory distress syndrome brachycephalic syndrome in dogs outcome and postoperative complications in dogs undergoing surgical treatment of laryngeal paralysis: 140 cases (1985-1998) full recovery following delayed neurologic signs after smoke inhalation in a dog aspiration pneumonitis the veterinary icu book. teton newmedia allergic airway disease canine pleural and mediastinal effusion, a retrospective study of 81 cases suggested strategies for ventilatory management in veterinary patients with acute respiratory distress syndrome laryngeal and tracheal disorders the veterinary icu book. teton newmedia medical and surgical treatment of pyothorax in dogs: 26 cases traumatic diaphragmatic hernia in cats: 34 cases canine pyothorax: clinical presentation, diagnosis, and treatment canine pyothorax: pleural anatomy and pathophysiology treatment of chronic pleural effusion with pleuroperitoneal shunt in dogs: 14 cases (1985-1999) effects of doxapram hydrochloride on laryngeal function of normal dogs and dogs with naturally occurring laryngeal paralysis an overview of positive pressure ventilation risk factors, prognostic indicators, and outcome of pyothorax in cats: 80 cases (1986-1999) use of percutaneous arterial embolization for the treatment of intractable epistaxis in 3 dogs systemic inflammatory response syndrome, sepsis, and multiple organ dysfunction cardiogenic shock and cardiac arrest hemostatic changes in dogs with naturally occurring sepsis multiple organ dysfunction syndrome in humans and dogs increased lactate concentrations in ill and injured dogs the role of albumin in health and disease pathophysiologic characteristics of hypovolemic shock usefulness of systemic inflammatory response syndrome criteria as an index for prognosis judgement current principles and application of d-dimer analysis in small animal practice choosing fluids in traumatic hypovolemic shock: the role of crystalloids, colloids and hypertonic saline colloid and crystalloid resuscitation thromboembolic disease: predispositions and management marks sl: systemic arterial thromboembolism retrospective study of streptokinase administration in 46 cats with arterial thromboembolism feline arterial thromboembolism: an update arterial thromboembolism in cats: acute crises in 127 cases (1992-2001) and long-term management with low-dose aspirin in 24 cases cut multiple holes in the side of a 14-16 fr red rubber tube or thoracic drainage catheter, using care not to make the cut wider than 50% of the circumference of the tube. insert the catheter into the abdominal cavity in a dorsal caudal direction. make sure that all incisions within the abdomen. secure the tube by placing a pursestring suture around the tube entrance site in the abdominal musculature with absorbable suture material. close the dead space in the subcutaneous tissues with absorbable suture. close the skin around the tube with another purse-string suture secured using a finger-trap technique. connect the tube to a closed urinary collection system and bandage the catheter to the abdomen. the tube can remain in place until the patient retrospective evaluation of acute renal failure in dogs uroabdomen in dogs and cats drug-induced nephrotoxicity: recognition and prevention peritoneal dialysis in emergency and critical care acute renal failure caused by lily ingestion in six cats early diagnosis of renal disease and renal failure acute renal failure in four dogs after raisin or grape ingestion disorders of the feline lower urinary tract the use of a low-profile cystostomy tube to relieve urethral obstruction in a dog renal biopsy: methods and interpretation feline idiopathic cystitis: current understanding of pathophysiology and management today's problem when did you first notice that something was wrong with your pet? when was the last time you noticed your pet act normally? what was the first abnormal sign noticed? what other conditions have developed and what are they? how soon did other signs develop? have the signs become better or worse since you first saw them? what is the name of the product? do you have the container with you today? is it a liquid concentrate, dilute spray, or solid? how long ago do you think that your pet was exposed to the poison? where do you think it happened? do you have any over-the-counter or prescription medications that your animal may have had access to? did you give any medications to your animal? is there any possibility of recreational drug exposure?your pet's recent activity did your pet eat this morning or last night? what is he/she normally fed? is there a chance that your pet may have gotten into the garbage? have you fed table scraps or anything new recently? if so, what? has your pet been off your property in the last 24-48 hours? does your pet run loose unattended? has your pet had any antiflea/tick medication within the last week?your pet's environment is your animal kept inside or outside of the house? is your pet kept in a fenced-in yard or allowed to run loose unattended? does your pet have access to neighboring properties (even for a short time)? where has your pet been in the last 24 hours? has your pet traveled outside of your immediate geographic location? if so, when? has your pet been to rural areas in the last week? has there been any gardening work recently? does your pet have access to a compost pile? any fertilizers or weed killer used in the last week? any construction work or renovation recently? any mouse or rat poison in your house, yard, or garage? any cleaning products used inside or outside the house within the last 48 hours? if so, which? have you changed your radiator fluid or does a car leak antifreeze? induce and maintain a patent airway and stabilize the patient's cardiovascular and respiratory status. control cns excitation with diazepam, if necessary, and control the patient's body temperature (both hypo-and hyperthermia) . induce vomiting if the patient is alert and can protect its airway; otherwise, perform orogastric lavage with the patient under general anesthesia with a cuffed endotracheal tube in place. alcohols do not bind well with activated charcoal. treat dermal exposure by bathing the area with warm water. introduction: if ingested, sodium or potassium hydroxide can cause severe contact dermatitis or irritation of the gastrointestinal tract. esophageal burns and full-thickness coagulative necrosis can occur. if an animal ingests a caustic alkali substance, feed the animal four egg whites mixed with 1 quart of warmed water. perform endoscopy within 24 hours to evaluate the extent of injury and to place a feeding tube, in severe cases. do not induce emesis , and do not perform orogastric lavage, because of the risk of worsening esophageal irritation. in cases of contact exposure to the skin or eyes, rinse the exposed area with warm water baths for at least 30 minutes. administer gastroprotectant, antiemetic, and analgesic drugs as necessary. avoid neutralization, which can cause a hyperthermic reaction and worsen injury to the skin and gastrointestinal tract. amitraz is the active ingredient in ascaricides and anti-tick and anti-mite products such as mitaban and taktic. the toxic dose is 10 to20 mg/kg. amitraz exerts its toxic effects by causing î±-adrenergic stimulation, and causes clinical signs similar to those observed with administration of xylazine: bradycardia, cns depression, ataxia, hypotension, hyperglycemia, hypothermia, cyanotic mucous membranes, polyuria, mydriasis, and emesis. a coma can develop. treatment of amitraz intoxication includes cardiovascular support with intravenous crystalloid fluids and induction of emesis in asymptomatic animals. if clinical signs are present, orogastric lavage may be required. many toxic compounds are impregnated in a collar form. if the patient has ingested a collar and does not vomit it, it should be removed using endoscopy or gastrotomy. administer activated charcoal to prevent or delay absorption of the toxic compound. yohimbine or atepamizole, both î±-adrenergic antagonists, are the treatment(s) of choice to reverse the clinical signs of toxicity. avoid the use of atropine, because it can potentially increase the viscosity of respiratory secretions and cause gastrointestinal ileus, thus promoting increased absorption of the toxic compound. ammonium hydroxide, or cleaning ammonia, can be caustic at high concentrations (see alkalis/caustics) and cause severe injury to the respiratory system if inhaled. pulmonary edema or pneumonia can occur, resulting in respiratory distress. ingestion of ammonia can cause severe irritation to the gastrointestinal tract and cause vomiting and esophageal injury. if ammonia is ingested, administer a dilute solution of egg white.administer gastroprotectant, antiemetic, and analgesic drugs as necessary. if pneumonia or pulmonary edema occurs secondary to aspiration of ammonia into the airways and alveolar spaces, treatment is largely supportive with supplemental oxygen administration, antibiotics, fluid therapy, and mechanical ventilation as necessary. diuretics may or may not be useful in the treatment of pulmonary edema secondary to ammonia inhalation. amphetamines cause cns excitation due to neurosynaptic stimulation, resulting in hypersensitivity to noise and motion, agitation, tremors, vomiting, diarrhea, and seizures. clinical signs of amphetamine toxicity include muscle tremors, tachyarrhythmias, mydriasis, ptyalism, and hyperthermia. amphetamines are rapidly absorbed from the gastrointestinal tract. treatment includes administration of intravenous fluids to maintain hydration and renal perfusion and correction of hyperthermia. administer sedative drugs such as chlorpromazine to control agitation and tremors, and diazepam to control seizures. urinary acidification can promote excretion and prevent reabsorption from the urinary bladder. in severe cases, treat cerebral edema with a combination of mannitol followed by furosemide to control increased intracranial pressure.antifreeze: see ethylene glycol antihistamines introduction antihistamines (loratadine, diphenhydramine, doxylamine, clemastine, meclizine, dimenhydrinate, chlorpheniramine, cyclizine, terfenadine, hydroxyzine) are available as over-thecounter and prescription allergy and anti-motion sickness products. clinical signs of antihistamine toxicity include restlessness, nausea, vomiting, agitation, seizures, hyperthermia, and tachyarrhythmias. treatment of antihistamine intoxication is largely symptomatic and supportive, as there is no known antidote. if ingestion is recent (within 1 to 2 hours) and the patient is not actively seizing and can protect its airway, induce emesis or perform orogastric lavage, followed by administration of activated charcoal and a cathartic. monitor the patient's heart rate, rhythm, and blood pressure. treat cardiac arrhythmias, if present, with appropriate therapies (see section on cardiac dysrhythmias). administer cooling measures and intravenous fluids to treat hyperthermia. a constant rate infusion of guaifenasin can be used to control muscle tremors. introduction î±-naphthylthiourea (antu) is manufactured as a white or blue-gray powder. the toxic dose in dogs is 10-40 mg/kg, and in cats is 75-100 mg/kg. younger dogs appear to be more resistant to its toxic effects. antu usually causes profound emesis and increased capillary permeability that eventually leads to pulmonary edema. treatment of antu toxicity includes respiratory support. mechanical ventilation may be required in severe cases of pulmonary edema. if an animal does not vomit, orogastric lavage should be performed. administer gastrointestinal protectant, antiemetic, and analgesic drugs. cardiovascular support in the form of intravenous crystalloids should be arsenic introduction inorganic arsenic (arsenic trioxide, sodium arsenite, sodium arsenate) is the active ingredient in many herbicides, defoliants, and insecticides, including ant killers. the toxic dose of sodium arsenate is 100-150 mg/kg; that of sodium arsenite is 1-25 mg/kg. sodium arsenite is less toxic, although cats are very susceptible. arsenic compounds interfere with cellular respiration by combining with sulfhydryl enzymes. clinical signs of toxicity include severe gastroenteritis, muscle weakness, capillary damage, hypotension, renal failure, seizures, and death. in many cases, clinical signs are acute in onset. treatment of arsenic toxicity involves procuring and maintaining a patent airway. administer intravenous crystalloid fluids to correct hypotension and hypovolemia, and normalize acidbase and electrolyte balance. if no clinical signs are present and if the compound was ingested within 2 hours, induce emesis. if clinical signs are present, perform orogastric lavage followed by administration of activated charcoal. if dermal exposure has occurred, throughly bathe the animal to prevent further absorption. dimercaprol (bal, 3-4 mg/kg im q8h) can be administered as a chelating agent. n-acetylcysteine (mucomyst) (for cats, 140-240 mg/kg po iv, then 70 mg/kg po iv q6h for 3 days; for dogs, 280 mg/kg po or iv, then 140 mg/kg po iv q4h for 3 days) has been shown to decrease arsenic toxicity in rats. aspirin causes inhibition of the production of prostaglandins, a high anion gap metabolic acidosis, gastrointestinal ulceration, hypophosphatemia, and decreased platelet aggregation when ingested in high quantities (>50 mg/kg/24 hours in dogs; >25 mg/kg/24 hours in cats). clinical signs of aspirin toxicity include tachypnea, vomiting, anorexia, lethargy, hematemesis, and melena. treatment of aspirin toxicity is largely supportive. if the ingestion was recent (within the last hour), induce emesis or perform orogastric lavage followed by administration of activated charcoal. administer intravenous crystalloid fluids to maintain hydration and correct acid-base abnormalities. administer synthetic prostaglandin analogues (misoprostol), gastroprotectant drugs, and antiemetics. alkalinization of the urine can enhance excretion. introduction baclofen is a gaba agonist centrally acting muscle relaxant. clinical signs of toxicity include vomiting, ataxia, vocalization, disorientation, seizures, hypoventilation, coma, and apnea. clinical signs can occur at doses as low as 1.3 mg/kg. treatment of baclofen ingestion includes induction of emesis if the animal is asymptomatic. otherwise, perform orogastric lavage. emesis or orogastric lavage should be followed by administration of activated charcoal. perform intravenous crystalloid fluid diuresis to promote elimination of the toxin, maintain renal perfusion, and normalize body temperature. supplemental oxygen or mechanical ventilation may be required for hypoventilation or apnea. if seizures occur, avoid the use of diazepam, which is a gaba agonist and can potentially worsen clinical signs. control seizures with intravenous introduction î²-adrenergic agonists, including terbutaline, albuterol (salbutamol), and metaproterenol, are commonly used in inhaled form for the treatment of asthma. animals commonly are exposed to the compounds after chewing on their owners' inhalers. clinical signs of î²-adrenergic stimulation include tachycardia, muscle tremors, and agitation. severe hypokalemia can occur. treatment of î²-adrenergic agonist intoxication includes treatment with beta-blockers (propranolol, esmolol, atenolol), intravenous fluids, and intravenous potassium supplementation. diazepam or acepromazine may be administered for sedation and muscle relaxation. introduction barbiturates such as phenobarbital are gaba agonists and induce cns depression. clinical signs of barbiturate overdose or toxicity include weakness, lethargy, hypotension, hypoventilation, stupor, coma, and death. treatment of barbiturate toxicity includes maintenance and support of the cardiovascular and respiratory systems. if clinical signs are absent and the patient can protect its airway, induce emesis followed by repeated doses of activated charcoal. perform orogastric lavage if emesis is contraindicated. administer supplemental oxygen if hypoventilation occurs. some animals may require mechanical ventilation. administer intravenous fluids to control perfusion and blood pressure. positive inotropic drugs may be required if dosedependent decrease in cardiac output and blood pressure occurs. alkalinization of the urine and peritoneal dialysis can be performed to enhance excretion and elimination. hemodialysis should be considered in severe cases, if available. automotive and dry cell batteries contain sulfuric acid that can be irritating on contact with the eyes, skin, and gastrointestinal tract. button batteries, which contain sodium or potassium hydroxide, cause contact irritation if chewed. to treat exposure, rinse the eyes and skin with copious amounts of warm tap water or sterile saline solution for a minimum of 30 minutes. if ingestion occurred, administer gastroprotectant and antiemetic drugs. induction of emesis and orogastric lavage is absolutely contraindicated because of the risk of aspiration pneumonia and worsening esophageal irritation. no attempt should be made at performing neutralization because of the risk of causing an exothermic reaction and worsening tissue damage. administer analgesics to control discomfort. benzoyl peroxide is the active ingredient in many over-the-counter acne preparations. ingestion can result in production of hydrogen peroxide, gastroenteritis, and gastric dilatation. topical exposure can cause dermal irritation and blistering. if an animal has ingested benzoyl peroxide, do not induce emesis, because of the risk of worsening esophageal irritation. instead, perform orogastric lavage. administer gastroprotectant and antiemetic medications and closely observe the patient observed for signs of gastric dilatation.bismuth subsalicylate (pepto-bismol): see aspirin bleach, chlorine (sodium hypochlorite) introduction sodium hypochlorite is available in dilute (3%-6%) or concentrated (50% industrial strength or swimming pool) solutions for a variety of purposes. sodium hypochlorite can cause severe contact irritation and tissue destruction, depending on the concentration. affected animals may have a bleached haircoat. treatment of exposure includes dilution with copious amounts of warm water or saline baths and ocular lavage. induction of emesis and orogastric lavage is absolutely contraindicated because of the risk of causing further esophageal irritation. to treat ingestion, give the animal milk or large amounts of water, in combination with gastroprotectant and antiemetic drugs, to dilute the contents in the stomach. administration of sodium bicarbonate or milk of magnesia is no longer recommended. nonchlorine bleaches (sodium peroxide or sodium perborate) have a moderate toxic potential if ingested. sodium peroxide can cause gastric distention. sodium perborate can cause severe gastric irritation, with vomiting and diarrhea; renal damage and cns excitation followed by depression can occur, depending on the amount ingested. to treat dermal or ocular exposure, rinse the skin or eyes with copious amounts of warm tap water or sterile saline for a minimum of 30 minutes; treat ocular injuries as necessary, if corneal burns have occurred. if the bleach has been ingested, do induce emesis and perform orogastric lavage. administer milk of magnesia (2-3 ml/kg). boric acid is the active ingredient in many ant and roach killers. the toxic ingredient (in amounts of 1-3 g/kg) can cause clinical signs in dogs by an unknown mechanism. clinical signs include vomiting (blue-green vomitus), blue-green stools, renal damage, and cns excitation and depression. treatment of boric acid or borate ingestion includes gastric decontamination with induction of emesis or orogastric lavage, followed by administration of a cathartic to hasten elimination. activated charcoal is not useful to treat ingestion of this toxin. administer intravenous fluid therapy to maintain renal perfusion. administer gastroprotectant and antiemetic drugs, as necessary. clostridium botulinum endospores can be found in carrion, food, garbage, and the environment. ingestion of endospores and c. botulinum endotoxin rarely can cause generalized neuromuscular blockade of spinal and cranial nerves, resulting in miosis, anisocoria, lower motor neuron weakness, and paralysis. respiratory paralysis, megaesophagus, and aspiration pneumonia can occur. clinical signs usually develop within 6 days of ingestion. differential diagnosis includes acute polyradiculoneuritis (coonhound paralysis), bromethalin intoxication, and tick paralysis. treatment of botulism is largely supportive; although an antitoxin exists, it often is of no benefit. treatment may include administration of intravenous fluids, frequent turning of the patient and passive range-of-motion exercises to prevent disuse muscle atrophy, and supplemental oxygen administration or mechanical ventilation. administer amoxicillin, ampicillin, or metronidazole. recovery may be prolonged, up to 3 to 4 weeks in some cases. bromethalin is the active ingredient in some brands of mouse and rat poisons. it usually is packaged as 0.01% bromethalin in green or tan pellets, and packaged in 16 -42.5 g place packs. the toxic dose for dogs is 116.7 g/kg, and for cats 3 g/kg. bromethalin causes toxicity by uncoupling of oxidative phosphorylation. an acute syndrome of vomiting, tremors, extensor rigidity, and seizures occurs within 24 hours of ingestion of high doses. delayed clinical signs occur within 3 to 7 days of ingestion of a lower dose and include posterior paresis progressing to ascending paralysis, cns depression, and coma. treatment of known bromethalin ingestion includes induction of emesis or orogastric lavage, and repeated doses of activated charcoal every 4 to 6 hours for 3 days, because bromethalin undergoes enterohepatic recirculation. supportive care includes intravenous fluids, anticonvulsants, muscle relaxants (methocarbamol up to 220 mg/kg/day iv to effect), frequent turning of the patient, and passive range-of-motion exercises. supplemental oxygen and /or mechanical ventilation may be required in patients with coma and severe hypoventilation. administer mannitol (0.5-1 g/kg) in conjunction with furosemide (1 mg/kg iv) if cerebral edema is suspected. the majority of caffeine toxicities occur in dogs that ingest coffee beans. caffeine causes phosphodiesterase inhibition, and can cause cardiac tachyarrhythmias, cns stimulation (hyperexcitability and seizures), diuresis, gastric ulcers, vomiting, and diarrhea. muscle tremors and seizures can occur, resulting in severe hyperthermia. treatment of caffeine toxicity is largely symptomatic and supportive, as there is no known antidote. if clinical signs are not apparent and the patient is able to protect its airway, induce emesis. alternatively, orogastric lavage can be performed, followed by administration of activated charcoal. administer diazepam to control seizures. administer betaadrenergic blockers (e.g., esmolol, propranolol, atenolol) to control tachyarrhythmias. give intravenous fluids to maintain hydration and correct hyperthermia. the patient should be walked frequently or have a urinary catheter placed to prevent reabsorption of the toxin from the urinary bladder. carbamate compounds are found in agricultural and home insecticide products. examples of carbamates include carbofuran, aldicarb, propoxur, carbaryl, and methiocarb. the toxic dose of each compound varies. carbamate compounds function by causing acetylcholinesterase inhibition. toxic amounts cause cns excitation, muscarinic acetylcholine overload, and slud (salivation, lacrimation, urination, and defecation). miosis, vomiting, treatment of carbamate intoxication includes maintaining an airway and, if necessary, artificial ventilation. administer intravenous crystalloid fluids to control the patient's hydration, blood pressure, and temperature. cooling measures may be warranted. induce emesis if the substance was ingested within 60 minutes and the animal is asymptomatic. give repeated doses of activated charcoal if the animal can swallow and protect its airway. control seizures with diazepam (0.5 mg/kg iv). bathe the patient thoroughly. atropine (0.2 mg/kg iv) is useful in controlling some of the muscarinic signs associated with the toxicity. pralidoxime hydrochloride (2-pam) is not useful in cases of carbamate intoxication. control muscle tremors with methocarbamol (up to 220 mg/kg iv) or guaifenesin. in humans, ingestion or inhalation of 3-5 ml of carbon tetrachloride can be fatal. clinical signs of carbon tetrachloride toxicity include vomiting and diarrhea, then progressive respiratory and central nervous system depression. ventricular dysrhythmias and hepatorenal damage ensue. the prognosis is grave. treatment of carbon tetrachloride inhalation includes procurement and maintenance of a patent airway with supplemental oxygen, and cardiovascular support. to treat ingestion, administer activated charcoal, and give intravenous fluids to maintain hydration and support renal function. chlorinated hydrocarbons include ddt, methoxychlor, lindane, dieldrin, aldrin, chlordane, chlordecone, perthane, toxaphene, heptachlor, mirex, and endosulfan. the toxic dose of each compound varies. chlorinated hydrocarbons exert their toxic effects by an unknown mechanism, and can be absorbed through the skin and the gastrointestinal tract. clinical signs are similar to those observed in organophosphate toxicity: cns excitation, seizures, slud, (salivation, lacrimation, urination, defecation), excessive bronchial secretions, vomiting, diarrhea, muscle tremors, and respiratory paralysis. secondary toxicity from toxic metabolites can cause renal and hepatic failure. chronic exposure may cause anorexia, vomiting, weight loss, tremors, seizures, and hepatic failure. the clinical course can be prolonged in small animal patients. treatment of chlorinated hydrocarbon toxicity is largely supportive in nature, as there is no known antidote. procure and maintain the patient's airway. normalize the body temperature to prevent hyperthermia. if the substance was just ingested and the patient is not demonstrating any clinical signs, induce emesis. if the patient is symptomatic, perform orogastric lavage followed by activated charcoal administration. bathe the patient thoroughly in cases of topical exposure. administer intravenous crystalloid fluids to maintain hydration. these compounds do not appear to be amenable to fluid diuresis. introduction: chlorphenoxy derivatives are found in 2,4-d, 2,4,5-t, mcpa, mcpp, and silvex. the ld 50 of 2,4-d is 100 mg/kg; however, the toxic dose appears to be much lower in small treatment treatment of chlorphenoxy derivative toxicity is largely supportive in nature, as there is no known antidote. secure the patient's airway and administer supplemental oxygen, as necessary. control cns excitation with diazepam (0.5 mg/kg iv). intravenous crystalloid fluid diuresis and urinary alkalinization can promote elimination. administer gastroprotectant and antiemetic drugs, as needed. the toxic effects of chocolate are related to theobromine. various types of chocolate have different concentrations of theobromine and thus can cause clinical signs of toxicity with ingestion of varying amounts of chocolate, depending on the type. the toxic dose of theobromine is 100-150 mg/kg in dogs. milk chocolate contains 44 mg/oz (154 mg/100 g) of chocolate, and has a low toxic potential. semisweet chocolate contains 150 mg/oz (528 mg/100 g), and baking chocolate contains 390 mg/oz (1365 mg/100 g). semisweet and baking chocolate, being the most concentrated, have a moderate to severe toxic potential, even in large dogs.clinical signs of theobromine intoxication are associated with phosphodiesterase inhibition and include cns stimulation (tremors, anxiety, seizures), myocardial stimulation (tachycardia and tachyarrhythmias), diuresis, and (at very high doses) gastrointestinal ulceration. with treatment, the condition of most dogs returns to normal within 12 to 24 hours (t1 /2 = 17.5 hours in dogs). potential side effects include gastroenteritis and pancreatitis due to the fat content of the chocolate. treatment of chocolate toxicity includes obtaining and maintaining a protected airway (if necessary), intravenous fluid diuresis, induction of emesis or orogastric lavage followed by administration of repeated doses of activated charcoal, and placement of a urinary catheter to prevent reabsorption of the toxin from the urinary bladder. cholecalciferol rodenticide ingestion can lead to increased intestinal and renal reabsorption of calcium, causing an increase in serum calcium and dystrophic mineralization of the kidneys and liver at 2-3 mg/kg. clinical signs include lethargy, anorexia, vomiting, constipation, and renal pain within 2 to 3 days of ingestion. seizures, muscle twitching, and central nervous system depression may be observed at very high doses. as renal failure progresses, polyuria, polydipsia, vomiting/hematemesis, uremic oral ulcers, and melena may be observed. if the compound was ingested recently (within 2 to 4 hours) induce emesis or perform orogastric lavage, followed by administration of activated charcoal. check the patient's serum calcium once daily for three days following ingestion. if clinical signs of toxicity or hypercalcemia are present, decrease serum calcium with loop diuretics (furosemide, 2-5 mg/kg po or iv q12h) and glucocorticosteroids (prednisone or prednisolone, 2-3 mg/kg po bid) to promote renal calcium excretion. in severe cases, salmon calcitonin (4-6 iu/kg sc q2-12h in dogs) or bisphosphonate compounds may be required. correct acid-base abnormalities with intravenous crystalloid fluid diuresis and sodium bicarbonate, if necessary. (see section on hypercalcemia.) denture cleaners contain sodium perborate as the active compound. sodium perborate can cause severe direct irritation of the mucous membranes and may also act as a cns depressant. clinical signs are similar to those seen if bleach or boric acid compound is ingested, namely vomiting, diarrhea, cns excitation then depression, and renal failure. treatment for ingestion of denture cleaner includes gastric decontamination along with induction of emesis or orogastric lavage and administration of a cathartic to hasten elimination. activated charcoal is not useful for treatment of ingestion of this toxin. administer intravenous fluid therapy to maintain renal perfusion. administer gastroprotectant and antiemetic drugs, as necessary. deodorants are usually composed of aluminum chloride and aluminum chlorohydrate. both have a moderate potential for toxicity. ingestion of deodorant compounds can cause oral irritation or necrosis, gastroenteritis, and nephrosis. treatment of deodorant ingestion includes orogastric lavage, and administration of antiemetic and gastroprotectant drugs. introduction anionic detergents include sulfonated or phosphorylated forms of benzene. dishwashing liquid is an example of an anionic detergent that can be toxic at doses of 1 -5 g/kg. anionic detergents cause significant mucosal damage and edema, gastrointestinal irritation, cns depression, seizures, and possible hemolysis. ocular exposure can cause corneal ulcers and edema. treatment of anionic detergent exposure is largely symptomatic, as there is no known antidote. to treat topical toxicity, flush the patient's eyes and skin with warmed tap water or 0.9% saline solution for a minimum of 30 minutes, taking care to avoid hypothermia. to treat ingestion, feed the patient milk and large amounts of water to dilute the toxin. do not induce emesis, because of the risk of worsening esophageal irritation. to dilute the toxin, perform orogastric lavage, followed by administration of activated charcoal. closely monitor the patient's respiratory status, because oropharyngeal edema can be severe. if necessary, perform endotracheal intubation in cases of airway obstruction. monitor the patient for signs of intravascular hemolysis. administer intravenous crystalloid fluids to maintain hydration until the patient is able to tolerate oral fluids. cationic detergents and disinfectants include quaternary ammonia compounds, isopropyl alcohol, and isopropanol. quaternary ammonia compounds have a serious toxic potential treatment treatment of cationic detergent exposure includes careful bathing and ocular rinsing of the patient for a minimum of 30 minutes, taking care to avoid hypotension. secure the patient's airway and monitor the patient's respiratory status. administer supplemental oxygen, if necessary. place an intravenous catheter and administer intravenous crystalloid fluids to maintain hydration. do not induce emesis, because of the risk of causing further esophageal irritation. give milk or large amounts of water orally, as tolerated by the patient, to dilute the toxin. nonionic detergents include alkyl and aryl polyether sulfates, alcohols, and sulfonates; alkyl phenol; polyethylene glycol; and phenol compounds. phenols are particularly toxic in cats and puppies. clinical signs of exposure include severe gastroenteritis and topical irritation. some compounds can be metabolized to glycolic and oxalic acid, causing renal damage similar to that observed with ethylene glycol toxicity. topical and ocular exposure should be treated with careful bathing or ocular irrigation for at least 30 minutes. administer activated charcoal to prevent absorption of the compound. as tolerated, give dilute milk or straight tap water orally to dilute the compound. administer antiemetic and gastroprotectant drugs to control vomiting and decrease gastrointestinal irritation. administer intravenous crystalloid fluids to maintain hydration and decrease the potential for renal tubular damage. monitor the patient's acid-base and electrolyte status and correct any abnormalities with appropriate intravenous fluid therapy. introduction diclone (phigone) is a dipyridyl compound that is a cns depressant. the ld 50 in rats is 25-50 mg/kg. dichlone reacts with thiol enzymes to cause methemoglobinemia and hepatorenal damage. to treat dichlone ingestion, induce emesis or perform orogastric lavage, followed by administration of activated charcoal and a cathartic. procure and maintain a patent airway. perform intravenous fluid diuresis to maintain renal perfusion. n-acetylcysteine may be useful in the treatment of methemoglobinemia. diethyltoluamide (deet) is the active ingredient in many insect repellants (e.g., off, cutters, hartz blockade). the mechanism of action of deet is not fully understood, but it acts as a lipophilic neurotoxin within 5 to 10 minutes of exposure. cats appear to be particularly sensitive to deet. a lethal dermal dose is 1.8 g/kg; if ingested, the lethal dose is much less. the toxic dose of dermal exposure in dogs is 7 g/kg. clinical signs of toxicity include aimless gazing, hypersalivation, chewing motions, and muscle tremors that progress to seizures. recumbency and death can occur within 30 minutes of exposure at high doses. treatment of deet toxicity is largely supportive, as there are no known antidotes. procure and maintain a patent airway and perform mechanical ventilation, if necessary. place an intravenous catheter and administer intravenous crystalloid fluids to control hydration and treat hypotension, as necessary. treat seizures with diazepam (0.5 mg/kg iv) or phenobarbital. because of the rapid onset of clinical signs, induction of emesis is contraindicated. perform orogastric lavage if the compound was ingested within the last 2 hours. administer multiple repeated doses of activated charcoal. cooling measures should be implemented to control hyperthermia. if dermal exposure has occurred, bathe the patient thoroughly to avoid further exposure and absorption. diquat is a dipyridyl compound that is the active ingredient in some herbicide compounds. the ld 50 of diquat is 25-50 mg/kg. like paraquat, diquat induces its toxic effects by causing the production of oxygen-derived free radical species. clinical signs of diquat intoxication include anorexia, vomiting, diarrhea, and acute renal failure. massive dehydration and electrolyte imbalances can occur as a result of fluid loss into the gastrointestinal tract. treatment of diquat intoxication is similar to that for paraquat ingestion. if the animal had ingested diquat within 1 hour of presentation, induce emesis. in clinical cases, orogastric lavage may be required. both emesis and orogastric lavage should be followed by administration of kaolin or bentonite as an adsorbent, rather than activated charcoal. place an intravenous catheter and administer crystalloid fluids to restore volume status and maintain renal perfusion. monitor urine output. if oliguria or anuria occurs, treatment with mannitol, furosemide, and dopamine may be considered. ecstasy (3,4-methylenedioxymethylamphetamine; mdma) is a recreational drug used by humans. ecstasy causes release of serotonin. clinical signs of intoxication are related to the serotonin syndrome (excitation, hyperthermia, tremors, and hypertension), and seizures may be observed. a urine drug screening test can be used to detect the presence of mdma. treatment of ecstasy intoxication is largely supportive, as there is no known antidote. administer intravenous fluids to maintain hydration, correct acid-base status, and treat hyperthermia. serotonin antagonist drugs (cyproheptadine) can be dissolved and administered per rectum to alleviate clinical signs. intravenous propranolol has additional antiserotonin effects. administer diazepam (0.5-2 mg/kg iv) to control seizures. if cerebral edema is suspected, administer mannitol, followed by furosemide. ethylene glycol is most commonly found in antifreeze solutions but is also in some paints, photography developer solutions, and windshield wiper fluid. ethylene glycol in itself is only minimally toxic. however, when it is metabolized to glycolate, glyoxal, glyoxylate, and oxalate, the metabolites cause an increased anion gap metabolic acidosis and precipitation of calcium oxalate crystals in the renal tubules, renal failure, and (ultimately) death.the toxic dose in dogs is 6.6 ml/kg, and in cats is 1.5 ml/kg. the toxin is absorbed quite readily from the gastrointestinal tract and can be detected in the patient's serum within an hour of ingestion. colorimetric tests that can be performed in most veterinary hospitals can detect larger quantities of ethylene glycol in the patient's serum. in a dog with clinical treatment begin treatment of known ethylene glycol ingestion immediately. induce emesis or perform orogastric lavage and adminiser repeated doses of activated charcoal. place an intravenous catheter and perform crystalloid fluid diuresis with a known antidote. the treatment of choice for dogs is administration of 4-methylpyrrazole (4-mp), which directly inhibits alcohol dehydrogenase, thus preventing the conversion of ethylene glycol to its toxic metabolites. the dose for dogs is 20 mg/kg initially, followed by 15 mg/kg at 12 and 24 hours and 5 mg/kg at 36 hours. 4-mp has been used experimentally at 6.25 times the recommended dose for dogs. in cats, treatment with 4-mp is effective if it is administered within the first 3 hours of ingestion.cats will demonstrate signs of sedation and hypothermia with this treatment. if 4-mp is not available, administer ethanol (600 mg/kg iv loading dose, followed by 100 mg/ kg/hour), or as a 20% solution (for dogs, 5.5 ml/kg iv q4h for five treatments, then q 6h for five more treatments; for cats, 5 ml/kg q8h for four treatments). grain alcohol (190 proof) contains approximately 715 mg/ml of ethanol. antiemetics and gastroprotective agents should be considered. urinary alkalinization and peritoneal dialysis may enhance the elimination of ethylene glycol and its metabolites. many fertilizers are on the market, and may be composed of urea or ammonium salts, phosphates, nitrates, potash, and metal salts. fertilizers have a moderate toxic potential, depending on the type and amount ingested. clinical signs of fertilizer ingestion include vomiting, diarrhea, metabolic acidosis, and diuresis. nitrates or nitrites can cause formation of methemoglobin and chocolate-brown blood. electrolyte disturbances include hyperkalemia, hyperphosphatemia, hyperammonemia, and hyperosmolality. treatment of fertilizer ingestion includes cardiovascular support, and administration of milk or a mixture of egg whites and water, followed by induction of emesis or orogastric lavage. correct electrolyte abnormalities as they occur (see section on hyperkalemia). administer antiemetic and gastroprotectant drugs, as necessary. administer intravenous fluids to control hydration and maintain blood pressure. n-acetylcysteine may be useful if methemoglobinemia is present. fipronil is the active ingredient in frontline, a flea control product. fipronil exerts its effects by gaba antagonism and can cause cns excitation. treatment of fiprinol toxicity includes treatment of cns excitation, treatment of hyperthermia by cooling measures, and administration of activated charcoal. fire extinguisher fluid contains chlorobromomethane or methyl bromide, both of which have a serious toxic potential. dermal or ocular irritation can occur. if ingested, the compounds can be converted to methanol, and cause high anion gap metabolic acidosis, cns excitation and depression, aspiration pneumonitis, and hepatorenal damage. to treat ocular or dermal exposure to fire extinguisher fluids, flush the eyes or skin with warmed tap water or 0.9% saline solution for a minimum of 30 minutes. do not induce emesis or perform orogastric lavage to treat ingestion, because of the risk of causing severe aspiration pneumonitis. gastroprotectant and antiemetic drugs may be used, if indicated. administer intravenous fluids to maintain hydration and renal perfusion. supplemental oxygen or mechanical ventilation may be required in severe cases of aspiration pneumonitis. fireplace colors contain salts of heavy metals-namely, copper rubidium, cesium, lead, arsenic, antimony, barium, selenium, and zinc, all of which have moderate toxic potential, depending on the amount ingested and the size of the patient. clinical signs are largely associated with gastrointestinal irritation (vomiting, diarrhea, anorexia). zinc toxicity can cause intravascular hemolysis and hepatorenal damage. to treat ingestion of fireplace colors, administer cathartics and activated charcoal and gastroprotectant and antiemetic drugs. place an intravenous catheter for intravenous crystalloid fluid administration to maintain hydration and renal perfusion. specific chelating agents may be useful in hastening elimination of the heavy metals. fireworks contain oxidizing agents (nitrates and chlorates) and metals (mercury, copper, strontium, barium, and phosphorus). ingestion of fireworks can cause hemorrhagic gastroenteritis and methemoglobinemia. to treat firework ingestion, induce emesis or perform orogastric lavage and administer activated charcoal. administer specific chelating drugs if the amount and type of metal are known, and administer gastroprotectant and antiemetic drugs. if methemoglobinemia occurs, administer n-acetylcysteine; a blood transfusion may be necessary. introduction fuels such as barbecue lighter fluid, gasoline, kerosene, and oils (mineral, fuel, lubricating) are petroleum distillate products that have a low toxic potential if ingested but can cause severe aspiration pneumonitis if as little as 1 ml is inhaled into the tracheobronchial tree. cns depression, mucosal damage, hepatorenal insufficiency, seizures, and corneal irritation can occur. if fuels are ingested, administer gastroprotectant and antiemetics drugs. do not induce emesis or perform orogastric lavage, because of the risk of aspiration pneumonia. to treat topical exposure, rinse the skin and eyes copiously with warm tap water or 0.9% saline solution. administer antiemetic and gastroprotectant drugs, as necessary. administer intravenous fluids to maintain hydration and treat acid-base and electrolyte abnormalities. children's glue contains polyvinyl acetate, which has a very low toxic potential. if inhaled, the compound can cause pneumonitis. treatment of polyvinyl acetate should be performed as clinical signs of pneumonitis (increased respiratory effort, cough, lethargy, respiratory distress) occur. introduction superglue contains methyl-2-cyanoacrylate, a compound that can cause severe dermal irritation on contact. do not induce emesis. do not bathe the animal, and do not apply other compounds (acetone, turpentine) in an attempt to remove the glue from the skin. the fur can be shaved, using care to avoid damaging the underlying skin. the affected area should be allowed to exfoliate naturally. glyophosate is a herbicide found in roundup and kleenup. if applied properly, the product has a very low toxic potential. clinical signs of toxicity include dermal and gastric irritation, including dermal erythema, anorexia, and vomiting. cns depression can occur. treatment includes thorough bathing in cases of dermal exposure, and induction of emesis or orogastric lavage followed by administration of activated charcoal. administer antiemetic and gastroprotectant drugs as necessary. administer intravenous crystalloid fluids to prevent dehydration secondary to vomiting. even small amounts of grapes and raisins can be toxic to dogs. the mechanism of toxicity remains unknown. clinical signs occur within 24 hours of ingestion of raisins or grapes, and include vomiting, anorexia, lethargy, and diarrhea (often with visible raisins or grapes in the fecal matter). within 48 hours, dogs demonstrate signs of acute renal failure (polyuria, polydipsia, vomiting) that can progress to anuria. to treat known ingestion of raisins or grapes, induce emesis or perform orogastric lavage, followed by repeated doses of activated charcoal. if clinical signs of vomiting and diarrhea are present, administer intravenous fluids and monitor urine output. aggressive intravenous fluid therapy, in conjunction with maintenance of renal perfusion, is necessary. in cases of anuric renal failure, dopamine, furosemide, and mannitol can be useful in increasing urine output. peritoneal or hemodialysis may be necessary in cases of severe oliguric or anuric renal failure. calcium channel blockers such as amlodipine and diltiazem can be used to treat systemic hypertension. supportive care includes treatment of hyperkalemia, and administration of gastroprotectant and antiemetic drugs and (if the animal is eating) phosphate binders. aromatic hydrocarbons include phenols, cresols, toluene, and naphthalene. all have a moderate toxic potential if ingested. toxicities associated with ingestion of aromatic hydrocarbons include cns depression, hepatorenal damage, muscle tremors, pneumonia, methemoglobinemia, and intravascular hemolysis. if an aromatic hydrocarbon is ingested, do not induce emesis, because of the risk of aspiration pneumonia. a dilute milk solution or water can be administered to dilute the compound. perform orogastric lavage. carefully monitor the patient's respiratory and cardiovascular status. administer supplemental oxygen if aspiration pneumonia is present. to treat topical exposure, thoroughly rinse the eyes and skin with copious amounts of warm tap water or 0.9% saline solution. imidacloprid is the compound used in the flea product advantage. clinical signs of toxicity are related to nicotinic cholinergic stimulation, causing neuromuscular excitation followed by collapse. the compound may induce respiratory paralysis. to treat imidacloprid toxicity, procure and maintain a patent airway with supplemental oxygen administration. control cns excitation with diazepam, phenobarbital, or propofol. administer enemas to hasten gastrointestinal elimination, and administer activated charcoal. bathe the animal thoroughly to prevent further dermal absorption. closely monitor the patient's oxygenation and ventilation status. if severe hypoventilation or respiratory paralysis occurs, initiate mechanical ventilation. iron and iron salts can cause severe gastroenteritis, myocardial toxicity, and hepatic damage if high enough doses are ingested. lawn fertilizers are a common source of iron salts. treatment of ingestion of iron and iron salts includes cardiovascular support in the form of intravenous fluids and antiarrhythmic drugs, as needed. induce emesis or perform orogastric lavage for gastric decontamination. a cathartic can be administered to promote elimination from the gastrointestinal tract. antiemetic and gastroprotectant drugs should be administered to prevent nausea and vomiting. in some cases, radiographs can aid in making a diagnosis of whether the compound was actually ingested. iron toxicity can be treated with the chelating agent deferoxamine. ivermectin is a gaba agonist that is used in commercial heartworm prevention and antihelminthic compounds and can be toxic in predisposed breeds, including collies, collie loperamide is an opioid derivative that is used to treat diarrhea. clinical signs of loperamide intoxication include constipation, ataxia, nausea, and sedation. induce emesis or perform orogastric lavage, followed by administration of activated charcoal and a cathartic. naloxone may be beneficial in the temporary reversal of ataxia and sedation. ingestion of macadamia nuts can cause clinical signs of vomiting, ataxia, and ascending paralysis in dogs. the toxic principle in macadamia nuts is unknown. there is no known antidote. treatment consists of supportive care, including administration of intravenous fluids and antiemetics and placement of a urinary catheter for patient cleanliness. clinical signs resolve in most cases within 72 hours. marijuana is a hallucinogen that can cause cns depression, ataxia, mydriasis, increased sensitivity to motion or sound, salivation, and tremors. along with these findings, a classic clinical sign is the sudden onset of dribbling urine. urine can be tested with drug test kits for tetrahydrocannabinoid (thc), the toxic compound in marijuana. there is no known antidote for marijuana toxicity; therefore, treatment is largely symptomatic. place an intravenous catheter and administer intravenous fluids to support hydration. administer atropine if severe bradycardia exists. induction of emesis can be attempted but because of the antiemetic effects of thc, is usually unsuccessful. orogastric lavage can be performed, followed by repeated doses of activated charcoal. clinical signs usually resolve within 12 to 16 hours. introduction "strike anywhere" matches, safety matches, and the striking surface of matchbook covers contain iron phosphorus or potassium chlorate. both compounds have a low toxic potential but can cause clinical signs of gastroenteritis and methemoglobinemia if large quantities are ingested. treatment of match and matchbook ingestion includes gastric decontamination with induction of emesis or orogastric lavage and administration of activated charcoal and a cathartic. if methemoglobinemia occurs, administer n-acetylcysteine, intravenous fluids, and supplemental oxygen. metaldehyde is the active ingredient in most brands of snail bait. the exact mechanism of toxicity is unknown but may involve inhibition of gaba channels. clinical signs associated with metaldehyde toxicity include severe muscle tremors, cns excitation, and treatment treatment of mushroom toxicity is largely supportive. if the mushroom was ingested within the last 2 hours, induce emesis or perform orogastric lavage and then administer activated charcoal. symptomatic treatment includes intravenous fluids to promote diuresis and treat hyperthermia and skeletal muscle relaxants to control tremors and seizures (methocarbamol, diazepam). if amanita ingestion is suspected, administer hepatoprotectant agents including milk thistle. mycotoxins from penicillium spp. are found in moldy foods, cream cheese, and nuts. clinical signs of intoxication include tremors, agitation, hyperesthesia, and seizures. if tremorigenic mycotoxin toxicity is suspected, a sample of the patient's serum and gastric contents or vomitus can be submitted to the michigan state university veterinary toxicology laboratory for tremorigen assay. there is no known antidote. perform orogastric lavage, followed by administration of activated charcoal. control tremors and seizures with methocarbamol, diazepam, phenobarbital, or pentobarbital. administer intravenous fluids to control hyperthermia and maintain hydration. in cases in which cerebral edema is suspected secondary to severe refractory seizures, administer intravenous mannitol and furosemide. naphthalene is the active ingredient in mothballs and has a high toxic potential. clinical signs associated with naphthalene toxicity include vomiting, methemoglobinemia, cns stimulation, seizures, and hepatic toxicity. a complete blood count often reveals heinz bodies and anemia. do not induce emesis if naphthalene ingestion is suspected. if the ingestion was within 1 hour of presentation, perform orogastric lavage. control seizures with diazepam or phenobarbital. administer intravenous fluids to control hyperthermia and maintain hydration. n-acetylcysteine can play a role in the treatment of methemoglobinemia. a packed rbc transfusion may be necessary if anemia is severe. observe the patient for clinical signs associated with hepatitis. nicotine toxicity occurs in animals as the result of ingestion of cigarettes, nicotine-containing gum, and some insecticides. nicotine stimulates autonomic ganglia at low doses, and blocks autonomic ganglia and the neuromuscular junction at high doses. absorption after ingestion is rapid. clinical signs include hyperexcitability and slud (salivation, lacrimation, urination, and defecation). muscle tremors, respiratory muscle fatigue or hypoventilation, tachyarrhythmias, seizures, coma, and death can occur. if the patient presents within 1 hour of ingestion and has no clinical signs, induce emesis, followed by administration of repeated doses of activated charcoal. in patients with clinical signs of toxicity, perform orogastric lavage. administer intravenous fluids to maintain hydration and promote diuresis, and treat hyperthermia. administer atropine to treat cholinergic symptoms. urinary acidification can promote nicotine excretion. nonsteroidal antiinflammatory drugs (nsaids) include ibuprofen, ketoprofen, carprofen, diclofenac, naproxen, celecoxib, valdecoxib, rofecoxib, and deracoxib. nsaids cause inhibition of prostaglandin synthesis, leading to gastrointestinal ulceration, renal failure and hepatotoxicity. ibuprofen toxicity has been associated with seizures in dogs, cats, and ferrets. the toxic dose varies with the specific compound ingested. to treat nsaid toxicity, induce emesis or perform orogastric lavage, followed by administration of multiple repeated doses of activated charcoal. place an intravenous catheter for crystalloid fluid diuresis to maintain renal perfusion. administer the synthetic prostaglandin analogue misoprostol to help maintain gastric and renal perfusion. control seizures, if present, with intravenous diazepam. administer gastroprotectant and antiemetic drugs to control vomiting and gastrointestinal hemorrhage. continue intravenous fluid diuresis for a minimum of 48 hours, with frequent monitoring of the patient's bun and creatinine. when the bun and creatinine levels are normal or have plateaued for 24 hours, slowly decrease fluid diuresis 25% per day until maintenance levels are restored. onions, garlic, and chives contain sulfoxide compounds that can cause oxidative damage of rbcs, leading to heinz body anemia, methemoglobinemia, and intravascular hemolysis. clinical signs of toxicity include weakness, lethargy, tachypnea, tachycardia, and pale mucous membranes. vomiting and diarrhea can occur. intravascular hemolysis can cause treatment treatment of onion, chive, and garlic toxicity includes administration of intravenous fluid diuresis, and induction of emesis or orogastric lavage, followed by administration of activated charcoal and a cathartic. in cases of severe anemia, packed rbc transfusion or administration of a hemoglobin-based oxygen carrier should be considered. opiate drugs include heroin, morphine, oxymorphone, fentanyl, meperidine, and codeine. opiate compounds bind to specific opioid receptors throughout the body and produce clinical signs of miosis or mydriasis (cats), and cns excitation, followed by ataxia and cns depression, leading to stupor and coma. hypoventilation, bradycardia, hypoxia, and cyanosis can occur. to treat known overdose or ingestion of an opiate compound, induce emesis (in asymptomatic animals) or perform orogastric lavage, followed by administration of activated charcoal. administer intravenous fluids and supplemental oxygen to support the cardiovascular and respiratory systems. mechanical ventilation may be necessary until hypoventilation resolves. administer repeated doses of naloxone as a specific antidote to reverse clinical signs of narcosis and hypoventilation. if seizures are present (meperidine toxicity), administer diazepam. organophosphate compounds traditionally are used in flea control products and insecticides. common examples of organophosphates include chlorpyrifos, coumaphos, diazinon, dichlorvos, and malathion. the toxic dose varies, depending on the particular compound and individual animal sensitivity. organophosphate toxicity causes acetylcholinesterase inhibition, resulting in clinical signs of cns stimulation, including tremors and seizures. muscarinic acetylcholine overload causes the classic slud signs of salivation, lacrimation, urination, and defecation. miosis, excessive bronchial secretions, muscle tremors, and respiratory paralysis can occur. an intermediate syndrome of generalized weakness, hypoventilation, and eventual paralysis with ventral cervical ventroflexion that may require mechanical ventilation has been described. if organophosphate toxicity is suspected, whole-blood acetylcholinesterase activity can be measured and will be low. treatment of toxicity includes careful and thorough bathing in cases of dermal exposure and, if the substance was ingested, gastric decontamination with induction of emesis or orogastric lavage, followed by administration of activated charcoal, and administration of the antidote pralidoxime hydrochloride . atropine can help control the muscarinic clinical signs. supportive care in the form of cooling measures, intravenous crystalloid fluids, and supplemental oxygen or mechanical ventilation may be required, depending on the severity of clinical signs. introduction ingestion of large amounts of paintballs can cause neurologic signs, electrolyte abnormalities, and occasionally death. paintballs are gelatin capsules that contain multiple colors of if ingestion was recent and if no clinical signs of toxicity are present, induce emesis or perform orogastric lavage, followed by administration of a cathartic and activated charcoal. there is no known antidote. treatment includes supportive care in the form of intravenous fluids and administration of phenobarbital or methocarbamol to control seizures and tremors. diazepam, a gaba agonist, is contraindicated, because it can potentially worsen clinical signs. urine acidification may hasten elimination. clinical signs can last from 3 to 5 days. pyrethrin and pyrethroid compounds are extracted from chrysanthemums, and include allethrin, decamethrin, tralomethrin, fenpropanthrin, pallethrin, sumethrin, permethrin, tetramethrin, cyfluthrin, and resemethrin. the oral toxicity is fairly low; however, the compounds can be significantly harmful if inhaled or applied to the skin. pyrethrin and pyrethroid compounds cause depolarization and blockade of nerve membrane potentials, causing clinical signs of tremors, seizures, respiratory distress, and paralysis. contact dermatitis can occur. to distinguish between pyrethrin/pyrethroid toxicity and organophosphate toxicity, acetylcholinesterase levels should be obtained; they will be normal if pyrethrins are the cause of the animal's clinical signs. treatment of toxicity is supportive, as there is no known antidote. carefully bathe the animal in lukewarm water to prevent further oral and dermal exposure. both hyperthermia and hypothermia can worsen clinical signs. administer activated charcoal to decrease enterohepatic recirculation. atropine may control clinical signs of excessive salivation. to control muscle tremors, administer methocarbamol to effect. administer diazepam or phenobarbital to control seizures, as necessary. rotenone is used as a common garden and delousing insecticide. fish and birds are very susceptible to rotenone toxicity. rotenone inhibits mitochondrial electron transport. clinical signs of tissue irritation and hypoglycemia can occur after topical or oral exposure. if the compound is inhaled, cns depression and seizures can occur. to treat toxicity, perform orogastric lavage, followed by administration of a cathartic and activated charcoal. bathe the animal carefully to prevent further dermal exposure and further ingestion. administer diazepam or phenobarbital to control seizures. the prognosis generally is guarded. treatment of ingestion includes dilution with milk, water, or egg whites. perform orogastric lavage, followed by administration of activated charcoal. administer intravenous crystalloid fluids to maintain hydration. administer antiemetic and gastroprotectant drugs to treat gastroenteritis and vomiting.shampoos, nonmedicated: see detergents, nonionic shampoos, selenium sulfide introduction selenium sulfide shampoos (e.g., selsun blue) have a low toxic potential, and primarily cause gastroenteritis. treatment of ingestion includes dilution with water, milk, or egg whites and administration of activated charcoal. carefully and thoroughly rinse the skin and eyes to prevent further exposure. administer antiemetic and gastroprotectant drugs in cases of severe gastroenteritis. zinc-based (zinc pyridinethione) anti-dandruff shampoos have a serious toxic potential if ingested or if ocular exposure occurs. gastrointestinal irritation, retinal detachment, progressive blindness, and exudative chorioretinitis can occur. treatment of ingestion includes gastric decontamination. induce emesis or perform orogastric lavage, followed by administration of a cathartic and activated charcoal.to treat ocular exposure, thoroughly rinse the patient's eyes for a minimum of 30 minutes. carefully monitor the animal for clinical signs of blindness. implement intravenous fluid to maintain hydration and renal perfusion in cases of severe gastroenteritis. silver polish contains the alkali substance sodium carbonate and cyanide salts, and has a serious toxic potential. ingestion results in rapid onset of vomiting and possibly cyanide toxicity. to treat ingestion, monitor and maintain the patient's respiration and cardiovascular status and administer intravenous crystalloid fluids. induce emesis, followed by administration of activated charcoal. administer sodium nitrite or sodium thiosulfate iv for cyanide toxicity. bath soap (bar soap) usually has low toxic potential and causes mild gastroenteritis with vomiting if ingested. to treat ingestion, include dilution with water, administration of intravenous fluids to maintain hydration, and administration of antiemetic and gastroprotectant drugs to treat gastroenteritis. sodium fluoroacetate is a colorless, odorless, tasteless compound that causes uncoupling of oxidative phosphorylation. the toxic dose in dogs and cats is 0.05-1.0 mg/kg. clinical signs of toxicity include cns excitation, seizures, and coma secondary to cerebral edema. the prognosis is guarded. to treat toxicity, procure and maintain a patent airway, monitor and stabilize the cardiovascular status, and control hyperthermia. perform orogastric lavage, followed by administration of activated charcoal. if clinical signs are not present at the time of presentation, induce emesis. administer intravenous fluids and supplemental oxygen, as necessary. strattera (atomoxetine hydrochloride) is a selective norepinephrine reuptake inhibitor used in the treatment of attention deficit hyperactivity disorder (adhd) in humans. peak serum concentrations occur in dogs within 3 to 4 hours of ingestion, with a peak half-life at 4 to 5 hours following ingestion. clinical signs of toxicity include cardiac tachyarrhythmias, hypertension, disorientation, agitation, trembling, tremors, and hyperthermia. treatment of intoxication is largely symptomatic and supportive in nature. first, induce emesis if the patient is conscious and has an intact gag reflex. orogastric lavage can also be performed. administer one dose of activated charcoal to prevent further absorption of the compound from the gastrointestinal tract. identify cardiac dysrhythmias and treat accordingly. control hypertension with sodium nitroprusside or diltiazem as a constant rate infusion. administer acepromazine or chlorpromazine to control agitation. do not use diazepam, because it can potentially worsen clinical signs. administer intravenous fluids to maintain hydration and promote diuresis. strychnine is the active ingredient in pesticides used to control rodents and other vermin. the toxic dose in dogs is 0.75 mg/kg, and in cats is 2 mg/kg. strychnine antagonizes spinal inhibitory neurotransmitters and causes severe muscle tremors, muscle rigidity, and seizures. clinical signs are stimulated or exacerbated by noise, touch, light, and sound. mydriasis, hyperthermia, and respiratory paralysis can occur. if strychnine toxicity is suspected, gastric contents should be collected and saved for analysis. if the animal is asymptomatic at the time of presentation, induce emesis. if clinical signs are present, perform orogastric lavage. both emesis and orogastric lavage should be followed by the administration of activated charcoal. administer intravenous crystalloid fluids to support the cardiovascular system, aid in cooling measures, and improve renal diuresis. treat cns stimulation with methocarbamol, diazepam, or phenobarbital. the animal should have cotton packed in its ears to prevent noise stimulation, and should be placed in a quiet, dark room. treatment of ingestion includes dilution with milk of magnesia or water, administration of antiemetic and gastroprotectant drugs, and administration of intravenous crystalloid fluids to maintain hydration. do not induce emesis, because of the risk of causing further esophageal irritation.sunscreen: see zinc and zinc oxide suntan lotion: see shampoos, zinc-based, and alcohols tar: see fuels tea tree oil (melaleuca oil) introduction tea tree (melaleuca) oil is an herbal-origin flea-control product. the toxic principles in tea tree oil are monoterpenes, which produce clinical signs of neuromuscular weakness, and ataxia. treatment of tea tree oil toxicity includes administration of cathartics and activated charcoal to prevent further absorption. carefully bathe the animal to prevent further dermal exposure. tetanus spores from clostridium tetani organisms are ubiquitous in the soil and feces, particularly in barnyards. cases have been reported in dogs after tooth eruption and after abdominal surgeries performed with cold sterilization packs. anaerobic wound infections can contain tetanus spores. the neurotoxin from c. tetani inhibits spinal inhibitory neurons, causing motor neuron excitation. extensor muscle rigidity ("sawhorse stance"), erect ears, and risus sardonicus (a sardonic grin) are characteristic features of tetanus. administer tetanus antitoxin if toxin has not already been bound in the cns. to eliminate the source of the toxin (e.g., abscess), open and debride all wounds. intravenous administration of ampicillin or penicillin g is the treatment of choice for tetanus. supportive care in the form of skeletal muscle relaxants, intravenous fluids and parenteral nutrition, and nursing care to prevent decubitus ulcer formation is required. in extreme cases, mechanical ventilation may be necessary. triazene compounds include atrazine, prometone, and monuron (telvar). the toxic mechanism of triazene compounds is unknown. clinical signs of toxicity include salivation, ataxia, hyporeflexia, contact dermatitis, hepatorenal damage, muscle spasms, respiratory difficulty, and death. treatment of triazene exposure includes cardiovascular and renal support in the form of intravenous crystalloid fluids, inotropic drugs, and antiarrhythmic agents, as necessary. if the exposure is recent, induce emesis. perform orogastric lavage in animals that cannot protect the airway. emesis and orogastric lavage should be followed by the administration of activated charcoal and a cathartic. carefully bathe the patient to prevent further dermal absorption. a variety of tricyclic antidepressants are available for use in both humans and animals, including amitriptyline, amoxapine, desipramine, doxepine, fluoxetine (prozac), fluvoxamine (luvox), imipramine, nortriptyline, paroxetine (paxil), protriptyline, sertraline (zoloft), and trimipramine. selective serotonin reuptake inhibitors (ssris) are rapidly absorbed from the digestive tract, with peak serum concentrations occurring 2 to 8 hours after ingestion. the elimination half-life for each drug differs in dogs, but typically last 16 to 24 hours. ssris inhibit the reuptake of serotonin, causing serotonin to accumulate in the brain. this can cause "serotonin syndrome," characterized by trembling, seizures, hyperthermia, ptyalism or hypersalivation, cramping or abdominal pain, vomiting, and diarrhea. other clinical signs of ssri intoxication include depression, tremors, bradycardia, tachyarrhythmias, and anorexia. any animal that has ingested an ssri should be promptly treated and carefully observed for at least 72 hours for side effects. the treatment of suspected ssri intoxication involves gastric decontamination if the patient is not depressed and has an intact gag reflex. perform orogastric lavage and administer activated charcoal to prevent further toxin absorption and hasten elimination from the gastrointestinal tract. treat other clinical signs symptomatically. administer intravenous diazepam to control seizures. treat tachyarrhythmias according to type. administer methocarbamol to control muscle tremors. cyproheptadine (1 mg/kg), a serotonin antagonist, can be dissolved in water and administered per rectum. vitamin k antagonist rodenticides, which are commonly found in pelleted or block form, inhibit the activation of the vitamin k-dependent coagulation factors ii, vii, ix, and x. clinical signs of hemorrhage occur within 2 to 7 days of exposure. hemorrhage can occur anywhere in the body, and can be manifested as petechiation of the skin or mucous membranes, hemorrhagic sclera, epistaxis, pulmonary parenchymal or pleural hemorrhage, gastrointestinal hemorrhage, pericardial hemorrhage, hematuria, retroperitoneal hemorrhage, hemarthrosis, and central nervous system hemorrhage. clinical signs include respiratory distress, cough, bleeding from the gums or into the eyes, ataxia, paresis, paralysis, seizures, hematuria, joint swelling, lameness, lethargy, weakness, inappetence, and collapse.diagnosis is made based on clinical signs and a prolonged activated clotting time, or prothrombin time. the pivka (proteins induced by vitamin k antagonism) test may be helpful but usually cannot be performed in-house. slight thrombocytopenia may be present secondary to hemorrhage; however, blood levels usually do not reach the critical level of <50,000 platelets/âµl to cause clinical signs of hemorrhage. in some cases, severe stressinduced hyperglycemia and glucosuria may be present but resolves within 24 hours. if the rodenticide was ingested within the last 2 hours, induce emesis. alternatively, orogastric lavage can be performed in an uncooperative patient. both emesis and orogastric lavage should be followed by administration of activated charcoal. the stomach contents can be submitted for analysis. following successful treatment, administer oral vitamin k for 30 days after the exposure; or a check prothrombin time 2 days after gastric decontamination. if the prothrombin time is prolonged, administer fresh frozen plasma and vitamin k.if the prothrombin time is normal, gastric decontamination was successful, and no further treatment is necessary.if an animal presents with clinical signs of intoxication, administer activated clotting factors in the form of fresh frozen plasma (20 ml/kg), and vitamin k 1 (5 mg/kg sq in multiple sites with a 24-gauge needle). packed rbcs or fresh whole blood may be required if the patient is also anemic. supportive care in the form of supplemental oxygen may be necessary in cases of pulmonary or pleural hemorrhage. following initial therapy and discharge, the patient should receive vitamin k 1 (2.5 mg/kg po q8-2h for 30 days), and prothrombin time should be checked 2 days after the last vitamin k capsule is administered. in some cases, depending on the type of anticoagulant ingested, an additional 2 weeks of vitamin k1 therapy may be required. xylitol is a sugar alcohol that, when ingested by humans, does not cause a significant increase in blood glucose, and therefore does not stimulate insulin release from the human pancreas. in dogs, however, xylitol causes a massive rapid and dose-dependent release of insulin from pancreatic beta-cells. following insulin release, clinically significant hypoglycemia can develop, followed by signs of vomiting, weakness, ataxia, mental depression, hypokalemia, hypoglycemic seizures, and coma. clinical signs associated with xylitol ingestion can be seen within 30 minutes of ingestion and can last for more than 12 hours, even with aggressive treatment. known xylitol ingestion should be treated as for other toxin ingestion. if no neurologic abnormalities exist at the time the patient is seen, induce emesis, followed by administration of activated charcoal. it remains unknown at this time whether activated charcoal actually delays or prevents the absorption of xylitol from the canine gastrointestinal tract. if clinical signs have already developed, perform orogastric lavage and gastric decontamination. blood glucose concentrations should be analyzed and maintained with supplemental dextrose as a constant rate infusion (2.5%-5%) until normoglycemia can be maintained with multiple frequent small meals. hypokalemia may develop because it is driven intracellularly by the actions of insulin. treat hypokalemia with supplemental potassium chloride by infusion, not to exceed 0.5 meq/kg/hour. pennies minted in the u.s. after 1982 contain large amounts of zinc rather than copper. other sources of zinc include zinc oxide ointment and hardware such as that found in metal bird cages. zinc toxicity causes intravascular hemolysis, anemia, gastroenteritis, and renal failure. if zinc toxicity is suspected, take an abdominal radiograph to document the presence of the metal in the stomach or intestines. (if zinc-containing ointment was ingested, this will not be visible on radiographs.) induce emesis or perform orogastric lavage, depending on the size of the object ingested. often, small objects such as pennies can be retrieved using endoscopy or surgical gastrotomy/enterotomy. always take an additional radiograph after the removal procedure to ensure that all objects have been successfully removed. administer intravenous fluids to maintain renal perfusion and promote fluid diuresis. administer gastroprotectant and antiemetic drugs. chelation therapy with succimer, calcium edta, dimercaprol, or penicillamine may be necessary. do not administer pulmonary contusions are a common sequela of blunt traumatic injury. a contusion basically is a bruise characterized by edema, hemorrhage, and vascular injury. contusions may be present at the time of presentation or can develop over the first 24 hours after injury. a diagnosis of pulmonary contusion can be made based on auscultation of pulmonary crackles, presence of respiratory distress, and the presence of patchy interstitial to alveolar infiltrates on thoracic radiographs. radiographic signs can lag behind the development of clinical signs of respiratory distress and hypoxemia by 24 hours. in most cases, cage rest is sufficient to temporarily diminish blood loss. sedation (acepromazine, 0.02-0.05 mg/kg iv, im, sq) may be helpful in alleviating anxiety and decreasing blood pressure. the hypotensive effects of acepromazine are potentially harmful if severe blood loss has occurred. if evidence of hypovolemia is present (see section on hypovolemic shock), intravenous fluid resuscitation should be administered. rapid assessment of clotting ability, with a platelet count estimate and clotting profile (act or aptt and pt), should be performed. if epistaxis secondary to vitamin k antagonist rodenticide intoxication is suspected, administer vitamin k 1 and fresh frozen plasma or fresh whole blood.persistent hemorrhage from a nasal disorder can be treated with dilute epinephrine (1:100,000) into the nasal cavity with the nose pointed toward the ceiling to promote vasoconstriction. if this fails, the animal can be anesthetized, and the nasal cavity packed with gauze, and the caudal oropharynx and external nares covered with umbilical tape to control hemorrhage. a rhinoscopy should be performed to determine the cause of ongoing hemorrhage. continued excessive hemorrhage can be controlled with ligation of the carotid artery on the side of the hemorrhage, or with percutaneous arterial embolization. systemic thromboembolism is most commonly recognized in cats with cardiomyopathies (hypertrophic, restrictive, unclassified, and dilatative) but can also occur in dogs with hyperadrenocorticism, disseminated intravascular coagulation (dic), systemic inflammatory response syndrome (sirs), protein-losing enteropathy and nephropathy, and tumors affecting the aorta and vena cava. thrombosis occurs through a complex series of mechanisms when the components of virchow's triad (hypercoaguable state, sluggish blood flow, and vascular endothelial injury or damage) are present. in cats, blood flow through a severely stretched left atrium is a predisposing factor to the development of clots and thromboembolism.the most common site of embolism is the aortic bifurcation, or "saddle thrombus." other, less common locations of thromboembolism include the forelimbs, kidneys, gastrointestinal tract, and cerebrum. diagnosis usually is made based on clinical signs of cool extremities, the presence of a cardiac murmur or gallop rhythm, auscultation of pulmonary crackles resulting from pulmonary edema, acute pain or paralysis of one or more peripheral extremities, respiratory distress, and pain and lack of a palpable pulse in affected limbs. the affected nailbeds and paw pads are cyanotic, and nails do not bleed when cut with a nail clipper.client education is one of the most important aspects of emergency management of the patient with thromboembolic disease. concurrent congestive heart failure (chf) occurs in 40% to 60% of cats with arterial thromboembolism. more than 70% of cats are euthanized during the initial thromboembolic event because of the poor long-term prognosis and the high risk of recurrence within days to months after the initial event, even with aggressive therapy. although the long-term prognosis varies from 2 months to 2 years after initial diagnosis and treatment, in the majority of cats thromboembolic disease recurs within 9 months. rectal temperature hypothermia and bradycardia on presentation are negative prognostic indicators.immediate treatment of a patient with chf and thromboembolic disease involves management of the chf with furosemide, oxygen, and vasodilators (nitroglycerine paste, morphine, nitroprusside). additional management includes analgesia (butorphanol, 0.1-0.4 mg/kg iv, im) and prevention of further clot formation. aspirin (10 mg/kg po q48h) is beneficial bcause of its antiplatelet effects. heparin works in conjunction with antithrombin to prevent further clot formation (100-200 units/kg iv, followed by 250-300 units/kg sq q8h in cats, and 100-200 units/kg sq q8h in dogs). acepromazine can cause peripheral vasodilation and decreased afterload but also can promote hypotension in a patient with concurrent chf. acepromazine (0.01-00.02 mg/kg sq) should be used with extreme caution, if at all.thrombolytic therapy can also be attempted, but in most cases is not without risk, and may be cost-prohibitive for many clients. streptokinase (90,000 units iv over 30 minutes and then 45,000 units/hour iv cri for 3 hours) was administered with some success in cats; however, many died of hyperkalemia or other complications during the infusion. tissue plasminogen activator (0.25-1 mg /kg/hour iv cri, up to 10 mg/kg total dose, to effect) has been used with some success but is cost-prohibitive for most clients. side effects of thrombolytic therapy include hyperkalemia with reperfusion and hemorrhage.in cats, the primary cause of arterial thromboembolism is cardiomyopathy. once an animal is determined to be stable enough for diagnostic procedures, lateral and dv thoracic radiographs and an echocardiogram should be performed. ultrasound of the distal aorta and renal arteries should also be performed to determine the location of the clot and help establish the prognosis.other diagnostic procedures to evaluate the presence and cause of thromboembolism include a complete blood count, serum biochemistry profile, urinalysis (to rule out proteinlosing nephropathy), urine protein:creatinine ratio, antithrombin levels, acth stimulation test (to rule out hyperadrenocorticism), heartworm antigen test (in dogs), thyroid profile (to rule out hyperthyroidism in cats, and hypothyroidism in dogs), thoracic radiographs, arterial blood gas analyses, coagulation tests, and coombs' test. selective and nonselective angiography can also be performed to determine the exact location of the thrombus.long-term management of thromboembolism involves management of the underlying disease process and preventing further clot formation. begin therapy with heparin until the aptt becomes prolonged 1.5 times; then administer warfarin (0.06-0.09 mg/kg/day). monitoring therapy based on prothrombin time and the international normalized ratio (inr, 2.0-4.0) is recommended. low-dose aspirin (5-10 mg/kg q48h) also has been recommended. physical therapy with warm water bathing, deep muscle massage, and passive range-of-motion exercises should be performed until the patient regains motor function. future therapy may involve the use of platelet receptor antagonists to prevent platelet activation and adhesion. key: cord-010980-sizuef1v authors: nan title: ectes abstracts 2020 date: 2020-05-11 journal: eur j trauma emerg surg doi: 10.1007/s00068-020-01343-y sha: doc_id: 10980 cord_uid: sizuef1v nan the gertality-score: a feasible and adequate tool to predict mortality in geriatric trauma patients introduction: a large number of prediction models and subsequent outcome scores for trauma mortality have been developed over the last decades. however, feasible scoring systems for the severely injured geriatric patient are lacking. the aim of this study was to develop a new mortality prediction model for severily injured geriatric patients. materials and methods: the german trauma registry was utilized and all geriatric individuals (c 65 years) admitted between 2008 and 2017 with an iss [1] c 9 were included. patient and trauma characteristics, diagnostics, therapy and outcome data were gathered. the specific odds of all variables for mortality were calculated. relevant variables were added to the novel gertality-scoring system. subsequently, this score as a sole predictor for mortality was compared with the geriatric trauma outcome score 2 , iss, patient's age and max ais. results: a total of 58.055 trauma patients with a mean age of 77 years were included. based on the univariable analysis, the following five variables were included in the gertality-score: age c 80 years, pbrc-transfusion requirements from admission to ward, asa-score c 3, gcs b 13, ais c 4. the values of a given parameter are added to reach the total gertality-score (range 0-5 points). the auc found in the novel gertality-score was 0.803, whereas the geriatric trauma outcome score had an auc of 0.784. conclusions: the novel gertality-score is a simple and feasible scoring system that enables an adequate prediction of the probability of mortality in severely injured geriatric patients by using only five specific parameters. references: 1. champion hr, et al. the major trauma outcome study: establishing national norms for trauma care. j trauma. 1990; 30:1356-65. 2. zhao fz, et al. estimating geriatric mortality after injury using age, injury severity, and performance of a transfusion: the geriatric trauma outcome score. j palliat med. 2015; 18(8) :677-81. the longer the better! 'extending thawed plasma shelf life to 14 days' introduction: major bleeding is one of the most common causes of death after severe polytrauma. one of the most recent interventions that aims for bleeding control is resuscitative balloon occlusion of the aorta (reboa). this study aims to compare macro-and microcirculatory changes of intraabdominal organs and the lower extremity during the use of reboa. materials and methods: six pigs were anesthesized and received a median laparotomy. the reboa catheter (reliant balloon, medtronic) was inserted via the inguinal artery and occluded in zones 3, 2 and 1. the occlusion of the reboa was vizualized with fluoroscopy. the balloon was inflated for 10 min per zone. during this time the local microcirculation was measured with oxygen to see (o2c, lea). between each zone the balloon was deflated for 10 min. blood pressure was measured at the carotis artery and the femoral artery. results: baseline values of microcirculation differ significantly among organs. the flow rate is significantly higher in intraabdominal organs (colon 205.7 a.u., stomach 170.2 a.u.) compared to the extremity (67.0 a.u., p \ 0.001). blood pressure measured at the carotic artery increased significantly after inflation of the balloon (p \ 0.001). this increase depends on the zone of inflation (increase of ? 60 mmhg in zone 1 compared to baseline). the increase of blood pressure after inflation in zone 3 is comparable to the baseline value. the colon is most sensitive to changes of microcirculation whereas the stomach and the extremity are most robust. conclusions: reboa is a new device to control for massive bleeding. different organ systems react differently to the same occlusion of the aorta. the systemic blood pressure does not mirror the local microcirculation of the abdominal organs. during emergency resuscitation with reboa these changes should be kept in mind. none of the authors have any conflicts of interests to declare. investigation of coagulopathies and its relevance with mortality and transfusion rates using thromboelastography in trauma patients introduction: fibrinolysis shutdown after injury is a common and lethal coagulopathic phenotype. patients with polytrauma, especially those with brain hemorrhage, require delayed initiation of prophylactic or therapeutic anticoagulation despite a measurable hypercoagulable state. to understand and modulate the post-trauma coagulation milieu, we assess patients with daily thromboelastography(teg). we hypothesized that persistently high clot strength and low dissolution is associated with thrombotic adverse outcomes in severely injured patients. materials and methods: adult patients with blunt or penetrating injuries admitted to the icu of a level i urban trauma center from jan-jul 2019 were included. adverse outcomes were defined as death, ventilator-free-days (vfd) = 0, acute lung injury (ali), acute kidney injury (aki), and venous thromboembolic events (vte). we assessed trends of clot dissolution (fibrinolysis, ly30%) and strength (maximum amplitude, ma) in the first 5 icu days using linear mixed models to account for repeated measures and missing observations. ly30% was box-cox power-transformed to approximate normality. significance for pairwise comparisons at each time was adjusted by false-discovery-rate. results: 175 patients: median age 48-years, 23% female, iss 15 (iqr 9-24), 89% blunt mechanism, median 4 icu days . overall, 16% developed one or more of the following; 9%vfd = 0, 8%ali, 14%aki, 5%vte, 7%death. ly30 was persistently lower in patients with adverse outcomes compared to those without (interaction time*adverse_outcomes p = 0.046), with fdr-adjusted significant differences at icu days 1 and 2 (fig 1) . conversely, ma did not differ significantly by adverse outcome status(interaction time*complications p = 0.44, fig 2) . conclusions: low clot dissolution, not clot strength, is associated with adverse outcomes in severely injured trauma patients. additional work is underway for earlier identification of sd phenotypes and strategies to mitigate impaired fibrinolysis. introduction: angioembolization (ae) is can be both diagnostic and therapeutic in management of a hemodynamically unstable trauma patient. however, patients who would benefit from ae typically require emergent surgery for their injuries. the critical decision of transferring a patient to the operating room versus the interventional radiology suite can be bypassed with the advent of intra-operative angioembolization (ioae) . while the ability to perform such an intervention was previously limited by the availability of costly rooms termed raptor (resuscitation with angiography, percutaneous techniques and open repair) suites, it has been suggested that using c-arm digital subtraction angiography (dsa) is a comparable alternative. this case series aims to establish the feasibility and safety of ioae. materials and methods: we conducted a retrospective anlaysis of all trauma patients at our level 1 trauma centre who underwent ioae with a concomitant surgical intervention from january 2011 to april 2019. results: a total of 49 patients (79.6% male, 43.9 ± 17.3 years, 91.8% blunt) underwent ioae using the c-arm dsa. all but one patient underwent exploratory laparotomy, 20.4% of which underwent an additional surgical procedure (ex. exploratory thoracotomy, orthopaedic). either gelfoam (89.8%), coils (2.0%), or a combination of both (8.2%) were used for embolization. internal iliac embolization was performed in 85.7% of cases (57.1% bilateral) and five patients (10.2%) required hepatic embolization. ae was successful in all but one case, inferior vena cava filters were placed in 71.4% of cases, and 12.2% of patients required a second ae. the 30-day mortality was 30.6%. conclusions: our results suggest ioae is a feasible and safe management option in severe trauma patients with the advantage of concurrent operative intervention and ongoing active resuscitation with good success in hemorrhage control. introduction: partial resuscitative endovascular balloon occlusion of the aorta (reboa) is a new concept of aortic occlusion to reduce the ischemic injuries below the occlusion level. it is, however, difficult to determine when the occlusion is partial in a clinical setting. end-tidal carbon dioxide (etco2) is a product of aerobic metabolism and its production is reduced during ischemia and anaerobic metabolism. the aim of this study was to investigate if etco2 is a good predictor of the degree of aortic occlusion during normovolemia and hemorrhagic shock in a porcine model. methods: nine pigs, 25-32 kg, were anesthetized and surgically prepared. then, gradual zone 1 aortic occlusion by 33%, 66% and 100% was induced, during first normovolemia and then controlled hemorrhagic grade iv shock. hemodynamic/respiratory variables, blood gases, aortic/mesenteric blood flow, blood pressure of common femoral artery and etco2 were measured continuously. oxygen consumption and carbon dioxide production were calculated for each timepoint for correlation measurement to different methods for partial occlusion determination. background: acute appendicitis is one of the most common surgical emergencies worldwide. the aim of this meta-analysis of randomized controlled trials was to compare the safety and efficacy of antibiotic treatment versus appendicectomy as the primary treatment for patients diagnosed to have acute appendicitis. methods: a systematic online search was conducted using the following databases: pubmed, scopus, cochrane database, the virtual health library, clinical trials.gov and science direct. only randomized controlled trials (rcts) that compared antibiotics treatment (a) versus surgical treatment (s) as primary treatment of appendicitis were included. results: eight rcts with 1.849 patients were included: 897 in the antibiotics group and 952 in appendicectomy group. higher rate of treatment success was noted in appendicectomy group 96.5% versus only 67.8% in the antibiotics group (p \ 0.00001) (fig. 1 ). follow up period for recurrence was one year in all studies and the recurrence at 1 year was reported in 15.2% (136/897) of patients treated with antibiotics and 69.9% (95/136) of them underwent appendicectomy. moreover, rate of overall were 8.3% in a group and 16.2% in s group (odd ratio 0.44 [0.21-0.94], ci 95%, p-value: 0.0002) (fig. 2) . a longer length of hospital stay was reported among antibiotics group (2.96 ± 0.52 in a group versus 2.51 ± 0.56 in s group, p 0.02). conclusions: appendicectomy has significantly higher efficacy rate but higher complications rate when compared to antibiotics treatment. most of the studies included in this meta-analysis conveyed a high risk of bias, hence more well-designed rcts are recommended. introduction: post-operative adhesions are associated with increased risk of morbidity and mortality. up to date no effective measures has been introduced to decrease intra-abdominal adhesions following laparotomy. oxiplex-ap gel has been used in extra-abdominal surgical procedures to prevent adhesions. in the current study oxiplex-ap was tested in a mural animal model to investigate its efficacy in reducing post-surgical intra-abdominal adhesions. materials and methods: forty rats subjected to laparotomy were randomly divided into 4 groups of 10. a serosa injury was made on the small intestine and three different treatments were applied: simple suture, simple suture ? oxiplexap, and oxiplex-ap only; the last group received no treatment of the injury before closure of the abdomen. all animals were kept alive for 14 days, and a second laparotomy was done to measure the intra-abdominal adhesion by the nair classification. results: at second look laparotomy a significant difference in adhesion was noticed between the simple sutures and simple suture ? oxiplex-ap were the latter had developed less adhesions. there was also a trend towards less adhesion development between the simple sutures and oxiplex-ap only group, with less adhesions in the latter. conclusions: the use of oxiplex-ap was associated with decrease adhesion formation in the current animal model particularly without suturing. further investigations into these findings are needed. introduction: emergency abdominal surgery is known to result in high morbidity and mortality. furthermore, evidence suggests that unplanned admissions to the intensive care unit (icu) are associated with higher in-hospital mortality than those patients with planned icu admissions 1 . the aim of the study was to describe the patient population who required an unplanned admission to icu following emergency laparotomy at the royal melbourne hospital. materials and methods: a single-centre retrospective observational study was performed using prospectively collected data between 2012 and 2017. patients who underwent an emergency laparotomy and experienced an unplanned icu admission were included. patients who underwent a trauma laparotomy were excluded from the study. results: 764 emergency laparotomies were performed. of these, 94 (12.3%) required an unplanned admission to icu. fourty-two patients (45%) were female, and 60 patients (64%) were aged 60 years and above. sixty-three (67%) were admitted due to single organ dysfunction (clavien-dindo iva). the median time to icu admission was 5 days in patients classified to have experienced clavien-dindo iva, while it was 6 days in patients who experience multi-organ dysfunction (clavien-dindo ivb). thirty-seven patients (39%) were admitted to icu due to complications classified as cardiopulmonary. conclusions: recognising that emergency laparotomy is a high risk procedure, with the elderly patients accounting for the majority of unplanned icu admissions, it is imperative to utilise risk stratification methods to guide optimal peri-operative management. this should result in improved utilisation of critical care resources and overall patient outcomes. introduction: the way of reconstruction following intestinal resection in the emergency settings is still controversial. the question which is better between hand-sewn and stapled anastomosis in trauma and emergency surgery occasionally arises; however, there have been few reports comparing these methods. materials and methods: a record-based retrospective study was performed to compare hand-sewn with functional end-to-end anastomoses in trauma and emergency operations from october 2014 to october 2019 in one of the largest trauma and emergency centers in japan. the patients who had intestinal resection with functional endto-end or hand-sewn anastomosis in an emergency surgery were included. the patients who had covering ileostomy or colostomy, or who underwent surgery as an elective operation were excluded. the primary outcome is the rate of complication associated with anastomosis. the statistical analyses were performed using a chi introduction: injuries are the fourth leading cause of death in europe. laparotomy is the standard treatment for penetrating abdominal wounds. because of the morbidity and the high rate of negative laparotomies, the nonoperative treatment is effectively developing. the aim of this study is to analyze the complications and the quality of life of the patients after laparotomy for this kind of wounds. materials and methods: a retrospective cohort of patients was studied between 2007 and 2016 at the laveran military teaching hospital in marseille. one hundred and eighty-six trunk gunshot or stab wound were recorded, including 74 abdominal wounds. thirtyfour patients were managed by laparotomy and included in this study. the patients and their referring general practitioners were contacted to complete missing data and the sf-12 quality of life score. results: among the 34 patients included, the average age was 39 years and most of them were men. the indication for laparotomy was mainly based on the hemodynamic instability, then according to the results of the computed tomography in case of suspicion of specific lesions: bowel injuries, major vascular injury, mesenteric or mesocolic vascular injury, diaphragmatic injury and intraperitoneal bladder rupture. only 5 laparotomies were negatives. eleven complications after laparotomy were found (32,4%), including 7 early (within the 30 days) and 4 late. no complication was found after negative or non-therapeutic laparotomies. the quality of life of the patients after one year is similar to those of the general population. conclusions: the most common indication for laparotomy for abdominal penetrating trauma is hemodynamic instability. the rate of laparotomy complications for penetrating abdominal trauma is similar to those of scheduled surgeries. the quality of life after this care remains unchanged. these results may insist on the fact that the ''gold standard'' treatment for penetrating abdominal injury remains the laparotomy objectives: splenic artery embolization (sae), a routinely used adjunct in the non-operative management (nom) of splenic injuries(si), was widely adopted in trauma about two decades ago. we examined complications that occurred with this modality at a level 1 trauma center over a recent 8-year period and compared this to the prior 11 years. methods: patients who had sae for si between 2011-2018 were identified. sae complications were noted. splenic abscess, splenic infarction and contrast-induced renal insufficiency were considered major complications. coil migration, fever and pleural effusions were regarded ''minor'' complications. the results were compared with data from a prior study examining similar indices at the same trauma center between 2000 and 2010. fishers exact test was used for comparison. results: there were 716 patients admitted with si in the recent period, of which 159 (22%) underwent immediate splenectomy. sae was performed in 74 (13.3%) of the 557 patients who underwent nom. of these sae patients, 50% had a contrast blush and 41.9% were either aast grade 4 or 5. five sae patients (6.8%) had splenectomy for continued bleeding. the overall complication rate was 28.4%. major complications occurred in 11 patients (14.9%) and minor in 13 patients (17.6%). embolization location in the splenic artery was proximal in 54.1%, distal in 20.3% and in both in 25.7%. there was no association between complications and coil location by logistic regression. differences between the two periods shown in table 1 . conclusion: sae continues to be a useful adjunct in nom of si and has seen increased utilization. complications continue to occur,although fewer minor complications were noted in the second period. no association between embolization location and complications was noted in the recent period. judicious utilization of sae is imperative given the complications that continue to be noted from this procedure. the effect of the time spent in the emergency department on the mortality rates and cause of death in patients who underwent emergent laparotomy introduction: the purpose of this study was to a) examine the effect of the time spent in the emergency department (ed) on hypotensive patients in need of emergent laparotomy and b) to determine the mortality rates and cause of death in these patients. materials and methods: between 2007-2017, 184 patients were included (99 men and 85 women, mean age 45.2 years) who underwent laparotomy less or equal to 90 min from ed admission. of the 184 patients, 107 (group 1) had a systolic blood pressure (sbp) greater than 90 mmhg and 77 had a sbp less or equal to 90 mmhg. all patients had abdominal injuries with an injury scale score (iss) between 3 and 6. the in-hospital mortality represented the primary outcome, while secondary outcomes included cause of death and time to death. results: in this study both groups spent a median of 51 min in the ed, but the time from the ed to the operating theatre was shorter in the group 1 (40 min versus 76 min). in total, the mortality rate was 27%, but in the group 1 the mortality was 49%. the sbp on arrival in the ed was strongly associated with the risk of death. furthermore, we observed significant positive correlation between the probability of death and the time spent in the ed, with an increase of probability of death equal to 0.40% per minute spent in the ed. in both groups the hemorrhage was the commonest cause of death (62%). the results of this study indicate that, in patients with abdominal injuries requiring emergent laparotomy, the probability of death is proportional to both extent of hypotension and the length of time spent in the ed. especially, in patients who were presented with a sbp inferior of equal of 90 mmhg, this probability increased as much as 2% for each 5 min. despite many advances in trauma surgery, half of hypotensive patients are going to die in the first 24 h. introduction: injury to the pancreas may lead to significant morbidity and mortality. we studied the prevalence of pancreatic endocrine and exocrine functions and evaluated the morphological regenerations in pancreas following partial pancreatectomy. materials and methods: patients with pancreatic trauma were recruited ambispectively from january 2010 to december 2017. endocrine functions were assessed at the time of admission and at 6 months follow up with 75 g oral glucose tolerance test (ogtt), serum insulin and c-peptide levels, hba1c estimation and exocrine functions were assessed with faecal elastase test. pancreatic volumetry was done with imaging studies at 1-and 6-months post discharge. results: twenty patients were studied with a median age of 30 years at the time of injury. all the patients were normoglycemic on admission; only one patient who underwent pancreatic resection developed diabetes mellitus requiring insulin on follow up. 7 patients (35%) were found to have prediabetes by american diabetes association (ada) criteria. 11 patients (55%) had pancreatic exocrine insufficiency. pancreatic volume increment, from mean pancreatic volume of 48.65 cm3 to 54.29 cm 3 , was noted in partial pancreatectomy patients. conclusions: overt endocrine and exocrine insufficiency is rare in pancreatic trauma patients. but subsets of patients are biochemically predicted to have higher risks of endocrine dysfunction and exocrine insufficiency. hence, while dealing with pancreatic trauma patients, one should remember the possible metabolic disorders associated and the need for specific investigations. pancreatic volume increment is a new finding which opens up more opportunities for further research. hospital de santo espírito da ilha terceira, general surgery, angra do heroísmo, portugal, 2 hospital de santo espírito da ilha terceira, orthopedics and traumatology, angra do heroísmo, portugal introduction: rope bullfights are traditional events in the azores islands, where a bull is set on the streets, arrested by a rope on its neck. around 220 events happen every year and it is already part of the island's touristic attractions. inevitably, every year, people get injured either from direct trauma with the bull or from falls when trying to escape from the animal. the aim of this study was to characterize the type of injuries that occur in these bullfighting events, as to their incidence, mechanism of injury, anatomical affected area and severity. materials and methods: we prospectively registered all cases of injured people who suffered any type of trauma during rope bullfights and received emergency therapy in the local hospital, between 2018 and 2019. results: 56 patients recured to the emergency department, 16.1% female, with mean age of 44.2 years. regarding the mechanism of injury, 66.1% occured due to direct trauma to the animal while in the remaining 33.9% resulted from falls during escape or handling of the rope. the most commonly affected anatomical areas were the limbs (39.3%) followed by the head and neck (23.2%) and thorax (7.1%). in 26,8% of the cases, patients suffered from multiple traumas. in 76.8% of the cases the treatments performed were wound care, wound closure and/or symptomatic therapy. in total, 10 patiens were hospitalized, 5 patients required interventions in the operating room (4 closed fracture reductions and 1 exploratory laparotomy with splenectomy) and 2 patients were hemodynamically unstable upon admission (hypovolemic shock due to splenic fracture and cet). conclusions: the rare articles published describe the mechanisms of injury associated with bullfights in spanish centers and injuries resulting from wild cow accidents in indian cities. this is the first local descriptive study on the prevalence of traumatic injuries associated to this specific type of rope bullfights. introduction: the two-stage splenic rupture is seldom, its risk is unpredictable and a precise diagnosis of a ct and/or mri imaging unexpectable or unexcludable. generally, and due to our experience and current literature a two-stage rupture occurs within one week after trauma. though dramatic courses after two or three weeks are known. therefore, it is suggested to perform a prophylactic angioembolization in (still) hemodynamically stable patients. materials and methods: a retrospective study in a level-one trauma centre of switzerland did analyse all patients that underwent a prophylactic angioembolisation after an explicit diagnose by ct and/or mri of a splenic parenchymal lesion after trauma between 2010 and 2016. further inclusion criteria were hemodynamical stability (sys rr [ 90 mmhg) and missing indication for immediate laparotomy. results: 11 patients (4 f, 7 m) with an average age of 44 ± 15 years underwent preemptive angioembolisation after traumatic lesions of the spleen. the ais abdomen was 3 in 9 and 4 in 2 patients. besides a splenic injury 3 patients did also have a kidney injury. the overall iss was 22 ± 5 points. 8 patients suffered additional thoracic or head trauma. in 5 patients the angioembolisation was performed on admission, in 1 on the 1st, in 3 at the 2nd and respectively 1 in the 3rd and 4th day of. in 1 case an uncomplicated selective embolization of a main duct of the splenic artery was performed. in 10 patients the trouble-free proximal embolization of the splenic artery was done. the average stay was 11 ± 6.0 days. no deaths or complications seen due to angioembolisation or splenic rupture. there were no complications or operative introduction: traumatic abdominal wall hernias (tawhs) are uncommon, and the optimal management is debated. tawhs most often result from blunt trauma and are associated with severe intraabdominal injuries. our institutional protocol mandates primary repair only if the patient undergoes laparotomy for other reasons and is without mesh. since 2011, primary repair of lumbar hernias included bone anchors when indicated. we wanted to describe the tawh patients treated operatively during initial hospitalization focusing on injury mechanism, diagnosis, associated injuries, operative techniques, early complications and outcomes. materials and methods: we performed a retrospective, descriptive cohort-analysis of data from the institutional trauma registry from 2007-2018. all operatively managed tawhs were identified based on ais codes, ncsp codes and relevant key words. results: of the 30 identified patients, 14 (47%) were women. median age was 37 years (range 10-73). median iss was 20 and 21 patients had iss [ 15. injury mechanism was blunt except for one explosion. 25 patients (84%) had been in a mvc, and 23 of these (92%) had seat belt injuries. 22 of these patients had a disruption of the muscle from the iliac crest, and one had a hernia through a fractured iliac wing. 3 bicycle falls and 1 fall from height had hernias in the anterior abdominal wall. two meshes were placed, with no known complications. bone anchors (twinfix ò 3,5 mm) were used in 7 patients. no recurring hernias were identified in the 18 patients with routine follow-up (1-21 months) . conclusions: surgery for tawh is uncommon in our institution. tawh is often associated with severe torso injuries and primary repair is only done when laparotomy for other reasons is indicated. primary suture of the muscle, including use of bone anchors seems to be adequate treatment, as we have identified no recurrences. a longterm follow-up study is warranted for operated and non-operated patients with tawh. a comparison of sub-specialty operative adolescent patient outcomes in adult and pediatric trauma centers introduction: adolescent trauma victims may be treated at either an adult (atc) or pediatric trauma center (ptc). these centers have different resources, surgeon training and overnight in-house coverage. it is not known how outcomes compare with regards to the very small subset of patients that actually undergo a surgical trauma intervention. we hypothesized that presentation to a ptc would yield increased mortality when subspecialty intervention was required and that this would be most pronounced at night when in-house attending coverage is absent at all state ptcs. materials and methods: a review of the pennsylvania trauma outcome study (ptos) database was performed to capture patients aged 12-18 who underwent any non-orthopedic trauma surgery. cohorts were created for cranial, thoracic, abdominal or vascular surgery from 2007-2017. trauma centers were divided as adult level 1 (atc1), adult level 2 (atc2) or pediatric (ptc). groups were created based on time of arrival with 7am-7pm being dayshift and 7:01pm-659am being night shift. age, race, mechanism of injury, vital signs, gcs, iss, los and mortality were evaluated. ancova was utilized to control for iss variation. spss was used for all analyses. results: 1851 patients met initial criteria. atc1s saw more minority patients and more males than other center types. atc1s saw an overall older cohort (16.9 years vs 16.6 years in atc2 and 14.6 years in ptc, p \ 0.001). despite this age difference, presenting systolic blood pressure was lowest at the atc1s (117.8 mmhg vs 125.7 mmhg at atc2 and 125.34 mmhg at ptc, p \ 0.001). iss and triss and overall mortality were not different and this included when grouped by day or night shift. of note, trauma thoracotomy was more likely to be performed at night in adult centers. hospital length of stay was significantly lower for atc2 (8.33 days vs 10.41 in atc1 vs and 11.38 in ptc). conclusions: adult and pediatric trauma centers see different patients. operative trauma cases are surprisingly low at our state's ptcs and trauma thoracotomy was more likely to be performed at night in atcs than ptcs. broader study is needed to uncover differences in operative care and outcomes. treatment of dislocation of the patella as a result of sports injuries in children. forecast and consequences in adulthood k. furmanova 1 , o. loskutov 1 , a. naumenko 1 1 medinua clinic and lab, ortopedics, dnepr, ukraine introduction: dislocations of the patella with a rupture of the medial patellofemoral ligament (mpfl) account for 8-10% of acute injuries of the knee joint [1, 2] . inadequate therapeutic tactics of these injuries in childhood and youth, as a result of sports injuries, are fraught with complications in the form of the instability of the knee joint, residual deformities and contractures in patients in adulthood [2, 3] . materials and methods: in the period from 2014 to 2018 349 cases of rupture of mpfl among children aged 7-18 years who were involved in sports were observed. the examination included conducting a clinical examination, axial radiography with flexion of the joint at angles of 45°and 90°, mri of the knee joint. results: in 87.9% (307 cases) the integrity of the mpfl(with a reduced number of sutures) was restored using a yamamoto suture, and in 42 cases (12.1%), the autoplasty of the mpfl was performed. excellent medium-term (5 years) clinical and functional results according to the ikdc scale were noted in 80.2% of cases, good in 14.9%, satisfactory in 4.9%. in 12 patients (3.4%) there was a relapse of dislocation after performing an mpfl suture during the first year after surgery mainly due to noncompliance with the recommendations. conclusions: injury to the knee joint with the patella dislocation in childhood and adolescence, associated with a sports injury is an indication for surgical treatment in order to adequately restore the integrity of the mpfl and prevent disabling complications. our yamamoto suture technique is more optimal for treating young patients with instability of the patella and is recommended for widespread use in pediatric orthopedists due to its undeniable clinical advantages. osteotomy with a defect 1 cm placed 8 cm below tibial plateau. 4 types of fixation have been simulated: plate fixation of only a medial pillar, plate fixation of only a lateral pillar, plate fixation of both pillars, and locking intramedullary nailing. results: in case of plate fixation of only a medial pillar, the injury to an interosseal membrane causes an expressed valgus deformation at axial loading, leading to a reasonable (1095.2 mpa) overload of the fixator in the osteotomy area. the use of a lateral plate leads to excessive loading on an external pillar, while the medial pillar remains unsupported. this causes overloads of the fixator in the osteotomy area (880.6 mpa). the double plate fixation is typical of the lowest extent of bone fragments displacements (1.25 mm) . this is a super-rigid type of osteosynthesis, able to cause a stress-shielding syndrome in the adjacent bone. it has been estimated that the method of im nailing is an optimal fixation method, with minimum loading of the fixator (250.4 mpa) and the best distribution of changed elastic strains in the bone-implant system. conclusions: the mathematical simulation demonstrates that fixation by a medial plate is possible only if support functions of the ligament system and interosseal membrane remained intact. if an injury is a high-energy one, nailing is preferable. introduction: treatment of large bone defects is one of the great challenges in contemporary orthopedic and traumatic surgery. grafts are necessary to support bone healing. a well-established allograft is demineralized bone matrix (dbm) prepared from donated human bone. a recent development is a new fibrous demineralized bone matrix (f-dbm) with a high surface-to-volume ratio. in this study we examine toxicity of an innovative dbm fibers preparation. materials and methods: f-dbm was transplanted to a 5 mm, platestabilized, femoral critical-size-bone-defect of 5 mm in sprague-dawley (sd)-rats (n = 6). healthy animals were used as control. after 3 months histology, hematological analyses as well as serum biochemistry was performed. were measured as indicators of free radical exposure. there were no significant differences between the control group and animals receiving f-dbm. hematology as well as biochemistry did not differ between operated animals and control. histologically no evidence of damage to liver and kidney and a good bone healing could be observed in most cases. conclusions: taken together, these results provide evidence for no systemic toxicity of the bone allograft. i have received no significant financial interest, consultancy or other relationship with products, manufacturer(s) of products or providers of services or financial support related to this abstract. • i hereby confirm that my abstract is based on previously unpublished data and that i own the rights to the written summaries of research or observations presented in the abstract, or that i have obtained permission for the acknowledged sources for other excerpts taken from copyrighted works. • in submitting an abstract i hereby agree that the copyright of my abstract is transferred to the european society of trauma and emergency surgery. • i hereby confirm that i will present my abstract at the congress in case it is accepted. sponsor: german institute for cell and tissue replacement (dizg, gemeinnützige gmbh), berlin, germany. intramedullary nailing through suprapatellar approach in distal tibia fractures: a retrospective study evaluating clinical and radiographic results d. bustamante recuenco 1 , a. gómez 1 , j. m. pardo garcía 1 , e. garcía 1 , p. castillón 2 , p. caba doussoux 1 1 hospital 12 de octubre, madrid, spain, madrid, spain, 2 hospital mutua terrasa, orthopaedics, barcelona, spain introduction: distal tibia fractures (dtf) can be operated either by intramedullary nailing (imn) or by orif with plates. the current literature shows a higher rate of malalignment and consolidation delay with imn when compared to plates. in these studies, an infrapatellar approach for the imn is performed. recent studies show a better alignment in dtf treated with imn by suprapatellar approach, though functional and biological outcomes have not been analyzed yet. our goal is to assess the clinical and radiographic results of the treatment of dtf with imn using a suprapatellar approach. materials and methods: a two-center retrospective study was performed, collecting the cases with dtf treated with suprapatellar imn from 05/2011 to 08/2018. results: a total of 82 patients were obtained, with a mean age of 45.5 years. the average follow-up was 13 months. 82% of the fractures were ao type 43a, presenting the remaining 18% intra-articular involvement. 6 patients presented complications, corresponding in 4 of them to superficial infections. as for clinical results, complete mobility in the knee and ankle was obtained in almost all cases. at the radiographic level, a total of 15% (12) of distal malalignment cases were detected, defined as more than 5°deviation from normal axis in the coronal and sagittal planes. most of the fractures consolidated in a period of 3-4 months. there were 13 cases of delayed consolidation, from which 2 developed pseudoarthrosis. conclusions: intramedullary nailing through a suprapatellar approach for dtf offers good clinical and radiographic results, with low rates of malalignment and lack of consolidation. more studies are required to compare the results obtained with other fixation methods for these fractures. reference: avilucea fr, triantafillou k, whiting ps, perez ea, mir hr. suprapatellar intramedullary nail technique lowers rate of malalignment of distal tibia fractures. j orthop trauma. 2016;30(10) :557-60. the clinical consequences of follow-up radiographs in ankle fractures are unclear and indications for these radiographs are seldom well-defined. routine radiographic imaging in the follow up of patients with an ankle fracture adds to treatment costs, although retrospective studies dispute its usefulness. the aim of this study was to assess if a protocol with a reduced number of routine radiographs would lead to cost savings, without compromising clinical outcomes. materials and methods: a multicentre randomized controlled trial was conducted. patients were randomly assigned in a 1:1 ratio to usual-care (consisting of routine radiography at one, two, six and twelve weeks) or reduced-imaging (radiographs only obtained for a clinical indication at six and twelve weeks). functional outcome was assessed using the omas and aaos ankle questionnaires, quality of life was measured with eq-5d-3l and sf-36 questionnaires. other outcome measures included complications, pain, the number of radiographs, health perception and self-perceived recovery. costs were measured with self-reported questionnaires results: the study group consisted of 247 participants, of which 154 (63%) received operative treatment. patients in the reduced-imaging group received median 4 radiographs, whilst patients in the usual care group received median 5 radiographs (p \ 0.005). omas, aaos scores, quality of life, pain, health perception and self-perceived recovery did not differ between groups. we observed 32 complications in the reduced imaging group. this did not differ significantly from the usual care group (29 complications p = 0.51). a significant reduction in radiographic imaging costs was observed (-€48 per patient, 95% ci -72 to -25). overall costs per patient were comparable (130 [95% ci -2975 to 3723]). conclusions: implementation of a reduced imaging protocol in the follow up of ankle fractures leads to cost savings and more importantly does not lead to worse functional outcomes. results after percutaneous and arthroscopically assisted osteosynthesis of calcaneal fractures w. grün 1 , m. molund 2 , f. nilsen 2 , a. stødle 1 1 oslo university hospital, orthopaedic department, ullevål, oslo, norway, 2 østfold hospital, orthopaedic department, grålum, norway introduction: operative treatment of calcaneal fractures using the extensile lateral approach is associated with high rates of soft tissue complications. during the last years there has been a trend towards less invasive fixation methods. percutaneous and arthroscopically assisted calcaneal osteosynthesis (paco) combines the advantages of good visualization of the posterior facet of the subtalar joint with a minimally invasive approach. materials and methods: we conducted a clinical and radiographic follow-up of 24 patients with 25 calcaneal fractures treated by paco with a minimum follow-up of 1 year. there were 16 sanders ii and 9 sanders iii fractures. the mean follow-up period was 17.6 months (sd 6.7). our primary outcome was the american orthopaedic foot and ankle society (aofas) ankle-hindfoot score. secondary outcomes were the calcaneus fracture scoring system (cfss), the manchester-oxford foot questionaire (moxfq), the visual analog scale (vas) for pain and the incidence of complications. radiographs were obtained to evaluate the reduction of the fractures as well as the presence of subtalar osteoarthritis. results: the median aofas score was 85 (range, 50-100), the cfss score 85 (26-100), the moxfq score 26.6 (0-76.6). the vas pain score was 0 (0-5.7) at rest and 4.05 (0-8.2) during activity. the böhler angle improved from mean 3.5 degrees (sd 12.6) preoperatively to 27.8 degrees (10.7) postoperatively. however, the follow-up radiographs showed subsidence of the fractures and a böhler angle of 20.4 degrees (13.2). 96% of the operated feet showed signs of posttraumatic subtalar osteoarthritis. there were no wound healing complications. two patients were reoperated with screw removal due to prominent screws. conclusions: our results suggest that paco gives good clinical results and a reduced risk of complications in selected calcaneal fractures. prospective longterm studies will be necessary to better evaluate the potential advantages and limitations of paco. with the nascent state of microsurgical services in the region the application of negative pressure wound therapy (npwt) has proven to be very helpful. an improvised npwt has made it locally available to patients. this report aims to show how this has improved the management of open fractures of the lower limb in a resource restricted setting. materials and methods: a 30-month review of cases of lower limb open fractures managed at a regional trauma centre in nigeria was done. the type of wounds were classified based on region and need for soft tissue coverage. results: a total of 256 cases were reviewed approximately 53% of these case were gustilo and anderson type iii. of these 87 had npwt as part of their management. some of the benefits of observed were; reduced frequency of wound dressings, and shorter time to optimize wound for closure. conclusions: the locally improvised npwt has proven to be an affordable and cost-effective tool in the management of open lower limb fractures. it remains an invaluable alternative of care in the absence of microsurgical skills and patented device with are far from reach owing to financial constraints. references: 1. hussain a, singh k, singh m. cost effectiveness of vacuum assisted closure and its modifications: a review. isrn plast surg. 2013; 2013:1-5. 2. isiguzo c, ogbonnaya i, uduezue a. modification of negative pressure wound therapy in the economically constrained region: a preliminary report. vol. 8, nigerian j plast surg. joytal printing press; 2012. p. 39-43. 3 . mba u, nevo a. challenges of limb salvage in a resource limited environment: case report and review of literature. niger j plast surg. 2018;14(1): 5. 4 . novak a, wasim sk, palmer j. the evidence-based principles of negative pressure wound therapy in trauma and orthopedics. open orthop j. 2014; 8:168-77 . introduction: lower extremity vascular trauma may result in limb loss or mortality. this study examined outcomes of lower extremity vascular trauma (levt) and potential associations to amputation/mortality. materials and methods: a retrospective cohort study of patients (n = 79; 82 limbs) with levt between 2000 and 2018 in a single trauma center. only patients requiring a vascular procedure were included. data were extracted from the swedish vascular registry (swedvasc) and the swedish trauma registry (swetrau). results: mean age 35 ± 17 years; men 85% (67/79); trauma mechanism 49% (39/79) blunt and 51% (40/79) penetrating. 71% of patients underwent preoperative cta; 30% of patients (23/76) were transferred to hybrid operating room. arterial injury was present in 73/82 limbs (89%) and venous injury in 43/81 limbs (53%). the most frequently injured artery was popliteal artery (25/73; 34%) followed by superficial femoral artery (23/73; 32%). most common vascular operative procedure was arterial bypass/interposition graft (45/82; 55%). a vascular shunt was used in 32% of cases (25/78). fasciotomy was performed in 49% (40/81) of limbs. four patients were lost to follow-up after less than five days. there were eleven limbs (11/75; 15%) amputated within 30-day postoperative follow-up. all amputations were caused by blunt trauma. 28% (7/25) of arterial injuries below-the-knee led to amputation. thirty-day mortality rate was 5.3% (4/75) . univariate analysis showed that fractures (p \ 0.001), soft tissue injury (p \ 0.001), multiple injuries (p = 0.011), and blunt mechanism (p \ 0.001) were associated with amputation and mortality after levt. conclusions: this study showed that amputations after levt are caused by blunt trauma. also levt combined with fractures, soft tissue injury, or multiple injuries increased the risk of amputation and mortality. multi-center study enabling multivariate analysis to adjust for potential confounding factors is imperative to confirm these findings. incidence, treatment and financial burden of tibial plateau fractures in belgium between 2006 and 2018 describe the incidence, evolution in management and financial burden of tpf in belgium between 2006 and 2018. we compare national data with data from uz leuven (uzl), the largest university hospital in belgium. materials and methods: this study includes all tpf treated in belgium between 2006 and 2018. we identified 35.226 tpf, of which 861 fractures were treated in uzl. despcriptive statistics were used to analyze the data. results: the annual incidence increased from 20.6 to 29.1/100,000/y. an increase in number was true for both operatively treated patients (otp) and non-operatively treated patients (notp), but was more pronounced in the latter (31% vs. 68% increase). the rate of surgery (ros) decreased from 41.4% to 35.5%. the mean ros for uzl was 49.0%. the total financial burden in belgium increased with 36%, mainly driven by increasing costs in otp. hospitalisation rates for notp decreased from 34% to 16%, as day hospital admission occured more commonly. the mean hospitalisation cost was €8,754 for otp and €9,103 for notp. costs for uzl inpatients were €10,358 and € 9,163. nursing days accounted for 64% of the cost in otp and 75% in notp. the mean los was 15.8 days for otp and 18.7 days for notp. uzl patients had a mean los of 16.3 and 11.7 days. conclusions: tpf are associated with increasing hospital related healthcare costs. as nursing days determine the majority of the financial burden, measures should be taken to avoid prolonged los. introduction: rotational malalignment (rm) is a common postoperative complication after intramedullary (im) nailing of tibial shaft fractures. computed tomography (ct) is commonly used for detection of malrotation, however reliability is frequently questioned. the purpose of this study is to evaluate the intra-and inter-observer reliability of low-dose protocolled bilateral postoperative ct-assessment of rotational malalignment after im nailing of tibial shaft fractures. materials and methods: a total of 155 patients were prospectively included with tibial shaft fractures that were treated with imn in a level-i trauma center. all patients underwent postoperative bilateral low-dose ct-assessment (effective dose of 0.03784-0.05768 mgy) as per hospital protocol. four observers performed the validated reproducible measurements of tibial torsion in degrees, based on standardized techniques. the intra-class coefficient (icc) was calculated to evaluate intra-and inter-observer reliability. the intra-and inter-observer reliability was categorized according to landis and koch. results: intra-observer reliability for quantification of rotational malalignment on postoperative ct after imn of tibial shaft fractures was excellent with 0.95 (95% ci = 0.92-0.97). the overall inter-observer reliability was 0.90 (95% ci = 0.87-0.92), also excellent according landis and koch. discussion and conclusion: first, bilateral postoperative low-dosesimilar radiation exposure as plain chest radiographs-ct assessment of tibial rotational alignment is a reliable diagnostic imaging modality to assess rotational malalignment in patients following imn of tibial shaft fractures and it allows for early revision surgery. second, it may contribute to our understanding of the incidence, predictors, and clinical relevance of postoperative tibial rotational malalignment in patients treated with imn for a tibial shaft fracture, and facilitates future studies on this topic. the trauma emergency laparotomy audit (tela) t. collaborators 1 , m. marsden 2 , p. vulliamy 2 , r. carden 2 , o. najiuba 2 , n. tai 2 , r. davenport 2 1 tela collaboration, natric, n/a, united kingdom, 2 queen mary university of london, centre for trauma science, london, united kingdom introduction: mortality for shocked trauma patients undergoing emergency laparotomy remains unchanged for 20 years. the tela study aimed to describe the contemporary peri-operative management and patient outcome following abdominal injury. materials and methods: a prospective multicentre observational study of all patients undergoing emergency abdominal surgery within 24 h of injury was performed in the uk and ireland for six months from the 1st january 2019. shock was defined as the receipt of blood transfusion, with clinical or biochemical evidence of hypoperfusion. results: the study included 363 patients from 35 hospitals, of whom 159 (44%) were shocked and received a median of 6 units red blood cells. shocked patients were more likely to have a blunt mechanism of injury (56% vs 32%, p \ 0.01) and had a 20% mortality (32/159). half of these deaths occurred in the operating room (or). patients that died were more severely injured (injury severity score 35 (iqr 24-50) vs 25 (iqr 16-36), p = 0.01) and had a greater degree of shock at hospital arrival (base deficit 13.0 (iqr 7.7-18.1) vs 6.3 (3.2-11.1) , p \ 0.01). processes of care were equivalent or better among non-survivors, with a higher proportion of patients that died undergoing laparotomy within 90 min of arrival in the emergency department (54% vs 26%, p = 0.01) and a lower proportion receiving crystalloid in the or (29% vs 75%, p \ 0.01). however, delays to achieving definitive haemorrhage control and delivering balanced blood transfusion ratios were observed among both survivors and non-survivors. conclusions: damage control resuscitation principles are followed most closely in patients that die. despite better processes of care, 1 in 5 shocked patients died in this study justifying the continued search for novel therapeutic approaches. pre-operative temporary haemorrhage control and pharmacological mitigation of the effects of shock may be productive avenues of research to improve patient outcomes. introduction: tranexamic acid (txa) has been shown to reduce mortality in bleeding trauma patients, with greater effect if administered early. normally administered intravenously, txa can also be administered intramuscularly, which could be advantageous in low resource and military settings. intramuscular use has only been tested in healthy patients, and it is likely that shock will reduce intramuscular uptake. materials and methods: in a prospective experimental study norwegian landrace pigs (40-50 kg) utilised in a surgical course in haemostatic emergency surgery were subjected to various abdominal and thoracic trauma. after 1 h of surgery the pigs were injected with 15 mg/kg txa either intravenously or intramuscularly. blood samples were drawn at 0, 5, 15, 25, 35, 45, 60 and 80 min. the samples were centrifuged and analysed with liquid chromatography-mass spectrometry (lc-ms/ms). results: preliminary results from 3 animals in the intramuscular and 2 animals in the intravenous group. mean plasma concentration with sd of txa as a function of time is shown in figure 1. plasma concentration in the intramuscular group was near 10 ug/ml 15 min after administration, and rose above 14 ug/ml after 60 min. conclusions: plasma concentrations reported to inhibit fibrinolysis in vitro is 10 -17.5 ug/ml (1, 2) . if this extrapolates to the clinical situation intramuscular administration would yield plasma levels within the lower end of therapeutic range after 15 min. in ongoing haemorrhagic shock plasma concentrations of txa after intramuscular administration were considerably lower than after intravenous administration, but within therapeutic range . introduction: fallowing laparoscopic cholecystectomy(lc), patients suffer from postoperative pain, especially in the abdomen. intraperitoneal local anesthesia (ipla) reduces pain after laparoscopic cholecystectomy(lc). acute cholecystitis(ac)-associated inflammation, increased gallbladder wall thickness, dissection difficulties, and a longer operative time are several reasons for assuming a benefit in pain scores in urgent lc with ipla application. the aim was to determine the postoperative analgesic efficacy of high-volume lowdose intraperitoneal bupivacaine in urgent lc. materials and methods: fifty-seven patients, american society of anesthesiologists(asa) physical status i or ii were randomly assigned to receive either normal saline(group a) or intraperitoneal bupivacaine(group b) at the beginning or at the end of the surgery in urgent lc. the primary outcome was the scores of postoperative pain by visual analogue scale score (vas) after surgery. results: postoperative vas scores at 1st and 4th hours were significantly lower in group b than group a (p \ 0.001). postoperative vrs scores at 1st, 4th and 8th hours were significantly lower in group b than group a (p \ 0.001, p:0.002, p:0.004). anelgesic use was significantly higher in group a at 1st postoperative hour than group b (p \ 0.001). shoulder pain was significantly lower in group b than in group a (p \ 0.001). patient satisfaction was significantly higher in group b than in group a (p \ 0.001). conclusions: high-volume low-concentration intraperitoneal bupivacaine instillation resulted in better postoperative pain control along with reduced incidence of shoulder pain and analgesic consumption in comparison to control group in urgent lc. introduction: in-hospital resuscitative thoracotomy is an established procedure for patients with penetrating cardiac injuries. the survival rate is dismal in patients with cardiac arrest prior to admission. prehospital resuscitative thoracotomy (prt) was introduced by the london hems with the highest published survival rate of 18%. we aimed to identify the number of patients who could potentially benefit from prt in our major trauma center catchment area. materials and methods: data from 2010 to 2017 were collected from the institutional trauma registry and electronic records. we included patients [ 17 years, with penetrating cardiac injury, or penetrating chest trauma and cardiac arrest, or penetrating chest trauma and sbp \ 70 mmhg. commonly used criteria for prt are tamponade with cardiac arrest lasting \ 10 min at the time of ambulance arrival and with [ 10 min remaining transportation time to hospital. results: cardiac injury was found in 25 of 54 included patients. of these 25, 14 arrived at the hospital with signs of life and survived. 8 of the 11 patients who died had tamponade. criteria for prt were not met in 6 of 8 patients with tamponade. two patients could have been eligible for prt. one patient was found in oslo with cardiac arrest lasting 10 min. the patient had multiple stab wounds to the chest and had several perforations of the right atrium, not technically manageable in a prehospital setting. the second patient was injured outside our primary catchment area and arrested with prehospital personnel present. prt was performed and the tamponade relieved, but compression of the aorta was necessary. the patient was declared dead shortly after hospital admission. conclusions: in 8 years in a population of 1.6 million, two patients met london hems criteria for prt. prt was performed in one patient who was declared dead shortly after hospital admission while one patient suffered from injuries which are unmanageable in a prehospital setting. isolated tissue injury leads to fibrinolytic shutdown, tpa resistance and alterations in clot structure in a porcine model introduction: trauma-induced coagulopathy includes a spectrum of hypo-to hypercoagulable phenotypes with differing levels of fibrinolysis and tpa sensitivity. fibrinolysis shutdown is associated with increased late mortality and shown in small animal studies to be driven by tissue injury. utilizing a novel method of clot structure analysis, we hypothesize that isolated tissue injury provokes fibrinolysis shutdown, tpa resistance and is associated with altered clot structure resulting in enhanced clot stability. materials and methods: all male pigs (n = 13) underwent anesthesia, intubation, femoral artery cannulation and mini-laparotomy. tissue injury (n = 9), was inflicted with bilateral chest wall muscular cutdowns and bilateral femoral fractures using a captive bolt pistol. mean arterial pressure was maintained at [ 50mmhg. timed blood samples analyzed using tpa challenged and citrated native teg to evaluate tpa resistance and fibrinolytic shutdown respectively. after 3 mm punch biopsy induced splenic injury, clot was collected, washed, and chemically fractioned by strong cation exchange chromatography. tandem mass spectrometry and bioinformatic analysis were used to evaluate clot structure and factor xiiia cross-linking patterns and covalently associated proteins. results: tissue injury pigs showed increased tpa resistance (change tpa-teg ly30: -39.1% vs -10.1% p = 0.0028) and a trend of fibrinolytic shutdown evidenced by teg compared to control (fig. 1) . splenic clot structure analysis demonstrated altered clot structure (fig. 2) and identified elevated levels of protease inhibitors such as alpha 2 macroglobulin and alpha 2 antiplasmin at 6 h post tissue injury compared to baseline. conclusions: in a porcine model, isolated tissue injury provokes fibrinolysis shutdown and tpa resistance resulting in altered clot structure with an increased incorporation of anti-protease proteins resulting in enhanced clot stability. there is a high incidence of rotational malalignment after intramedullary nailing of tibial shaft fractures: a prospective cohort series of 155 patients n. j. bleeker 1 1 amsterdam medical centre, flinders university, department of orthopedics and trauma surgery, amserdam, netherlands introduction: intramedullary nailing (imn) is the treatment of choice for most tibial shaft fractures due to its minimalistic surgical approach, superior fracture healing, and rapid recovery. however, an iatrogenic pitfall is rotational malalignment (rm). the aim of this prospective cohort study was to determine the incidence of rm and to evaluate the efficacy of protocolled bilateral postoperative computed tomography (ct) assessment of rotational tibial alignment. materials and methods: between 2009 and 2016 we prospectively included 155 patients (111 male (72%)), with a mean age of 41 years, with a unilateral tibial shaft fracture. as per hospital protocol, patients underwent a routine low-dose bilateral postoperative ct to assess rm. forty-two patients (27%) suffered open injuries; 29 (19%) were involved in a multi-trauma sustaining more than one injury. according to the ao/ota classification, there were 95 simple (61%), 35 wedge (23%), and 25 complex fractures (16%). fracture location within the tibial shaft varied with six patients (4%) being within the proximal third, 47 (30%) middle third, and 90 (58%) distal third. there were 11 segmental (7%) fractures that involved more than one third of the tibia. results: fifty-five patients (35%) had post-reduction rm including 46 patients (30%) between 10°-19°, seven patients (5%) with a rm between 20°-29°, and two patients (1%) with a rm greater than 30°w hen compared to the uninjured side. of the patients with rm, the tibia was externally malrotated in 29 patients (53%). three patients (2% of cohort or 5% of those with rm) underwent revision surgery to correct the rm as detected on ct scan. conclusions: this study reveals a high incidence of rm following tibial nails (35%) with a surprisingly low revision rate (5% of those with rm). a subsequent study should aim to assess clinical relevance of rm in terms of functional outcome and gait analysis. for now ctrotational-profiling provides a platform for early recognition and correction of rm secondary to tibial imn. level of evidence: therapeutic level ii -prospective cohort study. materials and methods: the tarn database was analysed retrospectively to quantify the number of trauma team activations, patients with major trauma (mt), causes of injury, and subspecialty-specific trauma procedures. crude and risk-adjusted mortality rates, observed to expected (o/e) mortality ratio, and risk-adjusted rates of survival from mt were also calculated. results: the number of trauma team activations has risen by a factor of 5. the predominant injury mechanism that resulted in mt was a fall from less than 2 m. there has been a fivefold increase in the overall number of trauma surgical procedures. orthopaedic surgeons have performed 84% of trauma procedures, followed by neurosurgeons, oral and maxillofacial surgeons, and visceral trauma surgeons. the rate of trauma laparotomies per consultant fluctuated between 0.4 and 0.8 per month. a fall from less than 2 m, road traffic accident and a fall from more than 2 m were the three leading causes of death from mt. the overall o/e mortality ratio was 1.1. conclusions: aintree trauma profile has significantly changed since 2011. this change highlights the potential need for a review of how mt services are offered at aintree to reduce the o/e mortality ratio. this may be achieved through more co-ordinated provision of trauma care, prevention, audit and research programmes. the role of visceral trauma surgery should be reconsidered within the context of the surgical patients' needs and demands, and fundamental requirements of the profession. inter-hospital variation in surgical intensity for trauma admissions: a multicenter cohort study l. moore 1 , m. p. patton 2 , i. farhat 2 , p. a. tardif 2 , c. gonthier 3 , a. belcaid 3 , f. lauzier 2 , a. turgeon 2 , j. clément 2 1 université laval, social and preventive medicine, québec, canada, 2 chu de québec-université-laval, québec, canada, 3 introduction: guidelines for trauma patients are increasingly moving away from surgical management towards less invasive procedures but there is a knowledge gap on how these recommendations are influencing practice. we aimed to assess inter-hospital variation in surgical intensity for trauma patients and identify determinants of surgical intensity. materials and methods: we conducted a retrospective multicenter cohort study based on the 57 trauma centers of an inclusive canadian provincial trauma system. we included adults admitted for major trauma between 2007 and 2016. analyses were stratified for orthopedic (n = 17,001), neurological (n = 12,888) and thoracoabdominal surgery (n = 9816). surgical intensity was quantified with the number of surgical procedures during the first 72 h. inter-hospital variation was assessed with the intra-class correlation coefficient (icc) from multilevel poisson regression models. relative risks (rr) were generated to identify determinants. results: moderate inter-hospital variation was observed for orthopedic surgery (icc = 14.4%, 95% confidence interval [ci]: 12. 1-20.4) whereas variation was low for thoracoabdominal surgery (icc = 2.7%, 95% ci: 1.7-3.1) and neurosurgery (icc = 0.8%, 95% ci: 0.8-1.2). level iv centers had similar surgical intensity for thoracoabdominal injuries (rr: 1.20, 95% ci: 0.65-2.25) but lower intensity for orthopedic injuries (rr = 0.31, 95% ci: 0.17-0.57) than level i/ii centers. during the study period, we observed a decrease in intensity for neurosurgery (rr for 2015 (rr for -16 versus 2007 .76, 95% ci: 0.68-0.84) and thoracoabdominal surgery (rr = 0.74, 95% ci: 0.63-0.87). conclusions: the observed inter-hospital variation in risk-adjusted surgical intensity suggests that there may be opportunities for quality improvement in surgical care for injury admissions. a better understanding of how surgical intensity influences clinical outcomes is needed to inform quality improvement activities. pre-hospital injury diagnosis a. easthope 1 , m. marsden 2 , g. grier 2 1 barts and the london medical school, london, united kingdom, 2 royal london hospital, centre for trauma science, london, united kingdom introduction: accurate pre-hospital diagnosis of a patient's injuries may improve care by facilitating effective intervention at the scene and reducing time to definitive treatment in hospital 1 . we sought to assess the diagnostic accuracy of injuries by london's air ambulance (laa) clinicians and identify conditions in which clinical accuracy may deteriorate. materials and methods: a retrospective review was undertaken of all patients conveyed to the royal london hospital by laa from october 2017 for six-months. pre-hospital injury scores, coded using the abbreviated injury score (ais) were compared to hospital discharge ais. patient outcomes were evaluated in the case of underscored injuries. results: during the study period 688 patients were seen and 177 met eligibility. mean clinical sensitivity and specificity was 62% and 93% respectively. chest injury identification was most sensitive (77%) and pelvic injury least sensitive (41%). the relative risk (rr) of underscored injuries to the chest, abdomen and pelvis increased with decreasing glasgow coma scale (gcs) peaking at 1.7 (iqr 1.3-2.0). the average accuracy of injury identification was 88% with a negative predictive value of 90%. no overt patient morbidity resulted from a missed, or under-scored injury. all missed injuries were subsequently identified in the emergency department. conclusions: the pre-hospital diagnosis of injuries has reasonable sensitivity and excellent specificity. accurate pelvic injury diagnosis is more challenging than chest or abdomen. with decreasing gcs, the risk of missing injuries increases. clinicians should be aware of the potential for error when treating trauma patients with impaired conscious levels. comorbidities, injury severity and complications predict mortality in severe thoracic trauma: a retrospective analysis from the norwegian national trauma registry of epidemiology, clinical factors and risk factors for mortality of patients with thoracic injuries. materials and methods: adult patients treated for severe thoracic trauma (injury severity ais c 3), between 2009 and 2016 at haukeland university hospital were included. data were extracted from (1) the haukeland university hospital local trauma registry, and (2) the norwegian trauma registry. additional data on comorbidities and complications was collected from patient records. the factors age, gender, comorbidities [charlson comorbidity index (cci)], anticoagulant use, injury severity [revised trauma score (rts)], [injury severity score (iss)] and complications [clavien-dindo scale (cds)] were analyzed for being predictive of in-hospital mortality. multivariate logistic regression analyses with backward selection methods were used. results: data of 399 patients were analyzed, of which 55 (14%) patients died. median iss was 34 in the non-survivors (iqr 22, 43) and 17 (iqr 13, 25) in survivors (p = .001). data of 282 patients were used in the risk factor for mortality analysis. two or more comorbidities measured by cci (or: 7.02, p = 0.006), injury severity measured with the rts (or: 0.41, p = \ 0.001), and grade c 3 complications on the cds (or: 7.66, p = 0.001) were significant predictors for mortality. conclusions: severe comorbidities significantly decreased the chances of survival after thoracic trauma. injury severity was also found to be a significant predictor of mortality. physiological injury severity, measured by rts, appeared to be a stronger predictor of mortality than iss after thoracic trauma. finally, severe complications led to considerably higher risk of mortality following thoracic trauma. the psychosocial impact of e-bike accidents and changing values of older patients in the netherlands, a qualitative study s. berben 1 , l. vloet 1 , e. c. t. tan 2 , m. edwards 2,3 , a. brants 2,3,4 , g. olthuis 2, 3, 4, 5 , a. oerlemans 2, 3, 4, 5 , f. haverkamp 2, 3, 5 introduction: the mechanical impact of e-bike accidents, increasingly used by older persons, has shown to be higher compared to regular bike accidents. however, the psychological impact of e-bike accidents in older trauma patients, their experiences in emergency and follow-up care, and the possible change in values and beliefs in response to the accident is still unknown. materials and methods: we used a qualitative design and included older patients (65 ? years) with a variety of (severe) injuries, who were admitted to the emergency department after an e-bike accident (n = 12) and their relatives (n = 11). they were interviewed within one month (t1) and after three months (t3) of the date of accident. interviews were transcribed verbatim and analyzed via a thematic analysis approach using an ethical perspective. results: many patients required (in)formal care after hospital discharge. in general patients were satisfied with the provided emergency surgical care, although some patients reported limited and insufficient information on rehabilitation and homecare support. the analysis yielded impaired physical condition, anxiety, increased vulnerability and dependency of care givers as psychosocial impact. freedom impairment, shifting relational autonomy, and confrontation with vulnerability and mortality were reported changes in values. central values as mobility and freedom, vitality and health, social participation and recreation were put under pressure and needed to be negotiated again after the accident in order to decide whether to use the e-bike again. conclusions: follow-up information of surgeons and emergency physicians after initial hospital care for older trauma patients with an e-bike accident shows room for improvement, with more specific consideration for the psychological impact of trauma and changes in values after e-bike accidents. eur j trauma emerg surg. 2018. https://doi.org/10.1007/s00068-018-1033-5. traumatic subaxial cervical fractures: functional prognostic factors and survival analysis introduction: the main goal of this study is to identify the risk factors for poor functional outcomes and to analyze the overall survival (os) and complications rate in patients with traumatic cervical spinal cord injury (sci) and subaxial cervical fracture (sacf) treated with open surgical fixation. materials and methods: the authors retrospectively reviewed sixtyfive consecutive patients from one single center with traumatic unstable sacf and associated sci treated surgically between 2010 and 2017. we exclude cervical fractures with concomitant severe head injury, brachial plexus injury, lumbar plexus injury, superior or inferior limb fractures and patients who were lost during the followup period. statistical analysis using a chi square test, student's t-test and logist regression were used to identify factors associated with poor functional outcomes after surgical treatment. os analyses were performed using kaplan-meier curves. results: the 5-year survival rate was 81.8%. four patients died in the first 30 days after surgery and 6,7% need a reoperation. the median time from injury to surgery was 3.6 days. the complication rate was 62%, being respiratory failure the most common one. preoperatively, 64% had an asia \ c. about 57% of the patients with asia between a-d had improve one or more asia grades. logistic regression analysis show that older age, sacf above c5, asia \ c pre-surgery and long time from injury to surgery were related with poor prognosis. the os rate was higher in patients with neurological improvement, without signs of neurogenic shock at presentation and in sacf bellow c4. conclusions: our results suggest that sacf should be treated as soon as possible in order to improve the os rates and functional outcomes. older patients, lower asia at presentation and sacf above c5 are related with worst functional outcomes. introduction: compression fractures of multilevel vertebral bodies are common in children. due to segmental plasticity, several adjacent vertebral bodies are compressed to a lesser degree at each body. plain ap and lateral x-ray is the first diagnostic examination in the emergency department (ed), but a proper diagnosis is often delayed or missed. materials and methods: this is a retrospective, monocentric study in children falling on their back who showed up at the orthopedic ed, between december 2017 and september 2019. nine children (4f, 5 m) with an average age of 11.1 years were included. trauma occurred playing games and doing sports in all cases. all children were subjected to x-ray, followed by mri scans for doubtful findings on the plain x-ray or persistent mild pain (t1, t2, t2-stir sequences). results: cuneiform vertebral fracture or vertebral body height reduction was diagnosed with x-ray in five vertebrae while mri showed fractures in 32 vertebrae including compression and edema of adjacent vertebrae in the t2-stir sequence. therefore only 15.6% vertebral fractures have been detected by plain x-ray. the injured vertebral bodies were so distributed: t3 n = 1, t4 n = 2, t5 n = 3, t6 n = 4, t7 n = 3, t8 n = 3, t9 n = 4, t10 n = 3, t11 n = 2, t12 n = 2, l1 n = 2, l3 n = 1, s4 n = 1, s5 n = 1. the most involved spine section was between t3 and t10 with 20 fractures. conclusions: vertebral fractures are not always related to hyperflexion or forward hinging mechanism. mri showed vertebral compression fractures and the t2-stir sequence showed edema as post-traumatic evidence that had not been detected by x-ray. in absence of a radiologically visible lesion, the persistence of pain should be investigated by performing mri scans. the middle thoracic spine level appeared to be the most involved one in pediatric vertebral fractures. introduction: occipitocervical fixation (ocf) is an effective surgical method to treat various craniovertebral junction (cvj) pathologies. a rigid fixation achieved from ocf displaces other techniques of cvj stabilization unfortunately during procedure deep and wide wound is performed. aim of this study is to share our experience in ocf and lately performed percutaneous ocfs with intraoperative ct guided navigation system. materials and methods: of 34 patients who underwent ocf 6 were performed percutaneously. o-arm ct scans were used to illustrate and measure radiologic parameters. screws were implanted in c1 lateral masses (2) , isthmus of c2 (68) and c3 pedicles (68) and assessed according gertzbein robbins (gr) in modification of bredow classification from a to e. results: a total 138 screws were implanted, 114 of them was performed in open surgery and 24 percutaneously. outcome in gr classification for screws implanted in open surgery was: a 58 (50,88%), b 22 (19,3%), c 16 (14,04%), d 9 (8,77%) and e 9 (7,02%) while in percutaneous: a 21 (87,5%) and b 1 (12,5%) . in open surgery one screw was revised. conclusions: percutaneous occipitocervical fusion seems to be a good option to achieve desirable effect in cervical pedicle screws implantation. during procedure whole nuchal muscles are preserved. ct guided surgery and microscope view are necessary to perform percutaneous ocf. introduction: studies have found higher risk of traumatic deaths in rural areas in norway combined with a paradoxically decreased prevalence of severe, non-fatal injuries (1) . this study investigates the risk of fatal and non-fatal injuries among all adults in norway in the period 2002-2016. materials and methods: all traumatic injuries and deaths among persons with residential address in norway from 2002-2016 were included. data was collected from the norwegian patient registry and the norwegian national cause of death registry. all cases were stratified according to six groups of centrality based on statistics norway's classification of centrality 2017. mortality-and injury rates was calculated per 100,000 inhabitants per year. results: the mortality rate differed significantly according to the levels of centrality (p \ 0.05). the mortality rate in the most urban group (1) was 64.2 and in the most rural group (6) 78.6. the lowest mortality rate was found in centrality group 2 (57.9). there was an increased risk of death between centrality group 1 and group 6 with a relative risk of 1.23 (ci: 1.0-1.5, p \ 0.05). the most common cause of death was transport injuries, self harm, fall injury and other external causes. the highest urban-rural gradient was seen in transport injuries with a relative risk of 3.0 (ci 1.7-5.3, p \ 0.001) comparing group 6 to group 1. group 2 had the lowest risk of nonfatal injuries (1531) and group 6 the highest (1803). the risk of nonfatal injuries increased with higher grade of rurality, comparing group 1 and 6 revealed a relative risk 1.07 (ki 1.02-1.11, p \ 0.001). conclusions: the more rural the higher risk of traumatic deaths and non-fatal injuries. transport injuries had the highest urban-rural gradient. references: 1. bakke hk, hansen is, bendixen ab, morild i, lilleng pk, wisborg t. fatal injury as a function of rurality-a tale of introduction: virtual fracture clinics (vfcs) are an alternative to conventional fracture clinics for management of musculoskeletal injuries. they have been shown to be a safe and effective model for upper and lower limb injuries. there is limited data to support their use for specialist thoracolumbar fracture follow-up. materials and methods: lean methodology including process mapping was applied to identify a safe virtual alternative for the pathway. first cycle analysis of 100 consecutive referrals to a traditional specialist thoracolumbar fracture clinic. second cycle analysis of 100 consecutive referrals six months after introduction of a vfc. results: mean time to first outpatient review in first cycle was 84 days. referrals led to 240 booked outpatient appointments and 66 were missed (28% non-attendance). 54% of referrals had 3 or more scheduled appointments. 82/100 were ao type a1-3 and all of these received non-operative treatment. 9/100 were ao type a4 or b and 8 of these received non-operative treatment. 1 patient received operative stabilisation (ao type b). process mapping identified two pathways-virtual review with advice letter and physiotherapy referral (outcome a-ao type a1-3) or face to face review (outcome b-ao type a4 or b). mean time to outpatient review in second cycle was 10 days. 79/100 received outcome a. 8/79 (10%) made a telephone call for advice and only 2/79 (3%) asked for a face to face appointment. 19/100 received outcome b and all were discharged after one visit. 0 patients in cycle 2 required operative stabilisation. statistically significant reduction in number of scheduled face-to-face reviews (240 versus 19; p \ 0.001) and mean time to first review (84 days versus 10 days; p \ 0.001). conclusion: virtual thoracolumbar fracture clinics are a safe and clinically effective alternative to traditional fracture clinic models. lean methodology can be uses to extend virtual clinic pathways to specialist trauma clinics. treatment prognosis of 340 cases of fragility fracture of pelvis m. yoshida 1 1 fujita health universityhospital, emergency, aichi, japan introduction: the number of cases of fragility fracture of pelvis in the elderly has been increasing in recent years, but there are still not enough reports of surgical treatment as a treatment method, but there is still no certainty how to treat. so we investigated prognosis of 340 cases of fragility fracture of pelvis. materials and methods: subjects were 340 fragility fracture of pelvis treated at a single center from april 2012 to april 2019, 40 males, 300 females, average age 82 ± 9.5 years. only cases that had ct scan were included. we examined rommens classification, the presence of injury, presence of hip implants, functional prognosis, and 1-year mortality. results: the breakdown of rommens classification is type ia 78 cases, ib 2 cases, iia 14 cases, iib 74 cases, iic 51 cases there were 32 cases of iiia, 3 cases of iiic, 1 case of iva, 50 cases of ivb, and 4 cases of ivc. surgical treatment was indicated in 16 cases (4.7%) (iic 1 case, iiia 7 cases, ivb 5 cases, ivc 3 cases) there were 28 cases (8.2%) with no injury mechanism and 61 cases (18%) with hip implants. 109 cases (32%) were able to follow up for more than 1 year including telephone surveys, and 42.3% of them did not recover to functional level before injury. the one-year mortality rate was 10.2%. conclusions: in the 340 cases studied here, 16 cases (4.7%) were indicated for surgery. the prognosis and mortality rate are almost the same as those reported overseas, and as with proximal femoral fractures, there is a possibility that it may be greatly involved in adl decline in the elderly. we think that further study is needed in the future. conclusions: patients with a femoral neck fracture who received a hip hemiarthroplasty and used anticoagulation had no significant longer delay to surgery and had a higher mean loss of hemoglobin points. as a clinical consequence of this, more packed cells were supplemented. also more postoperative hematomas were found in the population with anticoagulation. no differences were found in mortality rates at 30-days and one year. results: on all eight patients the easy-approach was applied without adverse events. in four cases the plate osteosynthesis was done completely endoscopically with excellent results for the patients regarding pain relief and scar development. in the remaining four cases the endoscopic stabilization was not performed for the following reasons: in the first overall case primarily only the endoscopic approach was planned. in the fourth overall case, ventilation showed high end-expiratory co2-levels after endoscopic situs preparation, so we converted to the open plating. in the fifth overall case, the easyapproach was applied to evacuate a retrosymphyseal hematoma in a patient with a stable pubic rami fracture. in the eighth overall case, the anterior pelvic ring injury was a bilateral multifragmentary pubic rami fracture in combination with a disruption of the symphysis. after endoscopic situs preparation with clipping of the corona mortis vessel, reduction of the displaced symphysis could not be done endoscopically. conclusions: we demonstrated that the endoscopic plate osteosynthesis of the anterior pelvic ring is feasible with existing standard laparoscopic instruments. the evaluation of the easy-approach in the clinical setting is going on, while the development of suitable reduction tools is one major goal of future studies. introduction: retrograde intramedullary pubic ramus screw fixation is less invasive method and biomechanically stable compared to the plate fixation. the purpose of this study is to examine the feasibility of screw insertion using computed tomography (ct). materials and methods: we analyzed sixty ct data (30cases in male and female each). by using ct analyzing software, the virtual column with 6.5 mm diameter was inserted so that we analyzed the feasibility of the screw insertion. and the intramedullary diameter of the pubic ramus at the parasymphyseal area, base, and acetabulum were measured. results: the virtual 6.5 mm diameter screws could be inserted in 100% (30/30) in male and 23.3% (7/30) in female. the cause that screws insertion was impossible was penetration to the hip joint in all cases. the screw inserting point was 19.2 mm and 21.5 mm from the medial border of the pubic symphysis and 11.5 mm and 9.8 mm from the upper border of the pubic symphysis in male and female respectively (p [ 0.05). the intramedullary diameter of pubic ramus was 15.7 mm, 13.8 mm and 12.5 mm at parasymphyseal area, 13.2 mm, 11.4 mm and 9.4 mm at the base of pubis, and 14.5 mm. 13.5 mm and 11.7 mm at the acetabulum in male, female who had the screw corridor and female who didn't have the screw corridor respectively. the diameter of the pubic ramus of the female who didn't have the screw corridor was significantly small compared to male and pubic ramus in three measuring points (p \ 0.05). , 5% of the screws were revised. there were no neurovascular or urologic complications. radiographic nonunion was observed in 10% with a minimum follow-up of 6 months, this correlated with a peri-implant infection (p 0.001), operation [ 6 months after trauma (p 0.02) and non-significantly with implant loosening (p 0.076). there was no correlation of nonunion with patient's age, the fracture mechanism or a non-excellent reduction. in total, 12.5% of the patients were re-operated, in 5.1% a re-osteosynthesis was conducted. conclusions: retrograde trans-pubic screws show good clinical results with lower or similar complication rates compared to alternative methods as plate fixation or external fixator. fracture union did not depend on fracture mechanism or age. hence, this minimal-invasive method is especially attractive in elderly patients with an ffp. because it is an internal fixation of the superior pubic ramus with relative stability, an anatomic open reduction is not necessary to achieve fracture union. the need for extraperitonal pelvic packing -finally confirmed to be vanishing? introduction: the presence of cerebral venous thrombosis (cvt) is increasingly recognized in traumatic brain injury (tbi), but its complication rate and effect on outcome remains undetermined. in this study, we characterize the complications and outcome-effect of cvt in tbi patients. materials and methods: in a retrospective, case-control study of patients included in the oslo university hospital trauma registry and radiology registry from 2008-2014, we identified patients with cvt (cases) and without cvt (controls). groups were matched regarding abbreviated injury severity (ais) head region score 3-6. cases were identified by ais or icd-code for cvt and a ct/mr venography confirmed to be positive for cvt, whereas controls had no ais or icd-code for cvt and a ct/mr venography confirmed to be negative for cvt. risk of mortality was assessed using multivariate logistic regression adjusting for initial gcs, iss and rotterdam score. results are also reported for subgroups according to cvt location ( fig. 1 introduction: the aims of this prospective cohort study were (i) to identify trajectories of recovery in patients with mild traumatic brain injury (mtbi) during the first two years after trauma and (ii) assess patients and injury characteristics for these trajectories. materials and methods: all adult trauma patients with mtbi (aisseverity 1 or 2 and an injury severity score \ 9) who were admitted to a hospital in a region of the netherlands from august 2015 to november 2016 were asked to complete questionnaires. the questionnaires could be completed at 1 week, and 1, 3, 6, 12 and 24 months and included the euroqol-5-d for health status, including a cognition dimension, the hospital anxiety depression scale (hads-d and hads-a for symptoms of depression and anxiety respectively) and the impact of event scale (ies) (for post-traumatic stress symptoms). latent class trajectory analysis was used to determine trajectories of recovery in latentgold 5.1, patient and injury characteristics of the classes were assessed in ibm spss 24.0. results: a total of 1027 patients (47% of total) completed at least one follow-up questionnaire. the number of classes (trajectories) ranged from 3 for cognition to 11 for depression. poor recovery classes of cognition and health status consisted of mostly females, patients with low education, higher age, longer length of stay at the hospital and frail patients. the class with full recovery consisted of young patients, with most recovery occurring during the first six months after injury. patients who reported poor health status before injury scored significantly lower health status after injury and showed no recovery over time. conclusions: different recovery patterns were present in patients with mild traumatic brain injury. especially frail elderly patients who reported poor health status before injury have poor outcome up to 24 months after injury. post-concussive symptoms in children and adolescents with traumatic brain injury: a center-tbi study introduction: acute respiratory is associated with high morbidity and mortality. in addition, its etiologies are heterogeneous and the outcome depends on the underlying cause. the aim of the present study is to analyze, whether the mortality of posttraumatic ards is affected (1) over time, (2) attributable to geographic distribution, (3) related to the used definition and (4) introduction: many factors of trauma care have changed in the last decades. this review investigated the effect of these changes on overall and cause-specific mortality in polytrauma patients admitted to the intensive care unit (icu). moreover, changes in trauma mechanism over time and differences between continents were analyzed. materials and methods: a systematic review of literature on overall mortality in polytrauma patients admitted to the icu was conducted. overall and cause-specific mortality rates were extracted as well as the trauma mechanism of each patient. linear regression on changes in overall and cause-specific mortality rates was performed. results: thirty studies, which reported mortality rates for 83,502observed patients, were included and showed a decrease of 0.4% in overall mortality per year ( fig. 1 ). brain-related death has become more common over the years, whereas multiple organ dysfunction syndrome (mods), acute respiratory distress syndrome and sepsis became less prevalent (fig. 2) . mods was the most common cause of death in north america and brain-related death was the most common in asia, south america and europe (fig. 3a) . penetrating trauma was most often reported in north and south america and asia (fig. 3b) . conclusions: overall mortality in polytrauma patients admitted to the icu has been decreasing as a result of the improvements in trauma care. a shift from mods to brain-related death could be observed. more research on preventative measures for the latter is required to ensure a further decline in mortality. moreover, we have shown geographical differences in cause-specific mortality, which may provide learning possibilities between similar trauma centers resulting in improvement of trauma care introduction: aim of the current study was to assess an association between trauma patient volume of the intensive care unit and inhospital mortality. materials and methods: from data of the japan trauma databank, this retrospective cohort study selected adult (c 16 y) trauma patients hospitalized in the intensive care unit with the injury severity score of c 9. after applying a multiple imputation on all the study variables, a logistic regression generalized estimating equation after adjustment for age, sex, mechanism of trauma, and the injury severity score as covariates and hospitals as a cluster assessed an association between quartile of patient volume in intensive care unit and hospital mortality. introduction: quality and content of early fracture hematoma (fh) dictate the healing process in long bone fractures. different reaming protocols for intramedullary nailing (imn) are available. however, the impact of reaming strategies on immune cell characteristics of early fracture hematoma is unclear. we hypothesized that the application of reaming irrigation and aspiration (ria) techniques optimizes cellular content of fracture hematoma. materials and methods: twenty-four pigs underwent standardized femur fracturing. then, animals were exposed to different protocols of imn. group a underwent no reaming prior to imn. group b was treated with conventional reaming plus imn and group c composed of animals treated with ria and subsequent nailing. fracture hematoma was collected 6 h after reaming. fh-immune cells were isolated and studied by flowcytometry. cell viability was tested by annexin-v-labelling. neutrophil activation was determined by mac-1/cd11bcell surface expression levels, whereas fcyriii/cd16-receptor expression was utilized to investigate neutrophil maturation. results: all animals survived the observation period. propertions of white blood cell subtypes in fh did not differ between conditions. however, the percentage of viable fracture hematoma immune cells was significantly higher in the ria-group, compared with conventional reaming (respectively mean 86.7% vs. 96.5%, p = 0.04). additionally, both neutrophil cd16-expression (-35%) and cd11bexpression (-61%) were significantly lower in those animals treated with ria compared with the conventional reaming condition. conclusions: this experimental study reveals that reamed irrigationaspiration (ria) prior to imn is associated with increased immune cell viability and less neutrophil senescence/activation in early fracture hematoma. this underlines the important role of imn in optimizing local cellular immune homeostasis during the formationphase of early fracture hematoma. introduction: the study and determination of the traumatic pattern in bicyclists-delivery employees. the recording of personal protective equipment and evaluation of the selection criteria of their self protection. materials and methods: a total of 22 patients (21 men and 1 woman) with mean age of 33.8 years (18 -52 years) were included over a study period from january 2017 to march 2019. twenty-one patients admitted to the hospital with a total of 26 injuries treated operatively, whereas 15 injuries were treated conservatively. we recorded and evaluated the use of adequate personal protective equipment of these delivery employees. results: the mean hospitalization time was 7.6 days (2-12 days) . a total of 2 thoracic injuries, 3 traumatic brain injuries, 6 spine injuries, 25 lower extremity injuries and 5 upper extremity injuries were recorded. surgical treatment concerned 3 patients with upper extremities and 18 patients with lower extremities injuries and the anatomic regions involved were the distal radius (3), pelvic ring injury (1), femoral fractures (6), tibial plateau fractures (4), patella fractures (2), diaphyseal tibial fractures (6), and ankle fractures (4) . conclusions: the lack of an adequate personal protective equipment due to their low financial status in combination with the absence of driving professional education among workers in this category of delivery employees results in lower extremity injuries with the majority requiring hospitalization and surgery. further investigation is needed, as well as constant training and setting right criteria for the pursuit of such employment. results: a total of nine rct's (462 patients) and the sixteen observational studies (4245 patients) were included. the pooled nonunion rate did not differ significantly between both treatment groups (risk difference: 0%; or 0.98, 95% ci 0.68-1.42). more patients treated with nailing required re-intervention (risk difference: 2%; or 2.11, 95% ci 1.09-4.08) with shoulder impingement being the most predominant indication. more patients treated with pate fixation developed radial nerve palsy compared to nailing (or 0.43, 95% ci 0.31-0.61). notably the absolute risk difference is small (2%) and during follow-up the palsy resolved spontaneously in the majority of patients. nailing lead to a faster time to union (mean difference: 2.5 week, 95% ci 3.1-1.8), lower infection rate (risk difference: 2%, or 0.48, 95% ci 0.31-0.75) and shorter operation duration (mean difference: 20 min, 95% ci 32.0-9.4). functional scores were comparable in both groups (standardised mean difference: -0.13, 95% ci -0.46 to 0.19). there was no difference between effect estimates form observational studies and rct's. conclusion: there appears to be no difference between plate fixation and nailing for humeral shaft fractures with regard to non-union rate and functional outcome. patients treated with plate fixation have a higher risk for infection and radial nerve palsy, but lower risk for reintervention. the absolute differences, however, are small. nailing does differ significantly from plate fixation in terms of shorter operation duration and time to union. the pooled estimates from randomised clinical trials did not differ significantly from estimates obtained from observational studies. post-traumatic complications are more often after medial clavicle injuries compared to lateral clavicle injuries introduction: medial clavicle injuries (mci) are widely unexplored, especially in contrast to lateral clavicle injuries (lci). current research concerning mci assumes a higher severity of mci, e.g. concerning concomitant injuries. our aim is to evaluate by big data analysis if these rare injuries would also lead to a higher number of post-traumatic complications. materials and methods: we focused on the mci subgroup consisting of medial clavicle fracture and sternoclavicular joint dislocation. the lateral clavicle fracture and the acromioclavicular joint dislocation were summarized to the subgroup of lci. the midshaft clavicle fracture was analyzed for comparison. the data are based on icd-10 codes of all german hospitals as provided by the german federal statistical office. anonymized patient data from 2012 to 2014 were evaluated. the retrospective analysis addresses the fracture healing in dislocation, delayed union and non-union. results: the proportion of all patients suffering from complications was 3.1%, which were attributed to one of the three post-traumatic complications. each complication rate for the single injury and the single complication was rather low with a maximum of 1%. mci were more likely to be affected by post-traumatic complications than lci with a ratio of 2.7 to 3.3 times (p \ 0.005). the midshaft clavicle fracture was similarly frequently affected by complications with 41.6% of all complications as the mci (44.2%). the lci accounted for the smallest proportion at 14.2%. conclusions: we proved that mci are more often associated with post-traumatic complications than injuries of the other parts of the clavicle. this is another hint that mci appear to be more complex than lci. this could be due to a missing standard procedure and the higher number of concomitant injuries in mci. further representative clinical studies are required since miscoding is a frequent issue in research concerning clavicle injuries, especially in a big data analysis. quantification of trauma center accessibility using gis-based technology introduction: there is no generally accepted methodology to asses trauma system access and optimal geographical trauma center distribution. the goal of this study is to determine the influence of trauma center(tc) distribution during high and low traffic density using geographical-information-system(gis)-technology. methods: using arcgis-pro, we calculated differences in transport time (tt) and population coverage in seven scenarios with 1, 2, or 3 tcs during rush [r]-and low traffic [l] hours in a densely-populated region with 3tcs in the netherlands (fig. 1) . results: in the seven scenarios, the population that could reach the nearest tc within (\) 45 min, varied between 96-99% ( fig. 2) in the three-tc-scenario, roughly 55% of the population could reach the nearest tc \ 15 min in [r] and [l] . the hypothetical scenarios with two geographically well-spread tcs showed similar results as the current three-tc-scenario. in the one-tc-scenarios, the population reaching the nearest tc \ 15 min decreased by 23-36% in both [r] and [l] compared to the three-tc-scenario. in the three-tcscenario the average tt increased with about 1.5 min to almost 21 min in [r] , in comparison to 19 min during [l] (fig. 3) . similar results were seen in the scenarios with two geographically well-spread tcs. in the one-tc-scenarios and the geographically close two-tcscenario the average tt increased by 5-8 min [l] and 7-9 min [r] in comparison to the three-tc-scenario. conclusion: this study shows that a gis-model for trauma center access offers a quantifiable and objective method to evaluate trauma system configuration in areas with different geography and demography. applying this technology to one of the most densely populated areas in the netherlands shows that the transport time from accident to trauma center would remain acceptable if the current situation with three trauma centers would be changed to a scenario with two geographically well-spread centers. classifying posttraumatic stress disorder courses in physical trauma patients: an observational prospective cohort study introduction: the aim was to identify different courses of posttraumatic stress disorder (ptsd) in physical trauma patients. then, to examine whether these classes could be characterized by sociodemographic, clinical, psychological, and personality outcomes. methods: patients completed the impact of event scale-revised (ies-r), m.i.n.i.-plus after inclusion, 3, 6, 9, and 12 months after injury to examine different courses. the hospital anxiety and depression scale, neo-five factor inventory, state-trait anxiety inventory-trait, and the whoqol-bref were completed after inclusion only. latent class analysis, chi square tests, and anova were performed to analyze the aims. results: in total, 267 patients were included. the mean age was 54.1 (sd = 16.1) and 62% were male patients. the ies-r (see figure 1 ) and the m.i.n.i-plus had five classes (1: moderately, 2: little bit, 3: worse, 4: none, 5: quite a bit of ptsd symptoms). patients in class 3 are diagnosed with ptsd (cut-off score c 33). on both questionnaires, patients (proportion & 11%) in class 3 or 5, scored higher on anxiety, depressive symptoms, neuroticism, and trait anxiety compared to the other classes over 12 months after trauma. lower scores on all domains, except for social domain on the ies-r, were found compared to the other classes (ies-r; physical domain: class 3 vs. 4 (mean ± sd): 10.4 ± 3.3 vs. 14.8 ± 2.4, p-value = \ 0.001). psychological and personality outcomes were significantly different on all courses. also, patients in class 3 or 5 were younger compared to the other classes (ies-r; class 3 vs. 4: 43.5 ± 15.4 vs. 59.1 ± 14.8, p-value = \ 0.001). no medical outcomes for ptsd were found. conclusions: about 11% suffer from ptsd symptoms 12 months after trauma. different courses were defined by sociodemographic, psychological, and personality characteristics. professionals can, short after trauma, recognize patients at risk for ptsd when they focus on these characteristics. then, an intervention can be offered. six meter, the criterion for severe adult trauma to falls from heights in cdc field triage needs to be lowered introduction: trauma is one of major public health care issue which is costly to society. differences vary from region to region, but blunt trauma accounts for a large part of the total trauma, and the rates of the falls from heights among the blunt trauma is getting higher. it is serious that falls from heights is often accompanied by severe multiple trauma. therefore, authors studied the relationship between the height of the fall/other related factors and outcomes including hospital stay/mortality. materials and methods: retrospective cohort study of the 670 adult falls-from-heights patients visited a regional trauma center for 4 years (from 2014.01.01 to 2017.12.31). results: of total 670 patients, the number of d.o.a patients were 69. the height from falls of the deceased patients was statistically significantly higher than that of the survived patients. (19.4 ± 15.3 m vs. 4.3 ± 4.2, p \ 0.001) the auc of the roc curve of the height from fall to mortality was 0.879. (figure) the sensitivity of 3.75 m was 90.7% and 6.5 m was 81.4%, respectively. the traumatic brain injury, pelvis fracture, visceral organ injury, age, and the height from fall were statistically significant risk factors in multivariate analysis for mortality (p = \ 0.001, 0.11, 0,001, 0.004, and 0.03 respectively). conclusions: the height from the fall is closely related with mortality. we think the current height for the severe fall injury in cdc field triage for trauma is high and needs to be lower to 3.5 introduction: operative management of severe trauma is a team effort, requiring excellent communication skills. surgeons, anesthesiologists and nurses need to coordinate effectively in order to ensure an excellent clinical outcome. the definitive surgical trauma care (dstc), definitive anesthesia trauma care (datc) and definitive perioperative nurses trauma care (dpntc) courses provide an excellent opportunity to train efficient teamwork. we aimed to study the impact of the joint dstc-datc-dpntc courses in candidates' perceptions and skills in perioperative communication. materials and methods: study population of 39 candidates (18 surgeons, 10 anesthesiologists and 11 nurses) participating in a joint dstc-datc-dpntc course in coimbra, portugal. median age of 32 years (range 27 -52). female gender in 26 (67%) of cases. all participants attended joint lectures, case discussions and surgical skills session, emphasizing intraoperative communication. postcourse survey on several aspects of peri-operative communication, with responses on a likert scale. participants were also asked which aspects of intraoperative communication they valued the most. statistical analysis with spps, 25.0 (wilcoxon signed rank test, significance with p-value \ 0.05). results: all participants responded to the survey. results displayed an increase in the self-assessed importance of team briefing and intraoperative communication, particularly routine periodic communication, rather than only at critical moments (p \ 0.05). postoperative team debriefing was also valued as highly relevant. closed-loop and direct, by-name communication were highly rated (p \ 0.001). self-reported communication skills improved significantly during the course (p \ 0.001). conclusions: joint training in the dstc-datc-dpntc courses provides a unique opportunity to improve candidates' self-awareness and skills in intraoperative communication. a public health approach to knife related trauma in liverpool: a geospatial study r. shellien 1 , n. misra 1,2 , j. germain 2 , m. whitfield 2 1 aintree university hospital, emergency general surgery and trauma unit, liverpool, united kingdom, 2 liverpool john moores university, public health institute, liverpool, united kingdom introduction: liverpool is a city that has undergone recent rapic socioeconomic change. despite reductions in overall deprivation, incidents of stabbings have increased by 64% in the last 7 years. this study will describe the trend in knife crime, drawing on governmental data and policies to conclude the reasons behind the trend. materials and methods: a retrospective cohort study of patients presenting to north-west ambulance service (nwas) with a penetrating injury in liverpool between 2012 and 2018. data collected included patient demographics, geography and timing of incidents and correlation to datasets of multiple indices of deprivation and knife crime prevention outreach education programmes. results: incidents of stabbings have increased by 64% between 2012 and 2018. victims were more likely to be males (82%) between the ages of 20 and 24 (13%). the peak rate was between 20:00-21:00 (7.9%) and trough between 08:00-09:00 (1.3%). there is a spike in incidents of stabbings of 15-19 year olds from 15:00 to 21:00, correlating with school closure. there appears to be statistically poor correlation between deprivation of lower super output areas and stabbings (r 2 = 0.11, 0.29 and 0.18 for 2010, 2015 and 2019 respectively). however, when the data is split into larger areas, middle super output areas (msoas), deprivation appears to be a further risk factor. this study has identified certain geographical areas as high risk. conclusions: this study allows for targeted public health interventions at populations most at risk of knife trauma, including geographical mapping of high-risk areas, so that interventions can be distributed appropriately. references: ministry of housing, communities and local government (2019 government ( , 2015 government ( , 2010 introduction: trauma teams treat complex patients with injuries posing significant resuscitative and management challenges. effective teamwork is essential to optimise patient outcomes and improve survival, with failure contributing to adverse events [1] . the role of multidisciplinary (mdt) trauma training has been demonstrated by the military operational surgical training course (most) [2] . it is imperative that civilian trauma training adopts similar methodology to optimise team work. materials and methods: the three-day multidisciplinary trauma course comprised cadaveric-based skills teaching supplemented by lectures and real-life scenario discussion. delegates were senior surgical and anaesthetic registrars and consultants, alongside trauma team leaders (ttl), scrub staff and operating department practitioners (odp). pre-and post-course questionnaires assessed perceptions of multidisciplinary trauma simulation and confidence in specialty specific skills. results: all delegates reported mdt simulation clarified each role, including their own, in the trauma team. post-course, scrub staff and odps felt confident gaining intraosseous access (p \ 0.0002), surgical delegates had improved confidence performing all skills (p \ 0.01), with anaesthetists and ttls more confident in haemorrhage control and performing resuscitative thoracotomy (p \ 0.02). conclusions: mdt trauma training improves team understanding of role and effectively teaches skills. mdt courses with experienced faculty are one way of improving mdt trauma team function. further careful evaluation is required to assess performance of trauma teams in real scenarios. introduction: despite a dramatic rise in youth knife crime, the factors associated with it remain underexplored, especially in the critical pre-college years, which hinders effective counter-knife carrying interventions. the current research is the first to addresses this deficit. materials and methods: 161 british male school students (mean age = 13.48, sd = 1.061) coming from four different schools completed a short 15-min survey. they indicated their standing on a number of dimensions (school-adapted and shortened-scale-based predictors) derived from theories of violence, developmental psychology and related research (i.e. violence acceptance, need for respect, belief in self-defence, belief in a just world, narcissism, psychopathy, impulsivity, sensation seeking, and need for closure). results: for perceived knife harmfulness (i.e., the knife's assumed value in inflicting injury and death)-the total variance explained by the model was 8.7%, r2 = 0.087; f(10, 167) = 2.585. the only statistically significant predictors were: right-wing authoritariamism (b = 0.242, p = 0.005) and need for respect (b = 0.192, p = 0.026). the other factors were not statistically significant. for the perceived value of knife defence (i.e., its assumed defensive worth in violent confrontations) -the total variance explained by the model was 26.5%, r2 = 0.265; f(10, 167) = 7.032, pviolence acceptance (b = 0.208, p = 0.007), followed by need for closure (b = 0.202, p = 0.005), narcissism (b = 0.194, p = 0.011) and psychopathy (b = 0.177, p = 0.034). conclusions: this study provides evidence for future knife-carrying prevention interventions, such as talks in schools or social media videos, to focus more on how to increase self-esteem, stimulate empathy for and better understanding of other people, and approach problems from multiple (rather than just two) perspectives, emphasizing the ultimate superiority of the human intellect over brute force. introduction: the physician's response unit (pru) is a novel service that operates from the royal gwent hospital's emergency department (ed), in newport, south wales. it involves an emergency medicine consultant and a paramedic responding to 999 calls in a rapid response vehicle. their aim is to treat and, hopefully, discharge patients at the scene, reducing ed admissions. the pru can also refer patients on to other departments, e.g. the medical assessment unit, allowing patients to bypass the ed. methods: the author spent six weeks out in the pru and in the ed to observe and speak to patients. to assess whether ed admissions were reduced, the dispositions of patients seen by the pru were recorded on a daily log sheet. the service users' satisfaction with the pru was evaluated using simple questionnaires. this included both patients and paramedics, who can request the pru for support with a patient. results: the pru saw 245 patients during the project's timeframe. 64% (n = 156) of these patients were discharged at scene, while 16% (n = 38) were sent to the ed. 100% (n = 32) of patients asked described the care they received from the pru as equal to or better than care they have received previously. 94% (n = 30) of patients rated their overall satisfaction with the pru as 10/10. conclusions: the pru is very well received by both patients and paramedics and has been shown to reduce the number of patients attending the ed. this system excellently implements the principles of prudent healthcare introduction: in germany reducing alcohol related harms in youth is still a priority, because adolescents and young adults still have the highest accident risk in road traffic. therefore, the p.a.r.t.y.-project aim to increase awareness of alcohol and risk-related issues. the purpose of this study was to analyse the risk behaviour of adolescents before and after a prevention project in two different hospitals in germany. materials and methods: during a one-day prevention project, young people within the age of 13 to 17 years got an overview of the route an accident victim go through from the ambulance until the rehabilitation. before and after the prevention day, a structured written survey was completed by the adolescents. results: 799 students participated in the p.a.r.t.y. program between 2013 and 2018. the gender distribution of the participating students were balanced. the average age of the adolescent was 15 years. according to the program, the risk assessment and risk behaviour improved through the project significantly (\ 0.05). the evaluation of the students' satisfaction was rated as good. the majority of students prefer to repeat the project day after 2 years. conclusions: the prevention program shows that the program increase for short-term the awareness for risk related trauma in youth. nevertheless, long-term studies are necessary to receive data regarding the long-lasting effect. references: the present study is funded by the ministry for energy, infrastructure and digitization of the country mecklenburg-vorpommern, germany. development of a claims-based risk adjustment model for trauma introduction: duodenal injury is rare. the diagnosis requires a high index of suspicion which might result in delayed treatment. there is limited data on the delayed diagnosis group, especially high grade duodenal injuries. the purpose of this study is to determine the characteristics and outcomes of delayed high grade duodenal injuries. materials and methods: charts of all patients from 2008-2018 who had history of small bowel injuries are reviewed. the inclusion criteria were age between 15-80 years old, diagnosis with duodenal injuries at least grade 3 with delayed operation at least 6 h after injuries. baseline characteristics and postoperative outcomes were recorded. results: of the 212 small bowel injuries, 32 (15%) were duodenal injuries. the overall mortality was 6%. delayed diagnosis more than 6 h with at least grade 3 of duodenal injuries were 9 cases. the overall in-hospital mortality rate of the delayed group was 22.2% (2/ 9) who had concomittent hemorrhagic shock and low initial systolic blood pressure. 4 cases (44.4%) were diagnosed within 72 h and had better outcomes without leakage. they could step diet within 14 days and had shorter length of hospital stay (mean = 18 days). 3 patients (33.3%) presented with delayed diagnosis more than 72 h (the maximum was 408 h after injuries). all these 3 patients had anastomosis leakage and need reoperation. they had initial low level of serum albumin (mean 2.5 mg/dl), high white blood cell count, low serum bicarbonate and presented with preoperative acute kidney injury. conclusions: delayed diagnosis and surgical treatment of high grade duodenal injuries lead to poor outcome. low initial blood pressure associated with mortality and delayed treatment more than 72 h had higher morbidity. references: gary sa, frederick am, charles sc, et al. delayed diagnosis of blunt duodenal injury: an avoidable complication. acs meeting. 1998; 187(4) :393-9. routine follow-up imaging has no advantage in the non-operative management of blunt splenic injury in adult patients modality. the aim of this study was to investigate the incidence and time to failure of nom as well as to evaluate the relevance of follow-up imaging. materials and methods: all adult patients with bsi admitted to our level i trauma center, including two associated hospitals, between 01/01/ 2010 and 31/12/2017 were retrospectively analyzed. demographic data, injury severity score, splenic injury grade, modality, results and consequences of follow-up imaging were retrospectively analyzed. results: a total of 122 patients with a mean age of 43.8 ± 20.7 years (16-84 years) met inclusion criteria. 20 patients (16.4%) underwent immediate intervention. 102 patients (83.6%) were treated by nom. failure of nom occurred in 4 patients (3.9%). failure was significantly associated with active bleeding (or 33.75, 95% ci 3.1, 363.2, p = 0.004) , and liver cirrhosis (or 197, 95% ci 7.4, 5265.1, p = 0.001) . 80 patients (78.4%) in the nom-group received followup imaging by ultrasound (us, n = 51) or computed tomography (ct, n = 29). in 57 cases, routine imaging examinations were conducted (43 us and 14 ct scans) without prior clinical deterioration. 55 (96.4%) of these imaging results revealed no new significant findings. every failure of nom was detected following clinical deterioration. conclusions: to our knowledge this study includes the largest monocentric patient cohort undergoing ultrasound as first-line followup imaging modality in the nom setting of bsi in adult patients. the results indicate that a routine follow-up imaging, regardless of the modality, has no therapeutic advantage. indication for radiological follow-up should be based on clinical findings. if indicated, a ct scan should be used as preferred imaging modality. the association between bmi and mortality of renal injuries in adult trauma patients introduction: the role of body mass index (bmi) on solid organ injuries remains debatable. while some studies have shown no association between bmi and hepatic or splenic injuries, others have reported that severe hepatic injuries were more common in pediatric patients with bmi [ 30. the aim of this study is to examine the association of bmi and mortality, as well as any significant differences between operative vs. non-operative management. materials and methods: this was a retrospective study using the 2016 american college of surgeons-trauma quality improvement program database to identify all adult patients (ages 18 to \ 65) with traumatic renal injuries. the primary analysis showed a different pattern of mortality between patients with bmi \ 29 and those with bmi c 29 kg/m 2 . then, the study population was divided into patients with bmi \ 29 and those with bmi c 29 kg/m 2 . multivariable logistic regression was conducted to assess any association of mortality with age, gender, bmi, and injury severity score (iss). results: 3782 adult trauma patients were identified. a greater proportion of males (75.2%) and females (24.8%) had bmi \ 29 kg/m 2 (p = 0.5). the average age of patients with bmi \ 29 kg/m 2 was 32.3 (sd = 12.7) years which was significantly younger than that in patients with bmi c 29 kg/m 2 , 37.8 (sd = 13.6) years (p = 0.001). patients with bmi \ 29 kg/m 2 were found to have a significantly higher mortality rate of 6.5% vs. 4.4% in patients with bmi c 29 kg/m 2 (p = 0.02). however, there was no significant difference in type of operative or nonoperative management between patients with bmi \ 29 vs. bmi c 29 kg/m 2 . after multivariable logistic regression, mortality was associated with age, bmi and iss. no effect modification of sex was observed in the relationship of mortality and bmi. conclusions: adult patients with renal injuries and bmi \ 29 kg/m 2 have significantly higher rates of mortality compared with adult patients with renal injuries and bmi c 29 kg/m 2 . introduction: trauma is an ever-evolving surgical discipline. trauma remains a major source of global mortality. the operative and non-operative options for trauma patients has steadily increased. the development of trauma protocols, advancement in transport to trauma centres and radiological techniques has seen a shift in trauma surgery caseload. observing and understanding this shift from operative management to an increasing non-operative management of trauma cases will better prepare the acute medical team in this setting. materials and methods: prospective trauma registry data was collected and analysed retrospectively. patients presenting to a tertiary referral hospital between jan 2011 to dec 2015 with an injury severity score of [ 15 were reviewed. patients who were transferred to another facility for management were excluded. the demographic data and surgical outcome data were collected and analysed. trend analysis of the operative cases performed for each specialty. results: 2162 major trauma patients presented to the john hunter hospital between january 2011 to dec 2015. there was a non-statistically significant increase in the number of presentations (389 pt in 2011 vs 494 in 2015, p = 0.1625). there was a decreasing rate of operations performed for trauma patients (60% in 2011 vs 43% in 2015, p \ 0.0001). there was an increasing rate of orthopaedic surgery cases and operative time compared to other specialties (178 in 2011 vs 246 in 2015, p \ 0.001). general surgical major trauma operating cases noted a significant decline over the study time (82 in 2011 vs 33 in 2015, p \ 0.001). conclusions: there is a sizeable shift in the caseload of different surgical specialties in regard to major trauma patients over the course of 5 years from 2011 to 2015. orthopaedics has seen a significant increase in operative caseload and surgical time required to adequately manage major trauma presentations. the workload and experience of general surgical teams will likely be affected by these changes. the distribution of resources needs to be reflected in the changing work demands of each surgical subspecialty. traumatic internal hernia with delayed small bowel strangulation after pelvic ring injury hospitalization, follow up abdomen ct checked. there was no other specific change than increased thigh hematoma. eight days after hospitalization, ct was re-examined due to abdominal pain with abdominal distraction. an ct showed peritonitis with pneumoperitoneum and small amount of ascites. small bowel herniation through right pubic bone fracture site with ischemic change also noted. diagnosis: diagnosis was traumatic pelvic hernia with delayed small bowel strangulation. therapy and progressions: an emergency operation was performed. ileal loop was hernitated and perforation was found. emphysematouns change and fluid collection was exsited at perineal area and left high. after small bowel loop segmental resection, wound vac was applied at thigh area. comments: traumatic pelvic hernia is rare. diagnosis is challenging in the acute setting and often delayed due to lack of awareness. when diagnosed, efforts should be made to look for other serious injuries as traumatic pelvic hernia usually associated with concomitant intraabdominal injuries. the optimal management of traumatic hernia should be individualised based on the mechanism and severity of injury, presence of concomitant injuries, size of defect, and presence of incarceration. delayed treatment may read to fatal outcomes. careful inspection of the patient is important. references: vincent k, cheah sd. traumatic abdominal wall hernia-a case of handlebar hernia. med j malaysia. 2018;73(6):425-6. angio-embolization in pediatric trauma patients with blunt splenic injury: a systematicreview t. nijdam 1 , r. spijkerman 1 , l. hesselink 1 , t. hardcastle 2 , l. leenen 1 , f. hietbrink 1 1 umc utrecht, traumasurgery, utrecht, netherlands, 2 inkosi albert luthuli central hospital, trauma, durban, south africa introduction: non-operative management (nom) for children with blunt splenic injury (bsi) is nowadays a commonly used treatment in pediatric trauma departments. in adult trauma departments the addition of splenic angio-embolization (sae) is suggested to decrease the failure rate of nom in high grade splenic injuries. however, the use of sae in pediatric trauma departments is very uncommon and it is unknown if sae is of additional value in pediatric trauma patients. therefore, the aim was to analyze the available literature on sae in pediatric trauma patients with bsi. materials and methods: a literature search was performed to find eligible studies that analyzed sae in pediatric patients with bsi. the primary outcome was failure of treatment in these patients. secondary outcomes were the success rate of sae, length of stay and mortality. the relative risk (rr) was calculated to compare primary outcome between study groups. results: in total 219 studies were identified through the search, a total of 6 studies matched our inclusion criteria and were selected for this review. studies included a total of 12.310 pediatric patients, of whom 539 underwent sae. patient age ranged from &lt;1 year to 18 years, mean age was 12.1 years. both injury severity score and spleen injury grade were higher in the sae group compared to the nom group. failure rate of sae was 8%. no spleen related morality was observed in the sae group. conclusions: the literature suggests that sae might be of added value in a very selective group of pediatric trauma patients with high grade splenic injures. however, since limited evidence is available concerning the use of sae in pediatric trauma patients with bsi, no firm conclusions can be drawn about safety and effectiveness. introduction: the management algorithms for trauma have changed with the development of specialised trauma centres. the aim of this study was to review the management and outcomes of patients with traumatic small bowel (sb) and colonic injuries. material and methods: patients treated for sb and colonic injuries between 2008-2018 at aintree university hospital (liverpool) were identified using the prospective trauma audit and research network database. the management and outcomes of the patients included were analysed. results: 44 patients sustained sb and colonic injuries. there were 29 (65.91%) sb injuries and 21 (47.73%) colonic injuries (6 patients had a sb and colonic injury). 17 patients (38.64%) of injuries were due to knife stabbing wounds, 14 (31.82%) patients were due to gunshot wounds, and 13 (29.55%) patients were due to road traffic accidents/ blunt blows. damage control surgery was performed in 7 (15.91%) patients. colonic injuries included 6 (28.57%) haematomas and 15 (71.43%) perforations. a resection and stoma (rs) procedure was performed in 9 patients (42.86%), primary repair (pr) in 8 patients (38.10%) and resection with anastomosis (ra) in 4 patients (19.05%). sb injuries included 6 (20.69%) haematomas and 23 (79.31%) perforations. pr was performed in 19 (65.52%) cases and ra in 10 (34.48%) cases. the overall complication rate after sb and colonic injury was 50% (22 patients) with a significant complication rate (7 patients, p value = 0.017) for patients undergoing rs in colonic trauma. the 30-day mortality rate was 2.27% (1 patient). conclusions: pr in sb and colonic injuries appears safe. in our dataset, rs appeared to have a higher complication rate. our study highlights that such injuries are uncommon with a high complication rate. surgeons need to provide individualised treatment. introduction: nowadays, patients with high grade bsi are preferably treated using spleen preserving treatments (spt). it is assumed that patients with low grade bsi treated with spt have a good splenic function after recovery. however, there is no consensus on splenic function after high grade bsi. in several institutions, asplenic/hyposplenic infection prevention protocol will be executed in all patients who had spt after high grade bsi, where other institutions evaluate splenic function first. scintigraphy is believed to be the best flow/activity test to approximate splenic functionality. the aim of the study was to analyze whether spleen injury grade is associated with diminished splenic function. secondarily, we aimed to evaluate whether splenic function testing is necessary in pediatric patients after bsi. material and methods: a retrospective study was performed from january 1998 to january 2018. in our institution patients with bsi grade iv of v are assumed hyposplenic and will receive a splenic function test. we included all patients with a minimum follow-up test period of 5 days. all tests were analyzed by the radiology specialist. for each patient we furthermore collected clinical data, including the date of trauma, gender, age, mechanism of injury, ais of splenic injury and iss. results: 33 patients consisted of 23 male and 10 female, with a median (iqr) age of 11.8 (7. 3-13.5) . median iss was 16.0 (13-30.5) and the median spleen ais was 4 (3) (4) . nom was used in 26 patients, sae in five patients and two patients were treated with surgical mesh technique. the median follow-up time of all performed tests was 59 (22-75) days. a total of 20 patients (61%) had a grade iv or v splenic injury. scintigraphy was utilized to test most patients. a total of 32 out of 33 patients had an adequate splenic function, including all sae patients. conclusions: even high grade splenic injuries show adequate splenic function in the follow-up of pediatric trauma patients after bsi. therefore routine diagnostic follow-up by scintigraphy is not necessary in this specific patient group. evaluation of abdominal injuries treated at stavanger university hospital: occurrence, severity and mortality j. w. larsen 1 , k. søreide 1,2 , j. a. søreide 1,2 , k. tjosevik 1 , k. material and methods: retrospective evaluation of data recorded prospectively in the hospital's trauma registry between january 2004 and december 2018. patients with abbreviated injury scale (ais) code for abdominal injury were included. descriptive analyzes are presented for demographic data, injury type, mechanism, and severity, as well as 30-days mortality. results: a total of 449 patients with abdominal injuries were included (6.2% of all trauma patients). 70% where men. median age was 31. the injury mechanism was blunt in 91%. transport accidents were the most frequent cause of injury (57%). median iss was 21, and median niss 25. overall 30-days mortality was 12.5%, with a median trauma injury severity score (triss) of 0,07. multiple abdominal injuries were recorded in 44% of the patients. 86% had associated injuries in other body regions, most frequently in the thoracic region (65.5%). solid organ injury occurred in 83% of the patients, with liver injury (38%), splenic injury (33%), and kidney injury (23%) encountered most frequently. an ais score c 3 was found in 56% of liver injuries, 65% of splenic injuries, and in 43% of patients with kidney injuries. hollow viscus injuries were found in 20% of the patients. injuries to the small intestine (8%) and colon (6%) were most frequent. abdominal vessel injuries were encountered in 15%, and 94% of these had an ais score c 3. conclusions: abdominal injuries are dominated by solid organ injuries following blunt injury mechanism and are often associated with concomitant thoracic injury. patients who dies within 30 days from admission are characterized by a low probability of survival shown by triss. pancreatic trauma management in a third level centre a. gonzález-costa 1 , r. gracia-roman 1 , s. montmany-vioque 2 , a. campos-serra 1 , r. lobato-gil 1 , c. zerpa-martin 1 , f. j. garcía-borobia 3 , p. rebasa-cladera 2 , s. navarro-soto 2 management. the aim of the study is to review the management and describe the most frequent complications of pancreatic trauma in our centre. material and methods: observational study with prospective collection of data, from march 2006 to march 2019. inclusion criteria: trauma patients older than 16 admitted to the emergency department who were admitted to icu or died before admission. demographic data has been collected, also vital signs, iss, mechanism of action, mortality, complications, and lesions. results: between 2006 and 2019, 1798 polytraumatic patients were registered. only 17 had pancreatic trauma (0.95%). the male: female ratio was 11:6; with an average age of 47.7 years (sd 13.4) . mean iss of 24.5 (sd 15.1), mean ais of 2.1 (sd 0.97) and mortality of 23.5% (4 patients). the most frequent pancreatic lesion was at the head of the pancreas (9 patients; 52.9%), followed by body-tail (6 patients; 35.3%) and two patients with full section (11.7%). 64.7% of patients were treated with non-operative management. five patients required urgent surgery (29%), requiring corporocaudal pancreatectomy in 2 cases and drainage in 3 patients. an embolization of a gastroduodenal artery aneurysm was performed in 1 patient. respiratory complications were the most frequent. 4 patients developed a pancreatic fistula (23.5%), although in surgical patients this complication was much higher (60% in our series). one of them required puestow pancreaticojejunostomy and 1 patient developed necrotizing pancreatitis (5.8%). conclusions: pancreatic trauma is very uncommon. its management can be difficult, depending on the degree of injury (aast), with a high rate of complications. therefore, combined management and monitoring by the surgery and intensive care team will be very important. introduction: the aim of this retrospective study was to evaluate and compare the clinical outcomes of conservative versus surgical treatment in a series of patients with liver injury. material and methods: between 2005-2017, there were included 128 patients. according the treatment chosen, the patients were subdivided in two groups. non-operative management was considered in hemodynamically stable patients. the failure of conservative treatment was defined as need to resort to operative management after a period of strict monitoring when the reason was related to the liver or associated injuries or need for late angioembolization. all hemodynamically unstable patients were subjected surgical treatment. results: conservative treatment was selected for 101 patients and only in 8 of them was failed due to associated delayed bleeding and small bowel injury. 27 patients underwent emergent surgery which included packing, lobectomy and splenectomy. operative findings revealed grade iii liver injuries in 71% and grade iv in 28%. pneumonia, sepsis and ards were the most frequently associated complications. the overall mortality rate was 8.6%. in 19 patients of conservative group, non-surgical treatment failed with surgery being required. the mortality in the group of patients who underwent emergent laparotomy on admission was of 6 patients. conclusions: conservative treatment of blunt traumatic hepatic injuries is applicable in patients presenting hemodynamic stability with mild hepatic injuries and it could be successful even in high graded injuries with low morbidity and mortality. surgical treatment is indicated in grade v injuries. nevertheless, failure of conservative treatment does not necessarily lead to an increase in the incidence of complications or mortality. with the trend towards more conservative management strategies, surgeons' exposure to laparotomies for blunt injuries in rtas has decreased. the aim of this study was to examine surgeons' exposure to laparotomies following blunt trauma which remains important to maintain low patient morbidity and mortality rates. material and methods: data was collected for adult patients admitted to mater dei hospital (malta) following rtas with ctproven intrabdominal injuries between january 2008 and january 2018. results: 114 patients (74 (64.91%) males vs. 40 (35.09%) female (p value \ 0.05), mean age = 36.66 years) were included in the study. 88 patients (77.19%) were car occupants whilst 26 patients (22.81%) were pedestrians. 94 (82.46%) patients had single intraabdominal organ injury, whilst 20 (17.54%) had multiple intraabdominal organ injuries. the 30-day mortality rate was 11.40% (13 patients). liver injuries occurred in 57 (42.54%) patients, splenic injuries occurred in 50 (37.31%) patients, kidney injuries in 18 (13.41%) patients and other organs were injured in 9 (6.72%) patients. conservative management was followed in 81 (71.05%) patients, angioembolisation was utilised in 12 (10.53%) patients and operative management was performed in 19 (16.67%) patients during the 10-year period. this resulted in 2 trauma laparotomies following rtas per year. conclusions: only a minority of patients require operative management after rtas. surgeons in small countries have limited exposure to complex rta's. in view of the low exposure to emergency laparotomies following rtas, changes to our local training programme was done. trauma courses, lectures and fellowships in eu have been implemented to maintain surgical skills to an optimal level. references: european commission, annual accident report. european commission, directorate general for transport june 2017. case history: a 61 year old female presented to the accident and emergency department 10 h post colonoscopy with complaints of left sided abdominal pain. this colonoscopy was requested under a 2-week wait for a history of chronic diarrhoea. this was a complete and uneventful examination ath the time, with random colonic and ileal biopsies taken. she attended a ? e with left sided abdominal pain increasing in severity. clinical findings: she was found to have an exquisitely tender abdomen, experienced more in the left upper quadrant. she was clinically shocked with a marked hypotension and tachycardia. investigation/results: a ct of her abdomen and pelvis showed free fluid within the abdomen and pelvis, with active bleeding and large haematoma adjacent to the spleen. the grade of splenic injury however was not commented upon by the reporting radiologist. interventional radiological embolism was considered but unfeasible as patient not stable haemodynamically. diagnosis: she was diagnosed with a splenic injury post-colonoscopy, with internal bleeding and haemodynamic instability. therapy and progressions: she underwent an emergency splenectomy overnight and was transferred to the intensive care unit for postoperative care. she recovered well, was stepped down to ward level care and was discharged with post splenectomy protocols, including all necessary vaccinations. comments: splenic rupture post-colonoscopy is a very rare event, with less than 115 cases reported worldwide since 1974. however, it still should be considered as a cause of a ? e presentation in patients with upper abdominal pain and haemodynamic instability after recent colonoscopy. we wanted to present this rare case to the international audience of estes congress to raise awareness of this rare complication. clinical findings: hemorrhagic shock and consciousness disorder were observed. her abdomen was distended, and she was intubated in the emergency room. investigation/results: ct revealed massive intra-abdominal bleeding. diagnosis: massive intra-abdominal bleeding due to hepatic laceration. therapy and progression: damage control surgery (dcs) and transcatheter arterial embolization (tae) were performed. she was transported to a hybrid operating room. she experienced cardiac arrest before operation. cardiopulmonary resuscitation was immediately initiated, resulting in the return of spontaneous circulation. laparotomy with perihepatic packing (php) was performed, but she experienced two more episodes of cardiac arrest during operation. then, tae was performed for right hepatic artery extravasation. after physiological function restoration, including rewarming, coagulopathy correction and hemodynamic stabilization in the intensive care unit. she gradually became hemodynamically stable. however, incomplete hemostasis was obtained at second-look laparotomy 18 h later. because of bleeding, we repeated php. we performed cholecystectomy and abdominal closure after confirming complete hemostasis (46 h post-accident). she was discharged ambulatory without neurological deficit (day 82). comments: prognosis of traumatic cardiac arrest is generally poor, and survival without considerable neurological deficit is very rare. we reported a surviving patient with severe hepatic laceration. sharing of strategies and tactics, such as blood transfusion, tae, trauma team approach to surgery, early decision of dcs improves outcome of patients with severe abdominal trauma. references: resuscitation. 2010;10:1400-33. introduction: the spleen is the most commonly injured organ after blunt trauma. non operative treatment (nom) of splenic injuries has gained wide acceptance. transcatheter embolization of the splenic artery is considered a useful adjunct in aast lesions c 3 without active bleeding. we report a retrospective review of all patients admitted to a level 1 trauma center with blunt splenic injury from 2012 to 2019 and compare their treatment and outcome with a previous series from 2007 to 2011, when angioembolization was performed only in case of contrast blush at ct scan. patients and results: from 2012 to june 2019, 59 patients with blunt splenic injuries were admitted to the ed of a level 1 university hospital in milan, italy. men to female ratio was 5:1,the mean age 44.9 ± 20 years (range 16-90), and the iss 22 ± 11.5(range 2-57). eight patients (13.6%) underwent emergent splenectomy due to hemodynamic instability. of the 51 stable patients treated with nom, those with aast lesions c 3 (n = 25) were submitted also to angiography and 23 to embolization of the spleen (45%), either proximally (12) or distally (11). two nom failed, and the patients were submitted to splenectomy or distal embolization. the median hospital stay was 13.1 ± 11.5 days. the total spleen salvage rate was 96%. no associated abdominal injuries were missed in the nom group. in the previous series of 31 patients (mean age 34.7 ± 15.4 years, range 17-88, #:$ = 7:1, iss 18 ± 7, range 4-38), 4 underwent emergency splenectomy (13%), and 27 (87%) were treated conservatively, with only 7 embolization (25,9%) in case of aast c 3 at ct scan. failure of nom were 2, and the spleen salvage rate 80.6%. liver injury following multiple cardiopulmonary resuscitations case history: this is a case of a 44 year old woman who presented to the emergency department (ed) due to worsening dyspnea complicated by two lengthy cardiac arrests. after the first resuscitation and return to spontaneous circulation (rosc), echocardiography was done and showed severely dilated right ventricle with strain, suggestive of massive pulmonary embolism, for which rtpa was given. arrest occurred again, and post rosc, heparin was started and the patient was transferred to the icu. extracorporeal membrane oxygenation (ecmo) was initiated but complicated by severe hemodynamic instability and a third cardiac arrest, so cardiopulmonary resuscitation (cpr) was performed till rosc and massive transfusion protocol was started for suspected intraperitoneal bleeding. clinical findings: after ecmo cannulation, abdominal distention was noted with a severe drop in hemoglobin and an increased intraabdominal pressure (25 mmhg). abdominal bedside ultrasound showed significant amount of dense free fluid. the decision for an urgent exploratory laparotomy was made and the patient was taken to the operating room. therapy and progressions: deep liver laceration over the right hepatic dome with rupture of the capsule and an estimated hemoperitoneum of 3 l were found intra-op. controlling the bleeding was difficult due to the laceration site and the patients coagulopathic status, so packing was done and the patient was transferred to icu for correction of the coagulopathy and re-evaluation in 48 h. the liver was unpacked after 48 h, bleeding sites were cauterized and sutured and the liver was wrapped with a mesh with an attempt for a tamponade effect. the patient's stay in icu was complicated with kidney injury requiring chronic dialysis but otherwise recovered well. comments: liver injury is a rare but serious complication after cpr that should be considered in case of persistent hemodynamic instability along with bedside findings. this case is intriguing due to the right sided liver injury with no overlying rib fractures. blunt renal trauma after electrical injury: a series of curious events. a. nixon 1 , e. falidas 1 , d. davris 1 , a. botou 1 , g. sofos 1 1 chalkida general hospital, department of surgery, chalkida, greece case history: a 25 yr old patient was referred to the emergency department (ed) of our hospital from a primary health center after sustaining an electrical injury (220 v ac). the patient experienced loss of consciousness (loc) and promptly fell to the ground in a supine position. the patient arrived approximately 3 h after the incident. clinical findings: vital signs: bp: 90/45 mmhg, hr: 110 bpm. the patient's major complaint was left flank and abdominal pain. no obvious thermal injuries were observed or any other signs of external trauma. a left abdominal mass developed which was evident on physical examination. in addition, examination of urine revealed gross hematuria. investigation/results: ekg monitoring documented sinus tachycardia without evidence of cardiac arrhythmias. fast indicated the presence of a massive retroperitoneal hematoma. the fast exam indicated the left kidney as the probable source of hemorrhage. the initial hematocrit (hct) from the primary health facility was 44% while results from the ed recorded a hct of 22%. diagnosis: grade v renal trauma. therapy and progressions: a massive transfusion protocol was initiated. the patient underwent an emergency laparotomy and a left nephrectomy was performed. subsequent imaging did not reveal other injures. comments: the history of electrical injury could have misdirected investigation efforts towards cardiogenic shock. this case suggests that even in the absence of a high energy impact, sustained hemodynamic instability should always be attributed to hemorrhagic shock until disproven. in addition, the management of grade v renal trauma in blunt injury remains a controversial topic, however we believe that in cases of class iv shock, surgical management is imperative. case history: 56 y.o. female with a history of chagas' disease of 30 years duration and esophageal involvement in the last few months. she's admitted for a first endoscopic balloon dilatation due to dysphagia, which is performed according to protocol, and a tear of the mucosa layer is observed during it. clinical findings: she's stable for the first 36 h but with continuous thoracic pain of moderate intensity according to the gi specialist. on the second day there's a general worsening of the patient's condition, with dyspnea, fever, desaturation and tachycardia. results and diagnosis: she develops leukopenia and elevations of acute phase reactants, and a ct scan reports a distal esophageal perforation with free extravasation of contrast in the mediastinum and bilateral pleural effusions. therapy and progressions: emergency surgery is performed through a midline supraumbilical laparotomy which shows peritonitis around the epigastric area. after opening the hiatus, a very long transmural esophageal tear with devitalized tissues and severe contamination are observed. a trans-hiatal esophagectomy was decided and, given the hemodynamic stability, a gastroplasty is performed and brought up to the neck without anastomosis, along with a terminal cervical esophagostomy and feeding jejunostomy. the patient did well in the postop period. we were able to do the esophagogastric anastomosis in the neck 14 days later, during the same admission. comments: the surgical technique in esophageal perforation depends mainly on the time elapsed since the perforation, and on the condition of the patient. esophagectomy is sometimes unavoidable, and a gastroplasty can be brought up to the neck at the same time in selected cases, with reconstruction of the upper gi tract during the same admission. introduction: the spleen is one of the most frequently injured abdominal organ. the anatomy of the lesion defines the degree according to aast, ranging from grade i to v in increasing complexity. the diagnosis of splenic trauma may be difficult, as 40% of patients may show no signs or symptoms at primary survey. the approach involves two main strategies: conservative or surgical. the strategy should take into account four aspects: hemodynamic status, anatomy of the lesion, associated injuries and organizational structures of the evaluation site. this study aims to evaluate the type of approach performed on different degrees of splenic trauma during 7 years in a portuguese trauma center. material and methods: we conducted a retrospective study including all patients diagnosed with splenic trauma during a period of seven years. by consulting the patient's clinical files we evaluated and compared: demographic data, trauma kinetics, degree of splenic injury and the approach taken as well as morbidity and mortality. results: of the 119 patients studied, most were male with blunt trauma. in 58 patients the inicial approach was surgery and in 61 the option was conservative treatment. in grade iii or iv lesions conservative treatment failed in 16% of patients. patients in whom the surgical approach was first chosen had predominantly grade iv lesions, with total splenectomy being the preferred approach. in grade iii lesions, the option was mainly conservative surgery of the spleen. conclusions: the initial approach of splenic trauma results essentially of the experience of emergency teams and support structures for surveillance and intervention (intervention radiology and 24-h operating room availability). the attempt to try conservative strategy is increasing over time. introduction: for decades, helicopter emergency medical services (hems) contribute greatly to prehospital trauma patient's care by performing advanced medical interventions on scene. unnecessary dispatches, resulting in cancellations, cause these vital resources to be temporarily unavailable. these cancellations contribute to overtriage and provide additional costs to society. an earlier study showed a cancellation rate of 44% in our trauma region. however, little empirical knowledge exists about reasons for cancellations for different mechanisms of injury (moi) and type of dispatch. this study aims to examine the current cancellation rate in our trauma region over a 6-year period. additionally, insights in cancellation reasons for different moi and type of dispatch are evaluated. methods: a retrospective study was performed, using data derived from the hems database of trauma region north west netherlands, between april 1st 2013 and april 1st 2019. information regarding patient's characteristics, date and time of day, moi, type of dispatch, and cancellation reason were compared. results: in total, 18,639 patients were included. hems was cancelled in 54.5% of dispatches. the majority of dispatches (76.1%) were cancelled because the patient was physiologic-and neurologically stable. dispatches simultaneously activated with ems were cancelled 58.3% of times, compared to 15.1% when hems assistance was additionally requested by ems on scene. no differences were found between dayand night-time dispatches. trauma related dispatches were cancelled more frequently compared to non-trauma related dispatches. conclusions: this study found a considerable-and increased cancellation rate compared to previous research. an explanation for this finding could be better adherence to dispatch protocols. furthermore, a great variety in cancellation rates was found among different moi's. therefore, continuous critical evaluation of hems triage is important and dispatch criteria should be adjusted if necessary. case history: two separate cases of high speed road traffic collision. the first is 31 years old female without significant past medical history. the second is 28 years old male who had short extremitis due to history of spastic quadriplegic cerebral palsy alongside congenital kyphosis and postural scoliosis. clinical findings: on examination the first patient was hemodynamically stable with soft abdomen and bruising over the left pelvic area. the second patient had left side neck and right side chest bruises; furthermore, he was tachycardic with normal blood pressure, but he was generally pale, getting clammy and significantly sweaty. investigation/results: fast scan for both patients showed free fluid in the abdomen and ct scan was uncertain of the source in the first patient. in the second, a large mesenteric haematoma was evident on ct with contrast extravasation with corresponding significant drop in hemoglobin and raised lactate levels. diagnosis: case 1: hemodynamically stable blunt abdominal trauma. case 2: hemodynamically unstable blunt abdominal trauma. therapy and progressions: the first patient was managed conservatively initially but worsened overnight with a drop in haemoglobin and increase in lactate mandating emergency laparotomy. hemoperitoneum and 60 cm of ischaemic bowel with tear in the mesentery was found. she had an uneventful recovery after resection and primary anastomosis. the second patient underwent immediate emergency laparotomy. there was evidence of hemoperitoneum (3 l) and similar mesenteric tear with ischemia involving 50 cm of the terminal ileum. resection with end to end anastomosis was done. patient was then transferred to itu; however, he developed chest infection which prolonged hospital stay. comments: hemodynamic instability is a major factor in mandating urgent exploratory laparotomy in bat and bucket-handle injury is not uncommon following road traffic accidents. introduction: incisional hernias are one of the most common complications post-abdominal surgery, affecting between 10-25% of patients undergoing a laparotomy. a number of risk factors are associated with their development such as age, bmi, type of surgery and co-morbidities. these risk factors also affect their levels of recurrence which is why the technique undertaken to repair these is of such interest. the primary purpose of this meta-analysis was to examine which repair technique is associated with the lowest level of recurrence whilst a secondary aim was to examine whether the frequency of common complications was dependent on the type of repair utilised. material and methods: this systematic review and meta-analysis was conducted by both co-authors. the following information sources were utilised; cochrane/embase/google scholar/pubmed/scopus. in relation to the eligibility criteria-papers that were published from 1990 onwards and in the english language were included with any length of follow-up. study selection was as per the inclusion/exclusion criteria below and only cohort studies/rcts/systematic reviews/ meta-analyses and case control studies were included. inclusion criteria: abdominal incisional hernias, all types of repairmesh/open/laparoscopic/sutured repair/primary repair etc. in terms of the exclusion criteria-any hernia repair that was not incisional was excluded. results and conclusions: in terms of the primary question posed by this repair, meta-analysis shows that there is a significant difference between open vs laparoscopic technique and recurrence rates in relation to the primary question posed by this paper whilst the use of mesh impacts negatively on post-operative wound infection rates. this invites an interesting debate on the merits of each technique whilst demonstrating the need for a multicentre randomised controlled trial. laparoscopic approach in penetrating abdominal trauma: case study and review of the literature b. vieira 1 , v. taranu 1 , a. silva 1 , d. galvão 1 , a. soares 1 1 hospital de santo espírito da ilha terceira, general surgery, angra do heroísmo, portugal introduction: laparoscopy(ls) has greatly improved surgical outcomes in many elective abdominal procedures. the use of ls in acute care is becoming widely accepted. however, a number of safety issues have limited its application in abdominal trauma. notwithstanding with the reports and studies of the past decade proving its safety and accuracy, ls is slowly replacing the need for exploratory laparotomies. case report: a 34 yo male sustained with penetrating stab wound on the left flank. he was hemodynamically stable. ct confirmed intraperitoneal positioning of the knife, without free fluid or air nor any evidence of organ injury. an exploratory ls was performed and confirmed the intraperitoneal positioning of the knife. abdominal exploration revealed a jejunal transfixating lesion about 1 m from treiz's angle that was manually closed. the patient maintained a favorable po evolution and was discharged on the 4thpo day. discussion/conclusion: a number of concerns have limited the use of ls in abdominal penetrating trauma. initially, it resulted in high rates of missed injury, mainly of the small bowel, generating considerable criticism. the development of systematic abdominal explorations in ls, as described by choi and kawahara, resulted in a rate of missed injuries close to zero. moreover, direct visualization using ls has shown superior specificity and sensitivity in identifying peritoneal penetration, hollow viscus injuries and diaphragmatic lesions when compared to ct. in the case reported here, ct didn't show any image suspected of perfuration such as free air or fluid, and yet ls showed a small bowell injury. besides its advantages as a diagnostic tool avoiding negative laparotomies in more than 50% of the cases, thanks to evolving techniques and improved practice, it may also be therapeutic and allow safe definitive treatment for many types of injuries as described here. method: this is a monocentric retrospective study from a database entered prospectively. all patients admitted to the university hospital in nice with splenic trauma between 01/01/2006 and 01/06/2018 were included. the primary endpoint was performing splenectomy as a failure of a nom. results: 290 patients were included in our study. the majority of splenic lesions were severe grades, that is to say greater than 3. in total, 83 splenectomies were performed urgently, i.e. 29% of patients; 88 angio-embolizations were performed, i.e. 31% of patients with a success rate greater than 80%; 14.7% of 136 patients who had not anterior angio-embolization required secondary splenectomy; 19.7% of the 61 patients who had anterior angio-embolization required secondary splenectomy. in the patient group with successful angio-embolization, the mean age was 44 years vs 37.5 years in the nom failure group (p = 0.15). a decrease in hemoglobin between admission and 6 h after admission was found in the nom failure group compared with the successful embolization group (p = 0.064). conclusion: hemoglobin monitoring in the hours following admission of a patient with splenic trauma may be an important factor in the surveillance of hemodynamically stable patients. prospective studies could confirm these results. missed ureteric injuries in gunshot injuries of the abdomen: how to avoid? introduction: traumatic ureteral injuries are uncommon. penetrating rather than blunt trauma is the most common cause of ureteral injuries. the aim of this study is to make a strategy to avoid missing ureteric injuries in gunshot injuries of the abdomen. material and methods: 765 patients were operated in our hospital in 3 years period. all patients were managed according to atls guidelines. for stable patients, full radiological work up was done, while hemodynamically unstable patients were shifted to or immediately for laparotomy and exploration. all patients demographic and clinical data were recorded these include :patient age, sex, mechanism of injury, hemodynamic state on arrival to the rr, anatomical site of gunshot injury, associated injuries, ureteric injuries detected early or late, early repair, delayed presentation and morbidly associated with delayed discovery. results: ureteric injuries were found in 12 patients out of 765 patients who underwent laparotomy for gunshot injuries had ureteric injury in an incidence of 1.5%. ureteric injuries were missed in the first laparotomy in 3 patients. associated injuries of other abdominal viscera include; colon injuries affecting ascending and descending colon in all the patients. conclusions: ct and pyelogram are the modalities of choice in stable patient but in unstable patients the early recognition of ureteric injuries depends on high index of suspicion leading to surgical exploration of the ureter along its course. case history: we present a case of a 72 year old man, who was injured by his agricultural machine in the abdomen. clinical findings: he was transferred in the emergency department and he was hemodynamically stable. he had several traumas in his abdominal wall. from the largest one, in the left iliac fossa, omentum, transverse colon and loops of the small intestine were protruded out of the abdominal wall. the small bowel was ischemic and ruptured. investigation/results: computed tomography investigation, revealed small amounts of liquid and air in the abdominal cavity. diagnosis: the patient was immediately operated. the destroyed loop of the small bowel was resected with the use of a stapler and the field was washout. then with a midline incision the abdomen was opened. there were no other injuries inside the abdomen cavity. there was an extensive injury with a creation of a large gap in the anterolateral abdominal wall. it was impossible to identify the left rectus abdominis muscle as also the lateral muscles (external and internal oblique and transversus abdominis). therapy and progressions: a side to side entero-enteric anastomosis was created and a meticulous observation and washout of the abdomen were performed. for the closure of the abdominal wall a double-sided mesh from polypropylene coated with silicone on one side (20 9 25 cm) was placed and the operation was completed. all the other wounds of the abdominal wall were closed with loop nylon stitches no 1. a closed suction drain was placed above the mesh. the patient had a very good postoperative course. he was dismissed from the hospital after 15 days in a very good condition. comments: the usage of mesh was very useful for the reconstruction of the abdominal wall. there is no conflict of interest. strategy shift from damage control surgery to primary radical surgery improve the outcome of blunt hepatic injury involving inferior vena cava introduction: the diagnosis of abdominal trauma is a real challenge even for surgeons experienced in trauma. clinical findings are usually unreliable, and abdominal examination is made up of various factors. diagnostic tools that help the attending physician make critical decisions, such as the need for laparotomy or conservative treatment, are mandatory if we propose a favorable outcome. material and methods: the study was performed in the clinic i surgery, the county clinical emergency hospital craiova, between 2014-2018 and analyzed a number of 70 abdominal traumas hospitalized, investigated and treated in the clinic. the methods of paraclinical diagnosis are evaluated comparatively, the study analyzing the evolution and the tendencies during the studied period, from 2014, to 2018. results: the study allowed an evaluation of the diagnosis and treatment methods compared to the data in the literature. conclusions: thus ct scan remains the standard criterion for detecting solid organic lesions. in addition, a ct scan of the abdomen may reveal other associated lesions. fast ultrasound is an important and valuable alternative for diagnosing abdominal trauma, especially for patients who are hemodynamically unstable and cannot be mobilized. there is a tendency in the treatment of abdominal trauma, as evidenced by the literature data on the use of conservative versus surgical treatment for a larger number of cases introduction: antiplatelet agents and anticoagulant drugs are widely used in prevention of cardiovascular incidents, which poses a challenge in surgical emergencies. the drafting of a multidisciplinary protocol for the treatment of pharmacological induced coagulopathy in patients who require urgent surgery standardizes management and increases patients' perioperative safety. material and methods: aims of the study were to describe the results from the protocol implementation. a retrospective study was conducted by examining reports of every patient presenting pharmacological induced coagulopathy and undergoing emergent surgery, recorded in our center from 2012 to 2017 inclusive. different algorithms used were explained and data such as need of transfusion, reintervention rate and perioperative complications were analyzed. results: data from 169 patients were analyzed, median age of 79, 100 (59%) men. 107 patients (63%) used anticoagulant drugs. fresh frozen plasma transfusion and/or prothrombin complex concentrates were used according to the guideline. 73 (43%) patients used antiplatelet agents. 77% of them underwent a delayed 48 h surgery directly. tirofiban therapy was established in 7 patients on dual therapy due to medium-high risk of cardiovascular event. regarding surgical approach, 59 (35%) were laparoscopic, 96 (57%) open and conversion occurred in 14 (8%) cases, but only 1 of them due to intraoperative hemorrhagic complication. only 2 cases of postoperative hemorrhagic complications led up to reintervention and only one isolated case of thrombotic complication was reported. finally, 7 (4%) mortality cases were reported, but none was caused by hemorrhagic nor thrombotic complications. conclusions: establishment of a guideline on management of pharmacological induced coagulopathy in emergent surgery is crucial in all surgical emergency units and has proven to be effective and safe. introduction: digestive haemorrhage is a frequent pathology. most of the episodes are self-limited, but in some cases massive haemorrhage occurs, leading to a 10% mortality rate. severe problems occurs when endoscopic treatment is not effective, requiring emergent surgery with poor prognosis. the aim of this study is to evaluate the implementation of interventional radiology techniques on short-term results. methods: a retrospective descriptive study was performed reviewing patients who underwent radiological embolization after failure of endoscopic conventional treatment between 2015-2019 in our hospital. a total of 41 patients were included. results: 22 patients were male. 24 cases were from lower gi track and 17 were from the upper gi with a similar death rate between them, with a higher rebleeding rate in upper gi (35.2% vs 12.5%). 29% of the arteriographies did not show any bleeding site, 4 of them developed a new bleeding episode. overall patients who undergo embolization, urgent surgery was avoided in 8 of the 11 patients diagnosed as upper gi haemorrhage and in 15 of the 19 patients diagnosed as lower gi haemorrhage. 5 patients died, those death occurred later on the recovery of the acute bleeding episode and embolization, all of them related to patients comorbidities. conclusions: arterial embolization has become an important tool in order to treat massive haemorrhages of the gastrointestinal tract. it seems to decrease the mortality and morbidity rate, but some complications can be associated such as rebleeding or bowel ischaemia. massive transfusion protocol with early administration of platelet and fresh-frozen plasma along with packed red cells in the initial phase of resuscitation is associated with improved outcomes introduction: massive transfusion (mt) in a ratio of 1:1:1 (prbc:platelet:ffp) is the standard of care in hemorrhaging trauma patients. the aim of our study was to compare the outcomes of patients who receive near balanced resuscitation (nbr) compared to unbalanced resuscitation (ubr) during the initial phase of resuscitation. material and methods: we performed a 4-year analysis of the acs-tqip. all adult patients (age [ 18) who received mt (defined as transfusion of prbc c 10 units in 24-h) were included. patients were stratified into two groups: nbr defined as prbc:platelets:ffp in 1: [ 0.5: [ 0.5 and ubr (1: \ 0.5: \ 0.5) in the first 4 h of resuscitation. primary outcome measure was mortality. secondary outcome measures were complications, and hospital length of stay. propensity matching was performed to match the two groups. results: a total of 10,321 patients received mt. mean age was 40 ± 12 years, median iss was 29 [22] [23] [24] [25] [26] [27] [28] [29] [30] [31] [32] [33] [34] [35] [36] [37] [38] [39] [40] [41] . overall 24 h mortality was 27.9%. only 36% patients received nbr while 74% received ubr in the first 4-h. using propensity score matching, patients were matched for demographics, ed vitals, iss, ais and injury parameters. patients who received nbr in the early resuscitation phase had lower mortality (23% vs. 31%, p = 0.01), lower overall complications (38% vs. 55%, p = 0.01), with no difference in hospital length of stay (17 days vs. 16 days, p = 0.53) compared to the ubr group. conclusions: only one-third of patient receiving massive transfusion receive prbc, ffp and platelet in a ratio closer to 1:1:1 in the initial 4-h and they have lower mortality and complications compared to patients with unbalanced resuscitation. material and methods: the goal is to assess mtp strategies in level-1 trauma centres in the netherlands and compare these with each other and (inter) national guidelines. a trauma surgeon or anaesthesiologist involved in compiling the mtp in each level-1 trauma centre in the netherlands and dutch ministry of defence was approached to share their mtp and comment on their protocol in a survey or oral follow-up interview. results: all eleven level-1 trauma centres responded. content of the packages and transfusion ratio (red blood cells/plasma/platelets) was 3:3:1, 5:5:1, 5:3:1, 2:3:1, 4:4:1, 5:2:1, 2:2:1 and 4:3:1. tranexamic acid was used in all centres and an additional dose was administered in eight centres. fibrinogen was given directly (n = 4), with persistent bleeding (n = 3), based on clauss fibrinogen (n = 3) or rotem ò (n = 1). standard coagulation monitoring are used in all centres, but most hospitals use also rotational thromboelastometry (rotem ò ) (n = 6), thromboelastography (teg ò ) (n = 1) or both (n = 1). all centres used additional medication for patients using anticoagulants, but its use was ambiguous. conclusions: mtps in dutch level 1 trauma centres differs from (inter) national guidelines in transfusion ratio and additional medication, which could be explained by misinterpretation of the 1:1:1 ratio, changes in components and following an outdated dutch national guideline. whether these differences in mtps actually leads to different patient outcomes will follow from data that is currently being collected. this study is sponsored by the dutch ministry of defence. anastomotic bleeding after colorectal surgery: incidence, management and complications introduction: postoperative anastomotic bleeding (pab) is a frequent minor complication (1-9%) that usually resolves by a conservative approach. hemodynamic instability and anemization may develop requiring urgent management. the aim of our study is to describe pab and its treatment. material and methods: observational retrospective cohort study of patients with pab collected between july 2014 and september 2019. pab was defined as an episode of lower gi bleeding after colorectal surgery with at least one anastomosis. characteristics of patients, surgery, length of hospital stay, morbidity and mortality, and management of pab were reviewed. results: a total of 38 (5.5%) patients with pab was collected. median age was of 75 years (iqr 64-80), with a median estimated asa grade of 3. the most common procedure was a right hemicolectomy (50%), followed by sigmoidectomy (24%). 95% of surgeries were laparoscopic. only 2 cases were converted to an open approach. 37% of patients had the first episode of pab during the first 24 h after surgery, while 32% after the third postoperative day. pab was treated conservatively in 84% of the cases. the remaining 16% required urgent endoscopic management identifying the bleeding through the anastomosis line, using clips in 5 patients and hemospray in 1 patient to control it. no complications were recorded after endoscopic treatment. just 1 case required surgical reintervention. a total of 12 (32%) patients required blood transfusion with a median of 2 (iqr 2-3.75) units. length of hospital stay was 6.5 days. no mortality related to pab was registered. conclusions: pab is a mild complication after colorectal surgery. most of the patients respond to conservative management. urgent endoscopic treatment seems to be effective and safe to control pab even during the first postoperative day. introduction: hemorrhagic shock and associated reperfusion injuries are davastating situations during the treatment of polytrauma patients. the aim of this study was to analyze and compare alterations of the local circulatory changes of various body regions during hemorrhagic shock and after fluid resuscitation. material and methods: this study was conducted on male pigs. they suffered a standardized polytrauma including femoral fracture, blunt thoracic trauma and liver laceration. further, the suffered a hemorrhagic shock for 1 h (aimed map 25 mmhg). fluid resuscitation with three times drawn blood volume after hemorrhagic shock. retrograde nailing for femoral fracture and chest tube in case of pneumothorax liver packing. measuring circulation at liver, colon, stomach, and extremity. results: inclusion of 27 animals. local circulation at the extremity decreased significantly compared to baseline values during hemorrhagic shock (82.3 a.u. versus 31.7 a.u., p \ 0.001). after resuscitation the flow rate at the extremity was comparable to baseline values. the stomach was least sensitive to hemorrhagic shock, whereas the oxygen delivery rate at the colon decreased during shock phase and remained decreased during fluid resuscitation (p \ 0.001). conclusions: different body regions react differently to hemorrhagic shock. the colon appears to be most vulnerable to changes based on hemorrhage. the delayed improvement of circulation in liver, colon, and extremities may represent a trigger for systemic hyperinflammation and subsequent sirs and sepsis. none of the authors have any conflicts of interest to declare. massive transfusion in penetrating trauma: the search for a specific prediction system introduction: prediction systems of massive transfusion (mt) were developed from cohorts with a small proportion of penetrating trauma. some of them required laboratory tests. we aimed to evaluate abc score and to identify independent predictors of mt in a cohort of torso penetrating trauma (tpt) material and methods: adults with tpt, managed in a level-i trauma center, who received one or more packed red blood cells (prbc), were included. variables obtained during the evaluation in the trauma bay were registered prospectively. the ability to predict mt was evaluated with simple, multiple logistic regressions and roc curves. results: we included 162 patients; 88.9% were male, and 84.6% received fire-arm wounds. twenty-one (13%) received mt. mt patients were intubated more frequently in the pre-hospital, had lower sbp, higher hr, lower gcs, and received more frequently vasopressors (p \ 0.05) when compared with the no-mt patients. trauma mechanism, number or localization of the wounds, and positive fast could not discriminate mt (p [ 0.05). hypotension, tachycardia, and alteration of the glasgow coma scale or its motor response behaved as independent predictors of mt. models created with these variables showed better discriminative ability than abc score, with adequate goodness to fit. conclusions: prediction models of mt, based on heart rate, systolic blood pressure, and neurologic alteration outperformed abc score in a tpt cohort. introduction: rectus sheath hematoma presents with abdominal pain and anterior abdominal wall mass. it can be followed conservatively and rarely causes mortality (1) . in this study we aimed to review rectus sheath hematoma cases consulted to our department and to present our management. material and methods: the data of 35 patients admitted with rectus sheath hematoma between 2009 and 2018 was collected using hospital database. treatment modalities, demographic data and complications were reviewed retrospectively. results: all the cases presented with abdominal pain and/or with a palpable abdominal mass. 82.8% of the patients (n = 29) were receiving anticoagulant therapy at the time of admission. the mean inr value was 2.34. 28 patients were followed up with es&ffp transfusion and conservative treatment. 3 patients not eligible for conservative care underwent inferior epigastric artery embolization and hematomas in 2 patients were evacuated via a percutaneous drainage catheter. 1 patient went through laparotomy for an infected hematoma and one patient underwent laparotomy plus packing. the patient who had laparotomy plus packing died due to intraabdominal hematoma and sepsis. conclusions: rectus sheath heamatoma is a rare cause of acute abdominal pain. the patients diagnosed early and have suitable indications can be treated conservatively (2) . rectus sheath hematoma should be considered in the differential when a patient with a history of anticoagulant drug use presents with acute abdominal pain in order to prevent unnecessary surgery and complications. introduction: an early delivery of blood products when massive transfusion protocols (mtp) are triggered is mandatory to improve trauma patients survival. scores predicting massive transfusion (mt) have already been described (1) . the aim of our study is to compare scores for predicting mt and identify the best trigger for mtp. material and methods: multicentric retrospective study from the trauma registry of the spanish surgeons' association. severe trauma patients (injury severity score [iss] c 15), admitted to 18 different level 1 trauma centers, from january 2017 to september 2019 were included. demographic and clinical information was recorded, and predictive scores for mt were assessed. results: 1113 patients were included. medium age was 47.1 ± 19.6 years, 861 (77.4%) were male. median iss was 22 (iqr 13). in 4% of the patients a mt (defined as c 10 units of packed rbc) was necessary, while a mtp was triggered in 13.6%. surgery was performed in 55.8%. the overall mortality was of 9.9%. predictive scores for mt were compared: gap (glasgow coma scale, age, systolic blood pressure), shock index (si), assessment of blood consumption (abc) and mabc (modified abc). auroc for gap was 0.735 ± 0.037, si 0.907 ± 0.016, abc 0.881 ± 0.034 and mabc 0.882 ± 0.036, showing differences between gap (the worst score) and the others, p \ 0.01. no differences were found between si, ab and mabc. best cut-off points were calculated. si c 0.8 better predicts mt with a sensitivity 100%, specificity 63.4%, positive and negative predictive values 10.3% and 100%. conclusions: si, abc and mabc are all good scores for predicting mt in our population. appealing by its simplicity, we recommend si as the best trigger for mtp. protocols should be standardized to improve the accuracy of mtp activation for trauma patients. introduction: the prevalence of knife-related offences is rising in the uk. successful management of trauma patients requires the co-ordinated response of specialist services, including transfusion. we aimed to assess the impact of knife-crime on transfusion support within a uk adult major trauma centre (mtc). material and methods: retrospective review of patients admitted to a uk mtc following knife injuries resulting from interpersonal violence during a three-year period (may 2015-april 2018). source material included electronic patient records, tarn database and massive transfusion protocol (mtp) logbook. patient characteristics, resource utilisation including transfusion, mtp activation and outcome were collated. results: 540 patients were identified, 502 (93%) were male. median age was 27 years. 237 (44%) were under the age of 25. 245 patients (45%) presented with circulatory compromise (sbp \ 110). 97 patients (18%) had attended our hospital previously for violencerelated trauma. 71% arrived at hospital between 1900 h to 0700 h. 346 (64%) required one or more surgical procedures. median length of stay was 3 days. 95 patients (18%) received blood transfusion. median units transfused were 4 prbc, 2ffp, 1 platelets (atd). mean component use was 6 pbrc (range 1-61), 3.8 ffp (0-36), platelets 0.6 (0-12), cryoprecipitate 0.6 (0-14). annual mtp activations increased from 99 to 157 during the study period (total 360). stabbings accounted for 25.4% of these (99 patients), of which 70 (78%) were transfused. conclusions: knife crime presents a burden to blood transfusion, accounting for a quarter of mtp activations. patients typically present out of hours with implications for service planning and delivery. patient profile together with repeat healthcare attendance and surgery requiring transfusion has implications for red cell allo-immunisation. we recommend timely baseline blood grouping and triage to optimise the safe use of rhd positive cellular components. introduction: spontaneous intramural small bowel hematoma is a very rare complication of anticoagulant therapy. nowadays, the prevalence is increasing due to the widespread use of computerized tomography and the increasing number of patients receiving anticoagulant therapy. material and methods: 15 patients admitted to our center between january 2010 and june 2019 and treated with the diagnosis of intramural hematoma were retrospectively evaluated. results: the median age of the patients was 69 years (44-84) and 9 (60%) were male. at the time of appeal, warfarin intoxication was present in 14 cases (93%) and the median inr was 7.25 (5) (6) (7) (8) (9) (10) (11) (12) (13) (14) . one patient had known factor 7 deficiency. diagnosis was made by computerized tomography in all cases. one intramural hematoma was localized in the duodenum (6.7%), nine in the jejunum (60%), and five in the ileum (33.3%) six patients (40%) had ileus findings. all patients underwent fresh frozen plasma replacement due to high inr levels and bleeding. median tdp transfusion was 3 units (2-7). only 3 patients (20%) required erythrocyte suspension replacement. all cases were followed up conservatively and there was no need for intensive care. the median hospital stay was 4 (3-10) days. conclusions: due to the limited number of studies in the literature with a large number of cases, retrospective evaluation of 15 singlecenter cases may be helpful. spontaneous intramural small bowel hematoma should be considered in the elderly population under warfarin therapy who present with abdominal pain, especially if inr values are above therapeutic limits spontaneous regression is seen in the majority of cases. non operative management and correction of coagulopathy with fresh frozen plasma replacement is the preferred approach. references: abbas ma, et al. spontaneous intramural small-bowel hematoma: clinical presentation and long-term outcome. arch surg. 2002; 137(3) :306-10. pre-hospital decision-making: identifying the challenges assessing and managing traumatic haemorrhage and coagulopathy m. marsden 1 , r. bagga 2 , k. gillies 3 , r. lyon 4 , s. kellett 5 , r. davenport 1 , n. tai 1 expert pre-hospital clinicians in making decisions about the diagnosis and treatment of patients with major haemorrhage and suspected tic. methods: semi-structured interviews were conducted with 10 senior pre-hospital consultants from london's air ambulance and air ambulance kent, surrey and sussex. interviews probed clinicians on how they make decisions relating to the pre-hospital assessment of major haemorrhage and tic and subsequent blood product transfusion. the interviews were analysed using descriptive thematic analysis. results: all clinicians agreed that identifying and treating major haemorrhage was vital. half of the clinicians reported making no conscious assessment for tic and six reported tic should be managed in a hospital setting. four broad themes were identified: collation of information, weighing utility of different approaches, influence of experience and evaluation of unknowns. collating information from multiple sources drove clinical decision-making. decisions on blood product transfusion were made after weighing potential benefits (e.g. improve microvascular perfusion) against harms. clinical experience was reported as key to nuance clinical assessment, detect subtle signs and identify patterns. uncertainty complicated clinical decision-making in two domains; incomplete knowledge of a patient's injury and uncertainty of best clinical practice. conclusion: the pre-hospital identification and treatment of major haemorrhage was recognised as challenging and fundamental. necessity of pre-hospital tic diagnosis and treatment divided opinion. identifying these four themes allows for a greater understanding of the factors involved in making these decisions and will guide the creation of more accurate decision support tools to aid pre-hospital clinicians. nothing to declare. introduction: massive transfusion (mt) is defined as the administration of c 10 packed red blood cells (prbc) in 24 h. alternative definitions have been proposed; however, there is little understanding about the discriminative ability of different mt definitions with regards to mortality and multiorgan failure (mof). we aim to assess and compare the discriminative ability of different definitions of mt concerning mortality and mof. material and methods: we included patients who arrived to the emergency department and required trauma team activation at a level i trauma center in the city of cali, colombia between 2014-2018. demographics and trauma characteristics were evaluated. the following mt definitions were measured: 50 units of blood products in 24 h (t50), 10 u prbc in 24 (t10-24), 6 u prbc in 6 h (t6-6), 10 prbc in 6 h (t10-6), the combination of t10-24 and t6 (t-combi), 5 prbc in 4 h (t5-4), 4 prbc in 1 h (t4-1) and 3 units of prbcs in 60 min. the operative characteristics were calculated for each definition. mof was defined as a sofa score of c 6 points. results: we included 394 subjects, 88.6% male. trauma mechanism was penetrating in 87.3%. the median and interquartile range (iqr) of age was 28 years iqr (22-37) and of iss 25 (16-26). lesions were located in the torso in 42.4% of patients, and 47.2% had a positive abc score. a total of 264 (67%) received at least 1 unit of prbc. tables 1 and 2 presents the operative characteristics of 10 definitions of mt with respect to mortality and mof, respectively. conclusions: although all definitions showed an association with higher odds with the outcomes of interest, none of them showed an accurate diagnostic capacity regarding mof and mortality. thus, we advise caution when relying on the classical definition of mt ([ 10 rbc units in 24 h) to guide the flow of care of severely injured patients. trauma and coagulation: trends in coagulation factors in the severely injured trauma patient introduction: trauma-induced coagulopathy (tic), affects about 25-30% of the major trauma patients. in the past, tic was considered as a consequence of the coagulation factors' dilution after a highvolume colloid administration. today tic is seen as a phenomenon that can arise after trauma; the first event is the c-protein activation by the tissue damage and hypoperfusion, resulting in the subversion of the hemostatic process. material and methods: the 40 patients of the 2018 pilot study ''trauma and coagulation'' run in irccs san raffaele scientific institute have been reviewed and analyzed using a suite of experimental coagulation factors including rotem parameters, activated protein c (apc), thrombomodulin, endothelial protein c receptor, thrombin-antithrombin complex (tat), plasminogen activator inhibitor 1 (pai-1), seselectin, interleukin-8 (il-8), interleukin-10 (il-10), d-dimer (xdp), antithrombin iii (atiii), and prothrombin fragment f1 ? 2 (f1 ? 2). new 15 patients have been enrolled to validate the results of the pilot study. results: there is a statistically significative correlation between clinical scores of severity of trauma and risk of massive transfusion (iss, abc and tash) and some of the experimental coagulation factors analyzed. case history: to evaluate the role of negative pressure wound-care systems applied to the pleural cavity in case of severe acute empyemas and frail patients not amenable to conventional surgery. clinical findings: we report the case of a 67 yrs old male critically ill patient suffering from complications of cardiac surgeries who developed a severe right empyema with broncho-pleural fistula through the site of a previous pulmonary hernia. investigation/results: we review the actual indications of negative pressure therapy in thoracic surgical emergencies especially in septic patients unfit for surgery. in our case the repeated application of negative pressure with dedicated dressings through the initial thoracotomy was the chosen damage control approach because of the sepsis and poor conditions. diagnosis, therapy and progressions: air leaks were later found to originate from a subsegmentary branch of middle lobe bronchus. subsequent video-assisted debridement procedures followed by negative pressure therapy managed to (1) control the infection, (2) reduce the thoracotomy incision into a thoracoscopic access and (3) heal the pleural cavity, restoring eventually better general conditions of the patient. the closure of the bronchial fistula required further procedures after the acute phase when sepsis was overcome. comments: negative pressure systems can be applied to the pleural cavity with many advantages in selected critically ill patients. they allow to contain, treat and resolve infections both of chest wall and pleural cavity in case of severe empyemas reducing also wound pain and eliminating the need of chest drains. air leaks may also be managed by negative pressure therapy with adequate indications and particular attention to its settings. references: sziklavari z. mini-open vacuum-assisted closure therapy with instillation for debilitated and septic patients with pleural empyema. eur j cardiothorac surg. 2015. flail chest: the renaissance of rib osteosynthesis c. leite 1 , a. oliveira 1 , a. lemos 1 , b. barbosa 1 , c. casimiro 1 1 centro hospitalar tondela-viseu, general surgery, viseu, portugal case history: we present the clinical case of a male patient of 79 years old. injury mechanism: fall from his own height over the right hemithorax. clinical findings: 5 rib fractures with flail chest and significant displacement of bone edges. symptoms: intense thoracic pain. diagnosis: rib fractures with flail chest. therapy and progressions: multimodal analgesia. on the 4th day, he presented a tension pneumothorax. after adequate intercostal drainage, the pneumothorax relapsed. on the 8th day, he underwent a right posterolateral thoracotomy, open reduction and internal fixation of 3 ribs with plates and screws and intercostal drainage. evolution: he received respiratory kinesiotherapy and was discharged on the 8th pos op day. follow-up at 1st and 5th months, without functional impairment and with preservation of quality of life. comments: rib fracture is the most common injury in the setting of thoracic trauma and is associated with a higher morbimortality. in the last 60 years, positive pressure mechanical ventilation was the first line treatment of respiratory insufficiency caused by rib fractures. however, severe complications associated with prolonged mechanical ventilation, have elicited the rising implementation of open rib reduction and internal fixation techniques. the most consensual indications are: flail chest with fracture of at least 3 ribs, significant displacement of bone edges or uncontrolled pain. rib osteosynthesis is a simple method but requires clinical experience in thoracic approaches and handling of specific instruments and material. its implementation in non-ventilated patients reduces the need for mechanical ventilation, pain, length of stay and allows preservation of quality of life. yokohama city university medical center, advanced critical care and emergency center, yokohama, japan, 2 saiseikai yokohama-shi nanbu hospital, department of surgery, yokohama, japan, 3 yokohama city university, department of general surgery, yokohama, japan, 4 yokohama city university, department of emergency medicine, yokohama, japan introduction: although americans and europeans report emergency room thoracotomy (ert) is of value in penetrating trauma patients, most of ert is performed for blunt trauma in japan. after the establishment of the local government-directed major trauma center in the city of yokohama, the unexpected trauma survivor rate increased in the single center study. we report our experience in ert and surveyed the effect of the establishment. material and methods: patient characteristics (backgrounds, mechanism of injury, indication for ert, anatomic injuries, interventions and survival) of those who underwent emergency thoracotomy compliant with the guideline of western trauma association, between october 2012 and september 2019 were analyzed. results: fifty-eight patients (42 males) underwent emergency thoracotomy. median age was 39.8 (5-85) years. fifty-seven were performed for blunt trauma (98%) and only 1 for penetrating injuries. twenty-three patients presented with cardiac arrest on arrival, while thirty-five had deep and refractory hypotension. overall, survival rate improved from 0 (0/14) to 14% (6/44) (p = 0.18) after the establishment of the trauma center. of patients presenting with cardiac arrest, only one survived. conclusions: the establishment of major trauma center seemed to affect the survival rate of the patient edt was performed. introduction: more than 45% of polytrauma events involve chest injuries. one third of these patients sustain thoracic instability due to serial rib fractures. thanks to numerous innovations in implant development several approaches currently exist for surgical rib stabilization (srs). however, no consensus exists regarding patient selection for srs to date. material and methods: retrospective single center cohort analysis in trauma patients. serial rib fracture was defined as three consecutive ribs confirmed by chest ct. cohort includes 243 patients that were treated conservatively and 34 patients that underwent srs by plate osteosynthesis. demographic patient data, trauma mechanism, injury pattern, injury severity score (iss), glasgow coma scale (gcs) and hospital course were analyzed. two matched pair analyses stratified for iss (32 pairs) and gcs (25 pairs) were performed to minimize selection bias. results: the majority of patients was male (74%) and aged 55 ± 20 years. serial rib fractures were located left/right/bilateral in 46%/ 36%/19% of cases. other thoracic bone injury included sternum (18%), scapula (16%) and clavicula (13%). visceral injury consisted of pneumothorax (51%), lung contusion (33%) and diaphragmatic rupture (2%). average iss was 22 ± 7.3. overall hospital stay was 15.9 and icu stay 7.4 days. in hospital mortality was 13%. srs did not improve hospital course or postoperative complications in the complete study cohort. however, patients undergoing srs had significantly reduced gcs (7.6 ± 5.3 vs 11.22 ± 4,8; p = 0.006). matched pair analysis stratified for gcs showed a reduced need for blood substitution and shorter icu stays (9 vs 15 days; p = 0.005) including shorter respirator time (143 vs 305 h; p = 0.003) and reduced in hospital mortality (4 vs 12%). conclusions: patients with serial rib fractures and simultaneous severe cerebral injury benefit from surgical rib stabilization. tracheal and bilateral recurrent laryngeal nerve disruption injury secondary to accidental strangulation by dupatta case history: 18 year old female brought to trauma emergency with a/h/o accidental strangulation injury with dhupatta at farm field while working with thresher machine after 6 h of injury. patient had severe dyspnoea, dysphagia, paining neck clinical findings: primary survey revealed threatened airway with extensive surgical emphysema, rr-29/min, spo2-80% on high flow oxygen mask, hemodynamically stable, and had no neurological deficits. patient was immediately intubated, however ventilation could not be maintained and surgical emphysema worsened hence immediate tracheostomy was established. investigation/results: computed tomography (ct) head and ct angiography of neck with venous phase study of neck and chest with ct esophagogram revealed complete disruption of cricotracheal junction with extensive cervical and upper thoracic surgical emphysema and no other injuries. diagnosis: disruption of trachea from cricoid cartilage with crushed trachea with loss of approximately 4 cm, cricoid and thyroid cartilage fracture, complete avulsion of bilateral recurrent laryngeal nerves and serosal tear of esophagus. therapy and progressions: neck exploration with debridement of tracheal margins and anastomosis between trachea and cricoid cartilage with repair of cricoid, laryngeal cartilage and esophageal serosal repair was performed. comments: post-operatively patient underwent fibreoptic bronchoscopy and revealed paramedian location of vocal cords. at present patient is with tracheostomy tube in situ undergoing speech therapy and is able to generate comprehensible sounds. further laryngeal framework surgery is being planned. introduction: emergency resuscitative thoracotomy (ert) is a lifesaving procedure in selected patients and it is often considered a controversial ''last chance'' method of resuscitation. objectives of ert are to resolve pericardial tamponade, to repair heart injuries, to perform an open cardiac massage, to cross-clamp the aorta to redistribute blood flow to the myocardium and brain, to control intrathoracic bleeding and air embolism in the bronchial venous system. outcome mostly in blunt trauma is believed to be poor. material and methods: we retrospective reviewed 32 patients c 18 years who underwent ert at san camillo-forlanini hospital (rome, italy) between january 2009 and september 2019 with traumatic arrest for blunt or penetrating injuries. results: of 32 ert, 7 (21.9%) were for blunt trauma, 25 (78.1%) were for penetrating trauma. 65.6% of patients were male. the collectively reported overall survival was 59% (n = 19). when including erts designated as done in the emergency department for blunt mechanism, only 1 patient survived (14.3%). survival after erts for penetrating trauma was 72% (18 of 25). conclusions: our experience suggests that ert is a technique that should be utilized for patients with critical penetrating injuries. the reported outcome after ert in european civilian trauma populations is favorable with an overall survival of 43%. multicenter, prospective, observational data are needed to validate the modern role of ert in blunt or penetrating trauma. references: narvestad jk, et al. emergency resuscitative thoracotomy performed in european civilian trauma patients with blunt or penetrating injuries: a systematic review. eur j trauma emerg surg. 2016;42 (6) case history: an 81-year-old male driving a car collided with a wall at a speed of 40 km/h and was brought to a hospital near the scene. he was diagnosed with right multiple rib fractures and hemopneumothorax, and transferred to our emergency center for definitive care. clinical findings: the patient's consciousness was clear and his heart rate, blood pressure, respiratory rate, and o 2 saturation (room air) on arrival were 60/min, 120/74 mmhg, 23/min, and 90%, respectively. subcutaneous emphysema was identified on the right side of his chest and his right breathing sound decreased on auscultation. there was no tenderness and rebound on abdominal examination. investigation/results: an enhanced whole-body computed tomography scan revealed a small disruption on the right diaphragm behind the sternum and free air in the abdomen. diagnosis: the diagnosis was right traumatic diaphragmatic injury, sternum fracture, and right multiple rib fractures with pneumohemothorax. there was free air in the abdomen but without evidence of perforation of the digestive tract as there was no finding of peritonitis on physical examination. thus, pneumoperitoneum from the thorax was strongly suspected. therapy and progressions: laparoscopic observation revealed a 1.5 cm-length of disruption on the diaphragm in the right sternocostal triangle. this was covered with falciform ligament using extracorporeal knot tying method because there was little seam allowance in front of the disruption on the sternum side, and direct suture was not possible. prognosis was good following surgery, and the chest drain was removed on postoperative day 3 and the patient was discharged on postoperative day 4. comments: laparoscopic repair of the diaphragm using extracorporeal knot tying method is often used for retrosternal (morgagni) hernias. however, the method was also useful in this case because the diaphragmatic injury occurred in the sternocostal triangle. rib fractures associated with pneumo-and/or hemothorax; does everyone need a chest tube? v. snartland 1 , p. a. naess 2 , c. gaarder 2 , m. hestnes 3 , p. majak 2,1,4 1 faculty of medicine, university of oslo, oslo, norway, 2 oslo university hospital, department of traumatology, oslo, norway, 3 oslo university hospital, trauma registry, oslo, norway, 4 oslo university hospital, department of cardiothoracic surgery, oslo, norway introduction: pneumo-and/or hemothorax are often seen in trauma patients with rib fractures (rfs). standard treatment for pneumothorax (ptx), hemothorax (htx) and hemopneumothorax (hptx) is tube thoracostomy (tt). however, a non-operative approach can be applied in selected patients. we wanted to assess our practice in patients with rib fractures and associated ptx, htx or hptx. material and methods: all adult patients (c 18 years) with rf, admitted by a trauma team at oslo university hospital in 2017 were identified retrospectively and those with associated ptx, htx or hptx were then included in the study. patients who underwent tt prior to arrival and those who died were excluded. spss v25 was used for statistical analysis. results: of the 241 patients with rfs, a total of 90 patients had ptx, htx or hptx. fifty-one percent (46/90) of these patients were treated with tt and 85% (39/46) of the patients underwent tt within 6 h after arrival. the presence of opacification (p \ 0.01), chest wall deformity (p \ 0.01) and pneumothorax size (p \ 0.01) were significantly higher on chest x-ray in the tt group compared to the nonoperative group. intubation at arrival was also significantly more common in patients treated with tt (p \ 0.01). there was no difference in the presence of subcutaneous emphysema between the groups. the tt group was sicker than the non-operative group (had a significantly lower systolic blood pressure, a lower gcs and a higher lactate on arrival). oxygen saturation, heart rate, respiratory rate, ph and hemoglobin did not differ significantly between the groups. conclusions: in trauma patients with rf concurrent ptx, htx or hptx should be suspected. in our study only half of these patients were treated with tt, and 85% of tubes were inserted within 6 h after admission. size of the ptx, radiological presence of opacification and deformity of the chest wall should be addressed when choosing treatment strategy. introduction: emergency department thoracotomy (edt) is a potentially life-saving surgical procedure performed in the emergency department (ed) in patients presenting with cardiac arrest following penetrating thoracic trauma. however, it is not clear if all surgeons are prepared or motivated to perform this procedure. furthermore, not all institutions are equipped, either in terms of logistics or team training, to perform edt. our purpose was to perform a pilot study in a cohort of polish surgeons of various specializations, in order to ascertain who would and who would not (and why) perform edt in their departments. material and methods: study population of 69 surgeons (27 specialists, 42 residents) from various hospitals in poland, mean age: 31-40 years, 55.1% men, 43.5% women. study respondents were asked to fill in a questionnaire on the indications and motivation to perform edt in their clinical practice. results: most respondents (n = 54, 78%) correctly recognized the indications to perform edt. however, only 35 (51%) declared they would perform it. the reasons for not performing edt were: lack of team training (63.7%); lack of equipment (58%); lack of motivation among ed personnel (40.6%); the ed is not prepared (27.5%); the respondent is not prepared (26%). only 6 participants (8.7%) declared that their institutions had the edt protocol. conclusions: this survey demonstrates that, although most surgeons agree on the indications for edt, the level of preparedness in its execution is lacking. the main reasons are the lack of team training, the lack of equipment and the lack of motivation among ed personnel. other relevant reasons were the lack of preparation of either a surgeon or a department. these results demonstrate that improvements in institutional logistics as well as in team and individual training can translate into improved care. we strongly advise the performance of a pan-european survey on edt to address other unrecognized issues. mediastinum widening: how to manage it? a. gonzález-costa 1 , r. gracia-roman 1 , s. montmany-vioque 2 , m. s. santos-espi 3 , r. lobato-gil 1 , m. pascua-solé 1 , a. campos-serra 1 , a. luna-aufroy 2 , p. rebasa-cladera 2 , s. navarro-soto 2 1 parc tauli hospital universitari, trauma and emergency general surgery department, sabadell, spain, 2 parc tauli hospital universitari, esofagogastric general surgery department, sabadell, spain, 3 parc tauli hospital universitari, angiology and vascular surgery, sabadell, spain case history: a 23-year old male was admitted to our emergency department as a polytrauma code, because of a gunshot wound in the neck. clinical findings: his airway was compromised with expansive cervical hematoma. intubation was difficult. he was hemodynamically unstable with cervical bleeding, in which manual compression was applied. results: chest x-ray showed mediastinal widening without pneumo or hemothorax. diagnosis: urgent sternotomy while maintaining manual compression on the cervical bleeding, followed by left antero-lateral cervicotomy. injuries: section of left jugular vein and left carotid artery, lesions of unnamed vein. free cervical chylous fluid. left pleura and pericardium were opened without identifying major injuries. therapy and progressions: jugular vein was repaired with continuous suture and carotid artery with patch sutured. unnamed vein was sectioned between ligatures. thoracic duct was ligated. after surgery, ct scan showed cervical and mediastinal hematomas without signs of active bleeding, and correct permeability of the vessels, with no cranial lesions. the patient was admitted to the intensive care unit. tracheostomy was performed. fibrobronchoscopy, fibrogastroscopy and esophagogastricoduodenal discarded airway and esophageal lesions. he presented the following complications: • small mediastinal collection • right diaphragmatic paralysis. • paralysis of vi left cranial nerve (mononeuritis of vascular origin). the patient was discharged on the 30th postoperative day. comments: in this kind of trauma is essential the airway management with intubation when necessary. it is important that mediastinal widening visualized in the chest x-ray in a traumatic patient, should be an indication of surgery. in our case, it was essential to start it with sternotomy while maintaining manual neck compression, and in a second time, perform the cervical approach since that prevented the patient from suffering a greater blood loss. background: clavicular fracture is very common in childhood. otherwise, the medial third of the clavicle is the less affected. the current report describes a new pattern of clavicular injury, in which a medial third clavicular fracture and posterior sternoclavicular joint (scj) dislocation occur together in a skeletally immature patient. clinical findings: an 8-year-old boy sustained a direct impact to his left shoulder resulting from the fall of a sofa. at admission, he complained of severe pain in the clavicular and shoulder associated with functional limb impotence. physical examination revealed deformity of the proximal third clavicle, with swelling and tenderness to palpation along the medial left clavicle. no signs of skin pression or neurovascular impairment were found. the anteroposterior radiograph of the left clavicle showed a fracture of the proximal third shaft and an asymmetry of the scj. computed tomography confirmed the association of a greenstick fracture of the proximal third clavicular shaft, accompanied by a mild posterior scj dislocation. therapy and progressions: the left limb was immobilized with a sling during 3 weeks, after which physical therapy was initiated to improve range of motion using active and gentle active-assisted exercises. at the 2 months medical consultation, he presented asymptomatic, with good bone healing, full range of motion of the shoulder and absence of relevant aesthetic deformity. comments: in the immature skeleton, scj dislocation and epiphyseal fracture of the proximal clavicle are very rare entities due to the multiple strong ligaments that stabilize the scj. trauma in the proximal third of the clavicle typically results in fractures in the region of the physis and only more rarely culminate in dislocations of the scj. these injuries warrant a high index of suspicion, and early ct scanning is recommended. although treatment may be conservative, in situations of major displacement, surgery should be considered. use of rib fracture scoring systems in a uk major trauma unit: a retrospective audit and lessons learnt introduction: rib fractures are detected in 10% of trauma patients [1] . significant morbidity and admission to intensive care units (itu) is common [1] . rib fracture scores do not have strong validity as a predictor, but are a useful screening tool to identify patients at higher risk, of morbidity. the aim of this study was to audit the use of rib fixation scores in a single major trauma centre. material and methods: a retrospective audit of trauma patients with rib fractures presenting to a single major trauma centre over a 1-year period subsequently admitted to itu was performed. demographics, length of itu stay, rib fracture score (rfs) and ribscore were recorded and comparisons made between patients who had surgical rib fixation and those who did not. results: 86 patients with traumatic rib fractures were admitted to itu over 1-year, 19 of whom had rib fixation. mean age of patients undergoing surgery was 74 compared to 52 in the non-surgical cohort. average rfs was higher in the surgical cohort (14 vs 6; p = \ 0.001), as was average ribscore (3 vs 1; p = \ 0.002). incidence of flail segment was higher in surgical cohort (37% vs 10%; p = \ 0.001), as was number of rib fractures (9 vs 5; p = \ 0.001) and incidence of 1st rib fracture (20% vs 8%, p = \ 0.289). rib fractures treated surgically had a longer itu stay (12.3 days vs 5.31; p = \ 0.001). conclusions: surgical rib fixation patients were older and had longer itu stay. higher rib fracture scores correlated with need for surgical intervention. this highlights the need for careful patient selection for rib fixation, as they appear to fall in a more vulnerable patient demographic. there is a need for a score combining ribscore and rfs, ensuring the nature of fractures and presence of flail segments are interpreted in the context of patient age, to ensure this vulnerable patient group undergoes surgical fixation only when necessary. jichi medical university, shimotsuke tochigi, japan case history: an 82-year-old female individual hurt her back while walking during a hospital rehabilitation program after experiencing a brain stroke. her hemoglobin level gradually decreased to 6.0 g/dl on the 5th day after injury. a non-enhanced abdominal ct scan revealed a burst fracture of the lumbar spine. the patient was brought to our emergency center for a thorough examination. clinical findings: her vital signs on arrival were gcs: e4v4m6, hr: 79, bp: 135/75, rr: 19, and bt: 36.3. her back presented a severe kyphotic spine. the palpebral conjunctiva was anemic and there were no injuries on her surface. no abnormalities were detected upon auscultation of the thorax and no tenderness and rebound was detected upon physical examination of the patient's abdomen. investigation/results: hemoglobin level was 5.9 g/dl and lactate 2.8 mmol/l on arrival. an enhanced chest and abdominal ct scan revealed a burst fracture of the 5th lumbar spine, a large hematoma around it, and a pseudoaneurysm of the lumbar artery. diagnosis: a pseudoaneurysm of the lumbar artery and a burst fracture of the 5th lumbar spine was diagnosed. therapy and progressions: the angioembolization of the lumbar artery was abandoned because the distance between the abdominal aorta and the aneurysm was \ 5 mm. endovascular aneurysm repair (evar) was finally performed. after the successful completion of the surgery, the patient was discharged on the 11th day after evar. comments: slight injury caused the fracture of the lumbar spine, possibly yielding pseudoaneurysm of the lumbar artery. such pseudoaneurysms are rare and employing evar for its treatment is equally rare. blunt lumbar artery injury may be a differential diagnosis for the elderly patients who present burst spine fractures with extreme anemia or shock, even if it results from a minimal injury. case history: a 23 year old co-driver was hit by another car on her side. air rescue found the patient with gcs 3 and right tension pneumothorax. oral intubation, decompression with chest tube and transportation to the nearest level one trauma center was undertaken. clinical findings/investigation/results: on presentation in the emergency room the patient was hemodynamically instable with free fluid in efast-sonography and a haemoglobin of 2.2 g/dl. she was immediately taken to the operation room where laparotomy was performed. liver rupture and right diaphragm rupture was found. diagnosis: right hilar bronchial disruption. therapy and progressions: despite packing of the liver the patient remained instable. due to continuous bleeding from diaphragm rupture side right anterolateral thoracotomy was performed. bronchial disruption close to the hilus was detected leading to total pneumonectomy. after surgery the patient recovered under intensive care. six weeks after initial trauma the patient presented with ileus. a gastric tube was placed without complications. chest x-ray was performed showing intrathoracal displacement of the gastric tube. in an emergency operation the insufficient bronchus trunk was covered with an intercostal muscle flap. comments: this case shows the rare necessity of total pneumonectomy after blunt chest trauma and its typical complication with insufficiency of the bronchial trunk. after total pneumonectomy surgery covering the bronchial trunk should be performed as soon as possible to prevent insufficiency. in these patients gastric tubes should only be placed under endoscopic vision. because of the high complication rate total pneumonectomy should only be performed as a last resort procedure in the context of damage-control surgery. introduction: multiple rib fractures continue to be a challenging problem as the associated pain leads to a compromise in respiration. proper analgesia is required for physiotherapy, and to prevent development of respiratory failure. ultrasound-guided serratus plane block (spb) has recently been described as a regional anesthetic technique to provide analgesia to a hemithorax by blocking the lateral branches of the intercostal nerves. material and methods: from sept 2018 we applied the serratus plane block for pain control in 12 patients with multiple rib fractures. we administered 0.25-0.125% bupivacaine solution with easypump for 5-8 days, the infusion rate was 5 ml/h. after admission we measured pulmonary function of patients and recorded the forced vital capacity (fvc). we repeated the test after the catheter insertion on the 2-5-10 days. in our control group (14 patients introduction: rib fractures are the most frequent injury after blunt thoracic trauma. it is very important to choose the most appropriate interventions to minimize or prevent complications. but who will benefit most of those interventions remains a challenge. material and methods: a retrospective study with a prospective data collection from march 2006 to december 2018. there have been included all traumatic patients older than 16 years old, that were admitted to the icu or who were died before the admission and had a plain chest radiograph (cxr) and thoracic or thoraco-abdominal scan (ct scan) in the first 72 h. demographic data has been collected, vital signs, iss, mechanism of action, need of ventilation or intubation, lesions, complications, cause of death. a total of 553 cxr were reevaluated by one general surgeon (one of the authors) and one radiologist, who were blinded to the results of the subsequent chest ct scan, the written radiology report and the patient's outcome. rib fractures, pneumothorax, hemothorax, pulmonary contusion, laceration and atelectasis were described. results: attending to the number of fractures, the kappa between the radiologist, the surgeon and the ct report is very low: surgeon-ct k = 0.18, radiologist-ct k = 0.2, and radiologist-surgeon k = 0.46. both radiologist and surgeon under-diagnosed rib fractures. we tried to predict respiratory failure and pneumonia using the number of fractures, and scores (chest trauma score, ribscore and rib fracture score). results are shown on the table. conclusions: plain radiography seems not to be a good diagnostic method for rib fractures. both radiologists and surgeons under-diagnosed rib fractures. scores based on radiography seem un-useful given that this under-diagnoses rib fractures; but with a precision of 71% by the surgeon evaluating cxr and using a score like rfs perhaps it is enough to decide which patients require a ct scan or more specific treatment in the icu. surgical experience of traumatic diaphragm injury in a single regional trauma center for 5 years introduction: this study is a retrospective review of the experience with the management of traumatic diaphragm injury in our trauma center from 2014 to 2018. material and methods: we identified a total of 31 patients with the traumatic diaphragm injury coded from the institutional trauma registry. we reviewed the radiographic finding of radiologists and the electronic medical record (emr). results: the mean of injury severity score (iss) was 30.3 ± 13.7. except for 1 case, the plain chest x-ray was evaluated in the patients before surgery, only 3 patients were revealed positive finding for diaphragm injury (n = 3/30, 10%). the computed tomography (ct) was performed for 22 patients, the positive finding was 31.8% (n = 7/ 22). according to the clinician impression before surgery, the diagnosis for diaphragm injury was showed 48.4% (n = 14/31). approaches were laparotomy in 14 patients (45.2%), thoracotomy in 9 (29.0%), thoracoscopy in 3 (6.5%), laparoscopy in 1 (3.2%), open conversion after thoracoscopic or laparoscopic exploration in 2 (6.5%), median sternotomy in 2 (6.5%). the occurrence of herniation was 10 (32.3%). the mean of the calculated rupture size in the operation field was 5.8 ± 3.8 cm. in our study, the herniated peritoneal organ was observed in more than 3 cm size rupture of the diaphragm. 6 patients were performed surgical management of diaphragm rupture after 24 h. conclusions: without herniation of organs, the radiologic evaluation was difficult to detect diaphragm injury. and, detect of diaphragm injury with herniation of organ, the injury of the diaphragm was predicted a larger than 3 cm. case history and clinical findings: a 44-year-old man presented to the emergency room with a single self-inflicted left chest gunshot wound at the level of 2nd rib. on arrival patient was conscious, with systolic blood pressure 100 mmhg and heart rate 120 bpm. extremities were pale, cold. jugular veins distended. investigation/results: fast scan was negative. chest radiograph revealed a metal foreign body with the size of 4 9 5 mm at the projection of heart. a ct scan of chest and abdomen demonstrated bullet inside the dorsal wall of the left ventricle and blood in pericardium and left pleural cavity (figs. 1, 2) . therapy and progression: patient was taken to the operation room for median sternotomy. due to severe deterioration of patient's condition, 30 ml of blood was aspirated from the pericardium prior to sternotomy. during subsequent pericardiotomy 500 ml of blood was evacuated. main pulmonary artery wall gunshot injury was detected above the pulmonary valve. the wound was sutured, after which the hemodynamics stabilized. cardiac surgeon was consulted about the air gun bullet inside the myocardium. it was decided that removal of the bullet is not indicated. the patient was observed in the icu for the next 36 h, later transferred to the thoracic surgery ward. the postoperative course was uneventful. an echocardiogram demonstrated a perforation of the anterior leaflet of mitral valve with a mild to moderate regurgitation, otherwise no abnormalities. patient was discharged on day 10. patient has been followed up on an annual basis for the last 2 years. patient's exercise tolerance and cardiac function according to repeated echocardiography remains unchanged with no evidence of dyskinesia or other abnormalities. bullet is retained in the same location (fig. 3) . comments: this case illustrates a successful management of usually lethal injury of main pulmonary artery and reflects that retained myocardial foreign body does not necessarily cause any complications. profile of penetrating chest injuries in hostile environment: a three year study introduction: penetrating chest injuries are one of the leading causes of death and major morbidity in operations involving high energy weapon systems. this study aimed at assess the profile of penetrating chest injuries suffered during armed combat operations in a hostile environment over a three year period. material and methods: a retrospective and prospective, non-randomized study designed to assess the profile of chest injuries in armed combat operations over 3 years. all patients with penetrating chest injuries were included in the study. results: there were 967 trauma cases out of which 111 patients suffered penetrating chest injuries. the age range of patients was 20-46 years and all were male. a total of 15 casualties were brought dead (14.73%). there were 11 lung injuries and two diaphragmatic injuries. thoracotomy was required in 7 patients (7.27%) and intercostal chest drainage (icd) in 29 patients (23.64%). average blood loss was 440 ml and duration of hospital stay ranged from 4 to 62 days. conclusions: ballistic injuries to the chest are frequently fatal due to injuries to the heart, major vessels and tracheobronchial tree. prompt and efficient pre hospital treatment, expedient evacuation to a surgical facility and swift management by critical care specialists and surgeons can be instrumental in reducing mortality and morbidity. the cornerstone of management is bedside intercostal chest drain insertion as a formal thoracotomy is seldom needed. penetrating chest injuries can be managed by general surgeons with training in thoracotomy and repair of intra-thoracic structures does the number of a-or low symptomatic but intervention requiring complications justify regularly chest x-ray controls after less than 3 rib fractures? c. deininger 1,2 , f. wichlas 1,2 , s. deininger 3 , v. hofmann 1,2 1 university hospital of salzburg, orthopedics and traumatology, salzburg, austria, 2 universitätsklinikum salzburg, klinik für orthopädie und traumatologie, salzburg, austria, 3 universitätsklinikum salzburg, universitätsklinik für urologie und andrologie, salzburg, austria introduction: fractures of less than 3 ribs may still cause delayed complications (1) . the aim of this retrospective study is to determine whether standardized control imaging in a-or low symptomatic patients reveals a significant number of intervention requiring complications and therefor should be recommended. material and methods: all patients with less than 3 rib fractures presenting in our emergency department after any trauma mechanism in the study period of 3 years (2015-2017) and available for follow up were included retrospectively in the study. results: we included 249 patients in this study, 137 (55.0%) of which were male, 112 female (45.0%), with a median age of 64.2 ± 24.8 years. in 150 patients (60.2%) 1 rib was affected, in 99 patients (39.8%) 2, the fractured ribs being true ribs (1-7) in 72 cases (28.9%), false ribs (8-12) in 151 cases (60.6%) and both in 26 cases (10.4%). the affected thorax half was the left side in 124 cases (49.8%), the right side in 121 cases (48.6%) and both thorax halves in 4 cases (1.6%). the trauma mechanisms were falls at home, traffic accidents, sporting accidents, work accidents, fighting related and minor trauma in 172 (69.1%), 30 (12.0%), 19 (7.6%), 18 (7.2%), 6 (2.4%) and 4 (1.6%) cases, respectively. the median follow up time was 9 ± 4 days. 4 patients (1.6%) required delayed intervention: 1 case of hemopneumothorax and 3 cases of pneumothorax all treated with chest tube. conclusions: planned chest x-ray controls seem not to be necessary. symptom triggered reappearance for patients after rib fractures in hospitals seems to be sufficient and more economical compared to regularly re-imaging (2) is computed tomography a first line modality in stable blunt chest trauma elderly patients? a. becker 1,2 , y. berlin 1,2 , d. hershko 3,2 1 emek medical center, department of surgery a, afula, israel, 2 technion-israel institute of technology, haifa, israel, 3 emek medical center, surgery, afula, israel introduction: adult older, patients aged [ 65 years, represent up to 20-25% of all trauma patients admitted to the trauma centers. chest trauma in older patients have been recognized to strongly influence mortality. the estimated of 20% mortality and pneumonia rate for these patients was observed (1, 2) . based on low diagnostic accuracy of cxr, interpretation difficulties due to aging chest wall deformities, we hypothesized that ct chest should be the first imaging modality in stable elderly blunt chest trauma patients. patients and methods a retrospective analysis of all blunt trauma admissions at emek medical center between 2014-2018 years was performed in order to identify patients with blunt chest trauma. only stable trauma patients with abbreviated injury score (ais). results: among 473 patients that met inclusion criteria, there were 289(61%) patients aged 18-64 years old and 184 (39%) patients aged c 65. in the first group of patients (18-64), 240 had ct chest on arrival. in the second group of patients (aged c 65), there were 18 (9.7%) patients with missed injuries. in this group, patients who had ct chest on arrival, 7 of 130 (5.4%) patients had missed injuries. eleven of 54 (20%) patients who had no ct chest on arrival, diagnosed with missed injuries (p-0.014). readmission rate in the first group of patients (18-64) was 5 of 240 (2%) who had ct chest on arrival, and 2 of 49 (4%) who had cxr on arrival only (p-0.3). in the second group (c 65), readmission rate was 5 of 130 (3.8%) patients with ct chest on arrival, and 7 of 54 who had cxr on arrival only (13%) (p-0.051). conclusions: based on our study result we conclude that ct chest should be a first imaging tool in stable elderly patients with blunt chest trauma. no disclosures. efficacy and safety of small-bored tube thoracotomy for chest trauma: large-bored chest tubes will no longer be needed introduction: tube thoracostomy drainage is an important treatment for traumatic pneumothorax and hemothorax. traditionally, largebored chest tubes have been recommended for successful drainage and prevention for clogging by clots. however, there is little evidence that large-bored tubes are more effective than smaller ones. in consideration of invasiveness, in our emergency room (er), we use 20 fr chest tube for all trauma patients when chest thoracotomy is indicated. the aim of our study is to investigate the efficacy and safety of small-bored tubes for chest trauma patients. material and methods: we conducted a retrospective observational study. we included the adult patients ([ 18 years old) who had undergone tube thoracostomy with 20 fr chest tubes for chest trauma during the 5 years from october 2013 to september 2018 in our er. the patients with cardiopulmonary arrest on contact or on arrival were excluded. we evaluated tube-size related complications defined as obstruction and worsening of pneumothorax/hemothorax due to ineffective drainage. results: there were 102 eligible patients, 77% were male, mean age was 59.6 and the average injury severity score was 17.8 (± 9.6). sixty-six tube thoracostomies were performed by emergency physicians and 38 were performed by thoracic surgeons. the average duration of tube placement was 3.86 days (± 1.8). there were not any tube-size related complications nor any patients who required additional tube insertion. case history, clinical findings: 4 different stable hemodynamic cases with thoracoabdominal penetrating trauma and negative fast evaluation were enrolled in study. subsequent hemo/pneumothorax was managed initially by tube thoracostomy. investigation/results: hence laparoscopic investigation is an effective method for evaluation of diaphragmatic injuries in thoracoabdominal penetrating trauma, patients underwent diagnostic laparoscopy. in case 1, classic approach was done by open technique 10 mm port insertion in sub umbilical. two 5 mm ports inserted in lower abdomen at the level of midclavicular line. then 10 mm port was added in subxiphoid area and by introducing zero-degree camera through it a better exposure was obtained. in case 2, 10 mm sub umbilical port, 5 mm port in subxiphoid and another 5 mm working port at the level of umbilicus and right midclavicular line were applied. a 30-degree camera used. exposure, working space and exploration maneuvers were much easier to perform in compare with case 1. in case 3, port placement was identical to case 2 but zerodegree camera was used. due to poor exposure, subxiphoid port was replaced by a 10 mm one and used for camera insertion, then an acceptable exposure was obtained. in case 4, port placement of case 3 was used by using 30-degree camera which resulted in a great exposure. diagnosis, therapy, progressions: patients tolerated the operation well and underwent appropriate management according to their intra operation findings; post-op courses passed without any complications. comments: in patients with suspicious diaphragmatic injury and according to available facilities in our centers, in unilateral injuries we suggest that a 5 mm port in subxiphoid area can be used instead of contralateral midclavicular 5 mm port. in bilateral injuries, if enough exposure doesn't achieve, a 5 mm port in subxiphoid can be added. in absence of 30 degree cameras, 10 mm port use in subxiphoid can give surgeons better exposure. hemodynamic instability in patients with extremity injuries: motor vehicle accidents and shot wounds vs. explosions a. mahamid 1 , i. ashkenazi 1 1 hillel yaffe medical center, hadera, israel introduction: we previously reported that hemorrhagic instability (hs) was a complication of extremity injuries in as many as 1 of 7 of patients treated in one medical center following explosions. the objective of this study was to evaluate whether the prevalence of hs in patients with other high energetic injuries such as motor vehicle accidents and shot wounds (mva/sw) is different or not. material and methods: victims following mva/sw with extremity injuries and hs treated in one medical center during 2017 were identified with the aid of the national trauma registry and the center's blood bank. hs was defined as tachycardia (pulse [ 100/min) and/or hypotension (systolic pressure \ 100 mmhg) in need of blood transfusions to reverse instability. patients in whom hs could be attributed to injuries other than the extremity injury were excluded. these were compared to patients treated following bomb explosions (1994) (1995) (1996) (1997) (1998) (1999) (2000) (2001) (2002) (2003) (2004) (2005) conclusions: the proportion of patients in need of blood transfusion is much higher in patients whose extremity injury was caused by an explosion. the relative risk for hs is almost 5 times higher in these patients. new technologies in soft tissue wound management limit reconstruction complexity and enhance recovery introduction: large soft tissue losses are associated with infection, increased morbidity and mortality, increased costs and poor outcome functionality. the purpose of this study was to evaluate the efficacy of a combination treatment of combined topclosure ò tension relief system (trs) and administration of regulated oxygen and antibiotic irrigation negative pressure-assisted wound therapy (roi-npt) in the treatment of patients suffering from significant soft tissue loss. patients with open abdomen, large infected wounds, and extensive soft tissue loss treated with trs and roi-npt. results: full wound closure was achieved in [ 100 patients treated without skin grafts or flaps. primary failure was successfully followed with secondary closure with the same system. the trs system allowed early postoperative physiotherapy with good to excellent functional results. limitations and complications will be discussed. 1. trs is a novel device for stretching, and securing wound closure, applying stress relaxation and mechanical creep for primary closure of large skin defects that otherwise would have required closure by skin grafts, flaps or tissue expanders. 2. irrigation may accelerate the evacuation of infectious material from the wound and may provide a novel method for antibiotic administration. 3. supplemental oxygen to the wound reverses reduced o2 levels in the wound's atmosphere inherent to the conventional negative pressure-assisted wound therapy restricting vacuum use in anaerobic contamination. moris topaz is the inventor and patent holder of the topclosure ò and vcarea ò . attendees' perceptions about tourniquet safety use aboard, easiness of application, and preference among four devices tested assessed. material and methods: the descriptive study design assessed employing a post-seminar survey, participants' perceptions of tourniquet safety use, application easiness, and preference among the four devices tested (cat, sam-xt, swat-t, and rats). the first two variables measured on a one-to-ten scale (being ten the easiest or safest, and one the least easy or least safe), while preference was measured by frequency count, with only one device to select as the preferred. frequencies and percentages for categorical variables and averages calculated and compared using the anova test (p \ 0.01). results: a total of 51 sailors, 12 (24%) females, and 39 (76%) males, aged between 20 and 21, participated in the workshop and completed the survey. the mean for the perception of safety regarding onboard usage was 7.5. as for application easiness, cat and sam-xt ranked equally high (8.5), followed by swat (7.9) and rats (6.9), and the only statistical difference found was for rats (p \ 0.01). cat was reported as preferred by 38 participants (74%), followed by sam-xt 10 (20%), swat-t 2 (4%), and rats 1 (2%). conclusions: jse crewmembers (non-medical personnel) considered safe the use of tourniquets on board. of the four devices assessed, cat and sam-xt were regarded as equally easy to use and rats the least of all. cat was reported as preferred by almost three out of every four respondents. introduction: surge capacity is the ability to manage the increased influx of critically ill or injured patients during suddenly onset crisis, like a mass-casualty incident (mci) or disaster. during such an event all ordinary resources are activated and used in a systematic, structured and planned way. there are, however, situations where conventional healthcare means are insufficient and additional resources must be summoned. this study investigates the possibility of using community resources such as primary health care centers, nonmedical professionals and non-standardized facilities together with educational initiatives to increase surge capacity in a flexible manner. purpose: to investigate the possibility of an increased and flexible surge capacity during a crisis, disaster or mass casualty incident (mci) by examining the main components of surge capacity (sc) (staff, stuff, structure, and system) in the västragötaland region of sweden. method: this thesis uses a mixed methods research approach with an explanatory sequential design. a literature search was performed by using standard search engines utilizing relevant keywords, questionnaires and semistructured interviews were used for data collection from primary health care centers, dental and veterinary clinics, schools, hotels and sports facilities to determine capabilities, barriers, limitations and interest to be included in a flexible surge capacity system. results: preliminary findings indicate that there is interest, capacity and capability in the investigated municipalities to partake in a fscplan: primary healthcare centers can be toned up with drills and exercises, civilians can be educated in advanced first aid procedures (immediate responders) and focused leadership (scene management), schools, hotels and sports facilities can be prepared with advanced first aids kits and be used as alternative care facilities. these alternatives together represent the concept of flexible surge capacity. conclusion: flexible surge capacity can be a possible approach to create extra resources in disaster situations, mci's, or whenever supporting infrastructure is not intact. new educational initiatives, drills and exercises, laymen empowerment and organizational and legal changes might be needed to realize a flexible surge capacity. introduction: a hospital may need partial or total evacuation because of internal or external incidents, such as in natural disasters and or armed conflicts. an evacuation aims either to transport a large number of patients to other medical facilities or to prepare enough space to receive a large number of victims. despite many publications and reports on successful and unsuccessful evacuations, and lessons learned, there is still no standardized guide for such an evacuation, and many hospitals lack the proper preparedness. we aimed to analyze the preparedness of hospitals for a total evacuation by looking into some key parameters necessary for a successful performance. material and methods: a literature search was performed by using the standard search motors in the related fields, and by using relevant keywords. eleven questions were sent to representatives from 15 euand non-eu countries. results: our findings indicate that there is neither a full preparedness nor a standard guideline for evacuation within the eu or other non-eu countries included in this study. some countries did not respond to our questions due to the lack of relevant guidelines, instructions, or time. conclusions: hospitals are exposed to internal and external incidents and require an adequate evacuation plan. there is a need for a multinational collaboration, specifically within the eu, to establish a standardized evacuation plan. references: nero c, ö rtenwall p, khorram-manesh a. hospital evacuation; planning, assessment, performance and evaluation. j acute dis. 2012;1(1):58-64. introduction: the importance of and the need for medical management during any armed conflict is a fact. many medical achievements have been accomplished due to wars and armed conflicts. the world is, however, divided into countries with and without related military healthcare services. there is a need for joint structure with the civilian in the former, while in the latter the civilian healthcare is responsible for offering services to the military. this study aims to identify the needs of military healthcare system and military medicine as an independent specialty. material and methods: a literature search was performed by using the standard search motors in the related fields, and by using relevant keywords. relevant professionals were asked about the pros and cons of having established military healthcare. the data was collected and analyzed. results: although our findings indicate a need for military medicine/ healthcare as a professional specialty, the organizational divisions between military and civilian healthcare systems seems to be changing. the current security issues worldwide, the pattern of injuries and resource scarcity indicates a need for improved collaboration and maybe a fusion between these entities. conclusions: new security threats, modern technology, the pattern of medical injuries, and the lack of adequate surge capacity may indicate a very close collaboration between military and civilian healthcare systems. such a close collaboration may develop to fusion and a total defense healthcare system that can act both in peace and during conflicts. references: ringel js. the elasticity of demand for health care. a review of the literature and its application to the military health system. https://apps.dtic.mil/docs/citations/ada403148 khorram-manesh, a. facilitators and constrainers of civilian-military collaboration: the swedish perspectives. eur j trauma emerg surg. 2018. https://doi.org/10.1007/s00068-018-1058-9. alternative methods of mandibular comminuted fracture fixation in severe maxillofacial injured patients introduction: severe maxillofacial injuries refer to significant facial trauma with communitive bony fractures and soft tissue loss. they result in violent trauma as firearm injuries (wartimes injuries, terrorist attack, suicide attempt) and high velocity motor vehicle accidents. the initial management consist of fighting hemorrhage, fighting asphyxia, wounds debridement and suture, and fractures stabilization, especially mandibular fracture stabilization. our study aims to share thoughts on the alternative methods of comminuted mandibular fracture fixation within the context: kind of injury, multitrauma patients, mass-casualty situation, precarious situation or hostile environment. material and methods: based on our experience (clinical cases), on senior surgeons questioning and on medical literature data, we sought to identify, to evaluate and to compare the different available methods to stabilize comminuted mandibular fractures in severe facial injured patients. results: open reduction and stable internal fixation (using macro plate), external pin fixation and closed reduction with maxillomandibular fixation are the methods of treatment which are the most classically used and described. however, some methods using kirschner wires are reported: in cross extrafocal pinning ( fig. 1) , external fixation and handmade splints. all these methods differ in their complexity of use, in their availability, and in their possibilities to treat one kind of mandibular fracture or another. conclusions: the stabilization method of comminuted mandibular fracture will be choose depending on material availability, on surgeon's abilities, on the time available (mass-casualty situation) and on the patient's overall condition. even if stabilization methods using wires are less commonly used, they appear to us to be useful in the initial management of the severe maxillofacial injured patient with comminuted mandibular fracture, especially in austere conditions. causes of combat casualties' death at medical treatment facilities (mtf) in modern conflicts: russian experience i. samokhvalov 1 , v. badalov 1 , k. golovko 1 , t. suprun 1 , v. chupriaev 1 material and methods: data including mechanism of injury, physiologic and laboratory variables, staged surgical treatment and cause of death were obtained from the combat trauma registry of the kirov military medical academy war surgery department. the combat trauma registry includes 5581 russian wounded in military conflicts over the past decades, 451 of them (8.1%) dead of wounds (dow) at the mtf. results: 50.3% of the total dow number died at the role ii field medical units, 17.3% died at the forward military role iii hospitals, and 32.4% died at the role iv hospitals. the causes of dow patients delivered to the mtf were nonsurvivable traumatic brain wound (19.7%), life-threatening consequences of injuries-mainly massive blood loss due to external and internal bleeding and acute respiratory failure (34.8%), as well as the late septic complications (45.5%). terms of death depended on the cause of dow. so for nonsurvivable traumatic brain injuries, they amounted to 0.5 ± 0.1 days, for lifethreatening consequences of wounds-2.1 ± 0.2 days, and in the development of complications-15.7 ± 0.3 days. conclusions: there is a high mortality rate among the combat casualties delivered to mtf in modern asymmetric warfare (8.1%). moreover, half of these patients (50.3%) die at role ii field medical units mostly from nonsurvivable injuries and from acute irreversible blood loss that occurred at the prehospital stage. the main cause of hospital combat mortality is severe septic complications of combat trauma. in consideration of the present counterterrorism practices, prevention and initial treatment for primary blast injury by shock waves constitute a particularly urgent subject because blast injuries and gunshot wounds account for the majority of terrorism deaths. in japan, due to strict ethical standards in animal experiments, there is no appropriate animal model of blast injury. we established an original small animal model of blast injury using a laser-induced shock wave at the national defense medical college (ndmc). however, since the experiments were conducted using only small animals, such as mice and rats, it was necessary to establish a medium-sized animal model aimed to test the applicability in human patients in the long term. correspondingly, we established a blast tube, which was authorized globally as a shock wave-generating device that causes blast injury based on air pressure differences, in the ndmc research institute using the budget of advanced research on military medicine of japan in 2017. this allowed us to conduct scientific studies on blast injury using mediumsized animals. in this presentation, we will introduce the structure and function of the blast tube installed in the ndmc and present some of the results of our research thus far. this research is financially unfortunately, even if hospital and their staff are an essential key for successful response to mcis, the plan are seldom well-known and, above all, exercises are quite neglected at local and national levels. due to mci rarity, simulation exercises are the only way to achieve proficiency in mci response. therefore, we tested an original mci training system (macsim ò ) adapted to the pemaf of a large university hospital in milan (italy). material and methods: the original mci training format called macsim-pemaf (emergency plan for massive influx of casualties)was developed for the italian society for trauma and emergency surgery (sicut) in 2016. it uses macsim ò , a simulation tool scientifically validated for training and assessment of healthcare professionals in mci management. between 2016 and 2018 the course was held for the emergency department staff of a single university hospital of milan (italy) (foundation cà granda-ospedale maggiore policlinico). macsim ò was used to reproduce the hospital resources, with different mci scenarios. during the simulation the participants had the opportunity to test the local pemaf, in adjunct to their knowledge and skills. course effectiveness was evaluated by a pre-and post-course self-assessment questionnaire. results: macsim-pemaf was tested in seven courses, for a total of 258 participants. pre-and post-test questionnaires showed a significant improvement in hospital staff self-perception of knowledge and skills in mci management. on a 1-10 scale, the improvement value was from 4.4 ± 2.5 to 7.5 ± 1.9 (p \ 0.001). conclusions: macsim-pemaf is a useful tool to test single hospital pemaf. it is versatile enough to adapt to specific realties, mimicking different traumatic scenarios. participants, acting in their usual professional roles, can increase their self-perception to be able to respond to a mci with in-hospital resources. introduction: emt are field health facilities, specifically structured to operate in case of disaster, where local healthcare resources are insufficient. there are 3 types of emt. ''emt2 regione piemonte'' is the first italian emt to be certificated by who. it's a type 2, meaning that more than triage and stabilization of emergency cases it's provided with an icu, a 24/7 working operation room, a test lab, radiological and ultrasound devices. it can admit up to 20 inpatients. cyclone idai made landfall on 3/15/19 in the district of dondo in mozambique. it brought torrential rains and strong winds and had heavy impacts on the city of beira and surrounding areas resulting in loss of communication and access. in addition important damage and destruction to shelter, settlements, health and wash facilities occurred. on 3/20 italian government approved the aid mission, from march 21st to 26th three italian military aircraft transported the medical staff and the boxes containing the hospital to maputo and then in beira. on 3/30, the hospital began working, treating an average of 80 patients and performing 4-5 surgeries per day, involving mozambican staff who immediately well integrated with the italian colleagues. results: 25 days of activities. 62 surgeries (28 orthopaedic, 10 general surgery, 18 gynaecology, 6 plastic surgery). 35.4% of the cases related to cyclone. mean tiss: 10 (8-13). mean age 33 (1-73) 34 females, 28 males. types of anaesthesia: 73% locoregional, 10% general, 17% analgosedation. conclusions: our first experience in a mass casualties' scenario showed how important is to refresh team skills through periodic drills. the leadership is of paramount importance to keep the team united and to support collaboration with other nations' teams and with the local population. adaptability and open-mindedness are fundamental. emts do not arrive in loco immediately so that longer periods of mission and integration with local medical staffs should be programmed. introduction: in utrecht, the netherlands, a worldwide unique major incident hospital is continuously standby to receive multiple victims during mass casualty events. each year, different types of mass casualty events are simulated with a varying number of victims, to train command and control under extreme circumstances. in utrecht, on march 18th 2019, a terrorist opened gunshot fire in crowded public transport. the aim of the study is to compare our experiences in simulation versus reality. material and methods: an internal evaluation was performed by questionnaires completed by participants and an external evaluation was performed by interviews. results: all five victims were brought to the major incident hospital, of whom two were dead on arrival, one died seven days after due to multiple organ failure and two survived after multiple surgical procedures. all victims arrived within 36 min after the major incident hospital was activated. a sufficient number of medical staff was alarmed for these five victims, however, since the event occurred during office hours, at least a double amount of staff showed up. among some medical staff on commanding key positions fear arose about their own safety and of relatives outside the hospital. this was exaggerated by incomplete and incorrect provided information from the scene. although medical care of the victims was not affected at all, occasionally the anxiety negatively influenced the command and control structure. conclusions: the combination of anxiety and a surplus of awaiting and benevolent curious medical staff resulted in occasional insufficient performance of the existing command and control structure, despite proper training. however, simulation of fear in a training is very difficult. nowadays, with the increasing threat of terror attacks, one should be aware of the influence of fear and anxiety on personnel, even with low numbers of victims. ethic and law issues during mass casualties management operations in foreign countries introduction: mass casualties incidents occur even more frequently during the last years globally. international help in order to manage them, when needed and asked, has to take into consideration special aspects of ethics and local law status in order to successfully fulfill its expectation. purpose: to demonstrate the ethic and law issues that arise during mass casualties management operations in foreign countries. material and method: literature review from recent management operations in syria, iran and sub saharan africa. results: during such operations a lot of ethical and law issues arise. the knowledge of ethics and laws in the country that these take place is essential and critical for the successful result of them. special care must be taken for the management of women, children and dead people. traditions and religion status of the local populations also must be taken into consideration and actions must take place in accordance to respect of the local authorities and social conditions. conclusions: mass casualties management operations in foreign countries is a challenging mission. ethic and law issues arise and must be taken into consideration for the success of the mission. western surgical experience is one thing, but surgical practice in countries in conflict zones is another. the pathologies are different, the thermal conditions are often difficult and the follow-up of the patients is fundamentally modified. humanitarian surgery is becoming more professional and most organizations are setting up a training program for new surgeons embarking on the humanitarian adventure. international committee of the red cross (icrc) has implemented an onboarding-surgeon experience, before to become a fully icrc surgeon. i hereby present my personal onboarding experience in south sudan: how to learn a new type of surgery, how to come with an helicopter to collect patients in the bush and then, how much you learn about yourself. conflict of interest: i only represent my own experience and i do not represent icrc. surgical clinical reasoning during the war in the period between 1992 and 1996, i was the head of operating rooms and icu at the clinic for orthopedic surgery and traumatology, in sarajevo. working in the operating room whose walls are shaking because of the sniping and shelling was not remembered by any other generation of surgeons. there were around 55000 traumatized citizens of sarajevo. thousands of injured, dying patients were seeking for help from a small number of surgeons. the duty of a surgeon working in the war conditions, without water, electricity, medicines, or heat, is not easy at all, and there were a lot of difficult situations. for example, one day, operated children were again wounded by direct shelling on the walls of pediatric department of our clinic. after we re-operated the children, we also operated the injured nurses. 27th may, 1992 , 5th february, 1994 , and 28th august, 1995 were the most painful experiences in the surgical treatment of disaster in the center of sarajevo, with a large number of massively traumatized patients. while you were helping one casualty, others were pulling our arms or legs. while you were helping one patient, others were dying in the cramp of pain. during the war, a series of traumatic events happened. above many thousands of them, i admitted a 13-year-old girl, severely injured, with traumatic lower leg amputation of the leg, and severe injuries of the thigh, pelvis, and neck. we operated on her through the night. during the surgery, she received 51 whole blood transfusions. following the surgery, she was stabilized on pediatric department of our clinic. one day, i saw her mother brought her a gift, immensely valuable in those days, a small canister of pure water. in the 2008, one girl approached me, and asked me if i remembered her. i remembered the canister of pure water. she was happy to show me how she can walk now, and told me she lives in canada and works as a university assistant. i was more than happy to see her walk proudly, as she was leaving. she injury pattern of 2019 earthquake in athens, greece: the panic-effect introduction: earthquakes are devastating events. greece is known to be in the first place of seismicity in europe and sixth worldwide. lately, a 5.1 richter earthquake shook the greek capital, and fortunately no substantial construction damage was sustained. the aim of the study is to evaluate the classification and severity of all injuries, as well as the type of orthopedic surgical procedures performed, in addition to the role that panic plays on the occurrence of these kind of trauma material and methods: prospective case-series study, conducted in the emergency department of our hospital after the july 19th, 2019 earthquake. the study included 18 patients treated by our department, who sustained injuries in their attempt to run away from the scene. age range was from 20 to 84 years old (mean 54.9 y.o), 11 were female and 7 were male. results: a total of 23 injuries reviewed. upper extremities were involved in 9 of all cases, lower extremities in 13 and one patient suffered minor head trauma. four patients required hospitalization and all of them underwent surgical treatment. open reduction and internal fixation performed in 2 patients (1 calcaneus fracture and 1 olecranon fracture), 1 patient underwent intramedullary nail fixation (tibial shaft fracture) and external fixation was applied to another (distal tibia fracture). six patients were conclusions: panic is an independent contributing factor in natural disaster associated trauma. prior education, preparedness and combined team effort are clearly needed, in order to reduce the incidence of these injuries. regardless of age, panic may result in various types of fractures, even in cases there are no substantial construction damages after an earthquake. digital and analogue record system for mass casualty incidences at sea: results, reliability and validity introduction: mistriage may have serious consequences for patients in mass causality incidences (mci) at sea. therefore, an exercise was conducted to compare the reliability and validity of an analogue and tablet based recording system for triage of sample patients. material and methods: 50 volunteers were asked to triage with the start-algorithm (black, red, yellow and green) 50 patients in a given time using an analogue and tablet based system. triage score distribution and agreement between the two triage methods and a predefined standard were reported. the present study assessed the triage results as well as the reliability through cronbachs alpha and kappa. for testing of validity and internal consistency, the sensitivity, specificity and predictive value was measured. results: forty-eight participants completed a total of 3545 triages. while the number of triaged patients in the given time was significantly higher with the analogue system compared to the digital system (p-value 0.001, t-test), the validity measured with the cronbachs alpha and unweighted cohens kappa was higher with the digital system. for each triage category, higher values were gained with the digital system. the sensitivity, specificity and predictive value for the digital system was higher than for the analogue system. conclusions: this study gives reliable and valid results comparing a digital versus an analogue triage system for a mci at sea. significant differences could be found for the number of triages and the number of under triage. the results of the study show that the used digital system has a slightly higher reliability and validity than the analogue triage system. references: the present work is part of the project improved emergency treatment and organization in the event of a mass casualty of casualties at sea (venomas), planned within the framework of the research network ''kompetenz und organisation für den massenanfall von patienten in der seeschifffahrt'' (kompass) and funded by the federal ministry of education and research (grant number: 13n13256). predicting outcome for extremity wounds in pediatric casualties of war introduction: during the early 90s, the international committee of the red cross (icrc) implemented the red cross wound classification (rcwc) for penetrating wounds. wound grades of 1, 2 and 3 describe the amount of kinetic energy transferred to the tissue (low, high and massive, respectively). currently, this classification system mostly serves as a descriptive tool, but it is hypothesized it could also support clinical decision making. the aim of this study is to assess whether the wound grade of a pediatric patient's extremity wound correlates with patient outcomes. material and methods: this study included pediatric patients (age \ 15 years), who have been treated by the icrc for conflictrelated extremity injuries between 1988 and 2012. the correlation of the following variables with the wound grade were analyzed: number of surgeries required, length of stay, and in-hospital mortality. results: the study cohort consisted of 2459 pediatric patients. the higher the wound grade, the more surgeries were performed per patient (p \ 0.05), with a mean of 4 surgeries per patient if they had a wound grading of 3. there were no significant differences in mortality rates between any of the wound grades, which were 1.0% (20/1953), 0.0% (0/342) and 1.9% (3/161) for wound grade 1, 2 and 3 respectively. pediatric patients with wound grade 3 were hospitalized for the longest period (mean 49.6 days), followed by wound grade 2 (mean 40.0 days) and wound grade 1 (mean 25.9 days; all with p \ 0.05). conclusions: the wound grade of pediatric patients' extremity wounds appears to correlate with some patient outcomes, but not with mortality. grading of extremity wounds according to the rcws could support clinical decision making in pediatric patients. introduction: during the last few decades, french armed forces have regularly deployed in asymmetric conflicts. surgical support for casualties of these conflicts occurs in nato role 2 and 3 medical treatment facilities (mtf); definitive surgical care occurs in france following a strategic medical evacuation. the aim of this study was to describe the combat injury profile of these soldiers who presented with either non-exclusively orthopedic and/or non-exclusively brain injuries. material and methods: this descriptive study is a retrospective analysis of the surgical management of french casualties performed in role 2 or 3 mtf in afghanistan, mali, niger, djibouti and the central african republic between january 2004 and december 2014. results: one hundred patients were included. forty had fragment wounds. the most severe lesions were of the head, neck or thorax. the average injury severity score (iss) was 34.9 (ic 95% 29.8-40). 17 damage control procedures were performed. thirty patients died with a mean iss of 61 (ic 95% 56-67); 5 deaths were considered as preventable deaths. the most frequent surgical procedures in the mtf were digestive (n = 31) and thoracic surgery (n = 19). thirty patients needed second-look surgery in france; eleven had severe complications. no patient died following medical evacuation to france. conclusions: results from this study indicate that the mortality following non-exclusively brain or orthopedic injuries remains high in modern asymmetric conflicts. introduction: telemedicine has been applied to disasters and extreme environments for more than 20 years, however, despite the many lessons learned so far, telemedicine is still not a common part of the immediate disaster response. for this reason, a review of the literature was conducted to investigate whether telemedicine technology can be used to address medical and non-medical needs in extreme environments. material and methods: this systematic review included 9 studies published in the period 2000-2019, originating from literature search bases medline, scopus, cinahl and pubmed. the case of neemo project were studied so to evaluate the diagnostical and surgical care of the patients regarding the emergency response in a remote and constricted area, with limited human medical resources and using the telecommunications and telerobotic technologies. results: the majority of the included studies have highlighted the importance of telemedicine interventions in extreme environments, stressing that it is a viable solution to health care provision. in addition, it has been found that telemedicinal technology provides the possibility of virtual collaboration between healthcare professionals with various specializations. projects neemo 7,9,12 engaged to eliminate the challenges of telesurgery. conclusions: future studies such as large multicentre randomized trials will have to be conducted that will lead to safe conclusions on the usefulness and efficiency of telemedicine applications in extreme environments. introduction: tourniquets are a critical tool in the immediate response to life-threatening extremity hemorrhage. the optimal tourniquet type and effectiveness of non-commercial devices is unclear, and the aim of this study. material and methods: this prospective observational cadaverbased study was performed using a perfused cadaver model with a standardized superficial femoral artery injury bleeding at 700 ml/ min. five devices were tested: cat (combat application tourniquet), rats (rapid application tourniquet system), swat-t (stretch, wrap, and tuck tourniquet), a triangle bandage and a stick and a leather belt. 48 volunteer medical students with no prior clinical tourniquet experience participated. each student underwent a practical hands-on demonstration of each of the 5 tourniquets, prior to the test. using a random number generator, they then placed all 5 tourniquets in random order. outcomes measures included time to hemostasis, total time to secure devices, estimated blood loss (ebl) and difficulty rating. a one-way anova repeated measures was used to compare efficacy between the tourniquets in achieving the outcomes. results: participants' mean age was 25 ± 2.6 years and 29 (60%) were male. all participants were able to stop the bleeding with 4 of the 5 tourniquets. with the rats there was a 4% failure rate. among the five types of tourniquets, time to hemostasis and ebl were not statistically significantly different (p [ 0.05). the swat-t required the longest time to be secured (47.8 ± 17.0), while the belt was the fastest (15.2 ± 6.5; p \ 0.001). conclusions: all five tourniquets, including the non-commercial devices, were effective in achieving hemostasis. a standard leather belt was the fastest to place and able to stop the bleeding. however, it required continuous pressure to maintain hemostasis. nevertheless, in an emergency setting where commercial devices are not available, improvised tourniquets may be an affective lifesaving bridge to definitive care. hospital preparedness for mass gathering events and mass casualty incidents in matera, european capital of culture for 2019 introduction: mass casualty incidents (mci) may occur during mass gathering events (mge). lack of preparedness of health system increases mortality. education and training are crucial. hospital mci plans are mandatory in italy, but they are poorly known. on 2014, matera was declared italian host of european capital of culture for 2019: the local hospital decided to revise the hospital plan for massive influx of injured (pemaf) and to start a program to train the staff. material and methods: the pemaf was reviewed through simulations that involved all the staff. a partnership with mrmi-italia (italian chapter of the international association medical response to major incident and disaster-mrmi&d) leaded to the support of experts and to the organization of residential courses based on the macsim ò (mass casualty simulation) simulation tool. educational capacity of the residential events was tested through a self-assessment tool. results: alert, coordination and command sequences were defined. all the available resources were recorded and the functional areas identified. the communication network was improved. documentation and registration system was prepared. standard operational procedures (action cards) were created for the key positions. 7 residential educational events of macsim-pemaf were organized. the educational capacity was tested through self-evaluation: knowledge of participants resulted improved. conclusions: mge are a great opportunity for the hosting community but they also represent an increased risk of mci. preparedness is mandatory for health system. the format macsim-pemaf seems to be adequate to review the existing plans and transfer skills to attendants. introduction: the cruise industry is facing a constantly growth of infectious diseases. some of them are reaching the extent of mass casualty incidences (mci), which are overwhelming the capacity of the local rescue system. our aim was to improve the ability to act in a mci due to an infectious emergency regarding the situation at sea/in the port. hamburg, as one of the largest ports in europe, was chosen for analysis. material and methods: the collaborative project ''adaptive resilience management in the port'' (armihn) is funded by the german federal ministry of education and research. scenarios due to an infectiological emergency were developed together with the university central department of occupational medicine and maritime medicine and the hamburg port health center in hamburg, germany. these scenarios were specified with all key stakeholders in the port. the organizational structure of the current emergency management was analyzed and a new concept was developed. results: for the ship and the port, emergency strategies dealing with mass casualties of injured persons are available. nevertheless, current concepts regarding this special situation of an infectiological mci were missing. we developed a new concept, which based on the models concerning mass casualties of injured persons. for this purpose, emergency surgeons can be recommended as experts regarding coping with a major emergency and for developing adaptive training concepts. conclusions: new operational concepts coping with mci of infectious patients were developed. in a second step, an emergency plan and a training concept for relevant stakeholders in the port will be developed. these will be evaluated in a full exercise in the port of hamburg and tested for their suitability. the results will be transferred to comparable infrastructures to cope with a major case incident with infected people in the port area. emergency surgeons should be involved in these steps due to their expertise. the work was funded by the german federal ministry of education and research (13n14925). no further significant relationships. war surgery training, the use of swine model in military simulation center introduction: due to the international instability, our forces are deployed in many place and our military surgeons have to deal with ballistics trauma and improvised explosive devices related trauma. in order to be well prepared and effective in these isolated situation, the val de grace school (our military health service academy) provide a 2 years course to train the young surgeon. this 2 year surgical courses ended with war trauma surgery simulation on a swine model. material and methods: this use of the swine alive model is incorporated in the cesimco (military surgical simulation center) and also use for the training of our fully registered surgical team. this laboratory responds to all civilian authorizations and ethical considerations as enacted by european rules (felasa). results: the aim of this presentation is to show the different procedures and the teaching provided in this structure to improve surgical skills in war condition. all procedures are approved by the ministry in charge of the animal experimentation and respond to the animal welfare regulation. the number of swine used in these teaching is reduced to the minimum. we think that this animal model and its use in military forward surgical facilities, is the end point of the 2 years military surgical course provided by the val de grace school. conclusions: this model is actually the most reliable and ethically acceptable teaching procedure we've found. during these teaching the students have to deal with open trauma and hemorrhagic lesions in damage control situation. we try to follow the different type of war related lesions observed in french military in order to stick to the reality of the field. this teaching is now mandatory before being deployed as a military surgeon on field. case history: 29-year-old male, previously healthy, admitted to the er due to shotgun injury to the right hip. during transport, the bleeding open wound was covered, two iv catheters were introduced, and saline and painkillers were administered. on admission, the patient was conscious, eupneic and normotensive, with a gcs score of 15. clinical findings: after the primary survey and exclusion of cranial, thoracic and abdominal lesions, the limb injury was addressed, showing a 3 9 4 cm oval-shaped wound. the right leg was shortened and externally rotated. pulses were present but the patient referred calf and foot hypoesthesia. investigation/results: x-rays showed a comminuted pertrochanteric fracture and the presence of metallic foreign bodies. diagnosis: open right pertrochanteric fracture. therapy and progressions: initially, the wound was covered, and iv antibiotics and supportive therapy were given. in the or, irrigation, surgical debridement, and foreign body removal were performed, followed by orif with one dall-miles cable and a cephalomedullary femoral long nail. after surgery, the patient maintained lower limb hypoesthesia and had plantar flexion and foot dorsiflexion grade 0 motor deficit. during follow-up, soft tissues recovered uneventfully and bone healing successfully occurred. full weight-bearing was tolerated at 6 weeks post-op but the neurological deficits persisted despite physiatric treatment. electromyography confirmed severe partial lesion of the sciatic nerve. comments: generally, clean wound, fracture stability, restoration of circulation and skin closure of neurovascular structures are a priority and should be a reason for delayed nerve repair. introduction: despite mass casualty incidents (mci) are becoming a common concern, particularly regarding the care of paediatric victims, pure paediatric trauma centres (ptc) are still rare in europe. the purpose of this study is to assess the capacity of the hospitals in the metropolitan area of milan in case of mci involving the paediatric population, with focus on the pre-impact planning phase. material and methods: relevant literature and existing guidelines were reviewed by the representatives of four referral centres for the management of either trauma or paediatric patients. minimum standard requirements of care of paediatric trauma and consequently the maximal surge capacities for each hospital were defined based on the severity of injuries and personnel/equipment availability. results: overall, the four hospitals are able to treat 8 patients with the highest priority (t1), 8 to 12 patients with intermediate priority (t2), and 24 patients with deferrable priority (t3). severely injured patients \ 3 years old should be preferentially transported to the hospitals with paediatric expertise, whereas patients between 3 to 12 years of age can be managed in multi-speciality structures. conclusions: in case of mci it is not always possible to rely on the availability of a ptc. hospitals with paediatric trauma care expertise can work in synergy with ptcs, or offer an alternative if there is no ptc, and should therefore be included in disaster plans for mci involving paediatric victims. case history: we present a case of a 46-year-old male with a proximal radius and ulna gunshot fracture associated with a complete lesion of the brachial artery, which was urgently repaired by grafting in his native country. a partial proximal radius excision was also performed. three months later, after soft tissue recovery, the ulna fracture was fixed with a dcp plate plus iliac crest bone graft. at 2 months follow up x-rays showed hardware loosening, so the plate was removed and an external fixator was implanted. in this situation the patient attended to our clinic 18 months after the initial injury. clinical findings: findings included proximal pin purulence, an elbow varus deformity and a limited joint motion: flexion 45°, extension 40°, supination/pronation 20°. investigation/results: x-rays and ct scan showed proximal ulna pseudoarthrosis. diagnosis: proximal ulna pseudoarthrosis after a gunshot fracture. therapy and progressions: a two-stage procedure was performed. initially we performed a wide debridement and external fixator removal. an ulna nail combined with gentamicin and vancomycin pmma spacer was implanted. s. aureus was identified in intraoperative cultures. in a second stage, 1 year after, the nail and spacer were removed and a vascularized fibula graft with saphenous loop was implanted and fixed with a va-lcp plate. the central band of the interosseous membrane was repaired with a prosthetic device. currently, the patient presents full flexion range, hyperextension of 20°, active pronation of 50°and supination of 20°. x-rays show graft consolidation. comments: gunshot fractures are complicated lesions with significant soft tissue damage and high risk of vascular and nervous injury. a thorough study and initial systematic approach is mandatory in order to avoid later complications. introduction: the purpose of our study was to independently analyze pediatric trauma data, especially that of preschool-aged children, including demographics, injury patterns, the associated mechanism of injury, and outcomes, at a single institution in korea to gain a better understanding of current trends in non-regional trauma centers. material and methods: we conducted a retrospective review of preschool-aged children with trauma, who presented to the emergency department a single center between march 2010 and december 2018. results: overall, there were 303 pediatric patients who experienced trauma admitted during this study period. the frequency of admissions was similarly high in all seasons except winter. falls were the most common mechanism of injury at all ages, except 1, 2, and 4 years of age, according to comparative analysis by age and mechanism. the most common place of trauma at 1-3 years of age was at home, and outside the home at the age of 4 years or older. the most common injury region was to an extremity (65.7%). mean injury severity score was 5 ± 4.3, and the mean hospital stay was 5.9 ± 10.4 days. conclusions: although mortality from trauma is low in pediatric patients, we must continue to improve treatment outcomes for children. it is unlikely for a hospital to have a pediatric trauma specialist, such as a pediatric orthopedic surgeon or plastic surgeon, due to manpower constraints. in order to further improve the outcome of treatment with insufficient resources, it is necessary to recognize agespecific characteristics. question: the new safety situation in europe and the lessons learnt civilian events of damage show that hospitals have to be prepared for mass casualties. the shift of the operational mode to ''emergency medicine'' have to be planed and practiced. the reporting tool for this is the hospital action plan (hap) that every hospital should have. the efficiency of the existing plan is already proven in different largescale exercises. in germany the legislator obligates the hospitals to enable there staff to properly perform the different tasks of the hap. in addition, the have to develop and evaluate proper training and exercises. goal of this study was to establish along the hap of a level one trauma center an modular mass casualty training (manv 100) that would help to analyze the tasks to face and to deepen the existing structures of communication. method: we set a scenario with 100 casualties and evolved the different shifting phases of the trauma center (alarming-, mobilization-, constitution phase). setting the concept of training outside the regular service period we took in account that there will be a lack of resources and material. we did not exercise in a large-scale but trained in small groups modular. we also did a screen adaption of the hap of the trauma center to have a mind set for the staff and a starting point to the scenario. to teach our operative procedure we simulated our ''3 columns concept'' (medical, personal and infrastructure) to the staff. specific to the different task groups (medical doctors, technicians, nurses) we exercised and the different sectors (er, triage, or, command etc.) and the necessary shifts of the different hospital sectors when a mass casualty occurs. before and after we did a query of the staff to see how much impact the modular exercise would have on the hap-knowledge of our staff. results: we were able to simulate realistically an identical mass casualty scenario to different staff groups of our hospital. knowledge about the hap increased significant from 76 to 92% after the trainings. 97% of the staff see a clear improvement of information about the hap. also, the specific shifting-phases and the enrolment of the plan to move in an ''emergency medicine mode'' understand 85% better. 95% of the staff fell now a much better preparedness than before. 89% think that through modular exercises and small group training the communication in between working groups improved. conclusion: we could manage to improve a significant increase of knowledge about the hap in our staff. all the small group modular training in the different sector can be easily but together in large-scale exercise and other teams like police, military or fire-department can easily be added. introduction: dstc course focusses on surgical skills for trauma care. it is designed to teach surgical techniques for the definitive treatment of severe trauma. currently, it has evolved into an international trauma team course. our objective was to assess faculty members' opinion regarding course content, educational methods, and incorporation of non-technical skills. material and methods: a descriptive study was designed using an anonymous online survey issued from may 1 to august 31, 2019. senior international faculties' opinion from 19 countries assessed. the survey inquired views of courses content, duration, adequacy of hands-on practice, need for updates, and usefulness of incorporating non-technical skills to the course. results: from the 102 surveys issued, 36 were (35%) answered. the course content was valued as very satisfactory by 58%; 97% were very satisfied or satisfied with courses educational method. 80% considered the time devoted to lectures, case discussions, and skills lab very adequate or adequate. course duration (2 days) was valued suitably by 80% of responders. the inclusion of non-technical skills was considered as very important by 19%, important 31%, of some importance 11%, of little importance by 31%, and unimportant by 8%. this result reflects the insufficient sense of significance, among some, of the importance of trauma team dynamics. course content updates were seen as convenient by 97% of the surveyed population, suggesting them at least every 2-4 years. conclusions: dstc international faculty response to the online survey tool was inadequate, receiving 35% of the targeted study population. of the assessed faculty, most were satisfied with course content, duration, and educational methods. the surveyed population lacked a uniform perception of the importance of incorporating nontechnical skills. introduction: dstc is an iatsic course emphasizing on teaching surgical skills for trauma care. in many countries, it is an essential course focused on the ''second hour'' beyond atls and teamwork. initially centered on the surgeon, it currently seems to be adopting a trauma team training (ttt) model, incorporating the anesthetist to the program (ds-datc). our objective was to review this changing trend in three countries: spain, portugal, and brazil. material and methods: a descriptive study was designed by faculty from the three countries examining course records and analyzing its evolution during the last five years. number and types of courses delivered in each country from 2015 to 2019 reported, and the proportion of dstc to ds-datc scrutinized. frequencies and percentages calculated for categorical variables and the proportion of course types also determined. results: during the 5-year studied period, 70 dstc courses were issued: 34 (48%) in spain, 30 (43%) in brazil, and 6 (9%) in portugal. a total of 15 (21%) ds-datc courses in the three countries, and the percentage of total delivered in each country was as follows; spain 7 (21%), portugal 5 (83%) and brazil 3 (10%). overall ds-datc to dstc ratio was 1:5, detailed as follows: portugal 5:6, spain 7:34, and introduction: thailand is a disaster-prone country with a high dependency on tourism. it has been affected by both natural and manmade emergencies. the thai emergency healthcare system consists of emergency physicians working at hospitals and prehospital levels, emphasizing their essential role in emergency management of any incident. we aimed to investigate the thai emergency physicians' level of preparedness by using tabletop simulation exercises and three different scenarios. material and methods: using the 3lc (three level collaboration) method, two training sessions were arranged for over 50 thai emergency physicians, who were divided into three groups of prehospital, hospital, and incident command staff. three scenarios of a terror attack and explosion, riot and shooting, and high building fire were discussed in the groups. results: our findings indicate that the initial shortcomings in command and control, communication, coordination, and the ability of situation assessment increased in all groups step by step and after each scenario. new perspectives and innovative measures were presented by participants, which improved the whole management on the final day. conclusions: tabletop simulation exercises increase the ability, knowledge, and attitude of thai emergency physicians in managing major incidents in strategic, tactical, and operative managerial levels, and should be included in their professional curriculum. introduction: non-operative management of traumatic injuries has led to decreased surgical exposure for trauma trainees [1] . while simulation using cadavers may improve exposure to damage control techniques, tissue handling realism is variable depending on embalmment and perfusion techniques [2] . objective: to evaluate the feasibility of perfused thiel cadaver use for trauma surgery simulation. material and methods: thiel cadavers were cannulated in the ascending aorta and right atrium to create a left-to-right perfusion system. a magnetic pump was used to achieve a pulsatile flow with a gelatin-based solution, aiming for a flow of 4 l/min. peripheral circulation was improved with arteriovenous fistulas (carotid-jugular, femoro-femoral and brachio-brachial). a left common iliac vein injury was performed laparoscopically through the sigmoid mesentery. the surgical trainee was blinded to the initial injury and assisted by a staff surgeon. results: a trauma laparotomy was performed. the small bowel was eviscerated and all four quadrants were packed with gauze. a left, expanding zone iii hematoma was detected. the left sigmoid colon was mobilized to achieve proximal control of the left iliac vessels. the left common iliac vein was actively bleeding and ligated according to damage control principles. the left ureter was uninjured. the sigmoid mesentery was closed, without active bleeding. the remaining of the abdominal cavity was explored without other injuries. time from laparotomy to closure was 43 min. tissue handling and circulation dynamics were highly realistic due to thiel embalmment and pulsatile perfusion. conclusions: pulse-perfused thiel cadavers represent a realistic simulation option for surgical trainees. widespread implementation may provide accurate simulation for lifesaving procedures rarely performed in an era of non-operative management of traumatic injury. a new concept of intra-operative performance monitoring and self-assessment in hepato-pancreato-biliary surgery and other surgical specialties s. kharchenko 1,2 , m. yanovsky 3 1 colmar civil hospital, university of strasbourg, department of general surgery, colmar, france, 2 hepato-biliary institute henri bismuth, paris, france, 3 interceg, kharkiv, ukraine introduction: currently, the majority of learning curve studies for surgical interventions associated with simple chronometric estimation in a whole: from incision to closure. a selective approach for step-bystep time fixation of all hpb interventions (hepatectomy, others) or other surgical specialties can bring a new vision of correlation between intra-operative timing and the clinical outcome. material and methods: every operation can be divided into step items so standardized worldwide, for example, planned or urgent laparoscopic cholecystectomy e.g. incision to port placement, exposure, dissection to cholangiography, cholangiography, extraction, closure. results: the prototype named chronoi of infrastructure for automated monitoring (simulator of time tracking activities, web-service for request processing, database and knowledge base collection subsystems, learning curve representative and analytics software) is designed and to be implemented. individual self-assessment is available in a real-time fashion. the learning curve changes are shown per procedure. up to our knowledge, we can firstly in the world describe the surgeons, incl. in hpb, as speedy, standard or nonstandard depending on the surgeon's ''individual speed'' in operative performance. it's to be documented in their e-logbooks according to the current fellowship standards or practice re-certification. conclusion: the intra-operative monitoring and worldwide standardization give a new vision of the surgical practice in hpb surgery meaning an introduction of monitoring-based clinical outcomes (timing with morbi-mortality or other). only new trials will approve the role of the presented concept in hpb surgery as well as in general, emergency and trauma. introduction: the management of patients victims of war weapons and collective emergencies represents a major public health issue in france, but also abroad. terrorist events in recent years on the national territory have highlighted the need for training the population and caregivers in the management of these injuries. because of his experiment in the domain, the french military medical service (fmms) was requested to cooperate with the french prehospital teams in order to improve knowledge and teaching in this area. today, a continuing medical education, easily available and free access is needed in this area. material and methods: development of video podcasts (infographics) of a few minutes on the theme of management of patients victims of war weapons and collective emergencies. the working group ensures the production and quality of educational messages. production is provided by the communication establishment of defense. the broadcast is displayed on the channel you tube of the fmms. results: the title of the traum'cast podcast is the contraction of trauma and podcast. twelve episodes are scheduled on a 2-weeks rhythm. the podcast program is as follows: conclusion: fmms knowledge and experiment in managing patients victims of war weapons is unique. teaching can take various forms, theoretical, practical, academic, or through publications. traum'cast is a major innovation in the dissemination of this knowledge and each episode focuses on a specific skill. traum'cast will highlight the applicability of military medicine concepts in a civilian environment. traum'cast will be translated in an english version. project was supported by grants of french ministry of defense (innovation department). splenectomy in current surgical practice: a tricky and elusive procedure for the surgical resident? introduction: splenic rupture and oncologic resections are the most common indications for splenectomy, but technical expertise is progressively being taken over by non-operative and more conservative approaches. material and methods: retrospective review of all total splenectomies performed between february 2012 and january 2019 at an italian academic hospital, assessing demographics, diagnosis, operating surgeon, surgical approach, complication rate, postoperative critical care admission, and 30-day mortality. results: over 7 years, 163 consecutive splenectomies were performed by 25 different surgeons, 4 of whom surgical trainees, with 83 unplanned (i.e. emergency/iatrogenic injury) and 80 planned (i.e. benign/malignant disorders) procedures and an average of 11.9 and 11.4 procedures per year respectively. over the study period, only 9 surgeons performed at least 6 procedures and only 5 performed at least 12 procedures. laparoscopy was performed in 9.8% of cases, predominantly during planned procedures, with an overall 37.5% conversion rate mostly related to technical difficulties (i.e. spleen dimension, difficult vascular visualization). overall major postoperative complication rate (clavien-dindo c 3) was 19.6%, slightly higher in emergency procedures although not significantly different (13.7% vs. 25.3%, p = 0.08). reintervention rate was 12.3%, due to hemorrhage in more than half of cases. overall 30-day mortality rate was 5.5%, with elective 30-day mortality rate of 3.7% (p = 0.49). conclusions: splenectomy may be required ever more rarely but potential risks are not irrelevant. competence for surgical trainees should be achieved elsewhere (e.g. simulated/cadaveric training case history: an 84 year old femal patient underwent changing of the components of the tha because of aseptic loosening. due to circumstances the surgeon decided to implant a cemented femoral component. the procedure was without any significant abnormalities. the first postoperative radiograph was planned after recovery-as usual. the x-ray imaging showed a misplaced femoral component. therefore a ct-scan was performed additionally and the malposition of the cemented femoral component was confirmed. the patient had to undergo another surgery-removing of the cemented femoral component and implantation of a new well placed one. therapy and progressions: after prompt resuscitation, an emergency laparotomy was performed and an anastomotic leak was found, requiring re-do ileo-ileal anastomosis. postoperative course was complicated by intra-abdominal collection treated by antibiotics alone (clavien-dindo grade 2). the patient was discharged on 20th pod. at pathological report, segmental absence of intestinal musculature (saim) was diagnosed. the revision of past specimens confirmed the same finding. comments: usually recognized in neonates/premature infants, saim is generally an incidental finding in adults [1] , often undiagnosed and more frequently described in the colon [2] . in such scenario, main differential diagnosis is ischemia. etiology is unclear and can be classified as either primary/congenital or secondary. the former is characterized by acute onset of symptoms, whereas in the latter a longer history of intestinal symptoms is usually present [1, 3] . most authors agree upon a congenital pathogenesis. generally, saim is associated with hollow viscus perforation and treated with surgical resection. contrary to our experience, no recurrence of intestinal perforation has been reported [2] virgen del rocío university hospital, general surgery, seville, spain, 2 hospital regional de málaga, general surgery, málaga, spain, 3 hospital de estella, general surgery, navarra, spain, 4 hospital gregorio marañón, general surgery, madrid, spain, 5 complejo hospitalario de jaen, general surgery, jaen, spain introduction: specific training in the management of trauma patients is essential for surgeons. training through courses in this area (atls, dstc, musec) directly impacts the care of these patients. the aim of this study is to know the specific training in trauma care of spanish surgeons. materials and methods: a national survey has been sent to all member surgeons of the spanish surgeons association. it has evaluated their degree of participation in emergency surgery acute care, and therefore the possibility of attending trauma patients, their participation in the initial care at their hospital, as well as their specific training in this area. results: the survey has been completed by 510 surgeons from 47 spanish regions, and most surgeons who responded were from catalonia and andalusia. 456 (89.41%) of those surveyed take calls for the ed. only 171 (33.53%) report having a hospital registry of trauma patients. 72.15% of surgeons answer that in their hospital the general surgeon is not involved in the initial care of trauma patients. 66.47% have taken the atls course, 40.78% the dstc course, and 11.57% the musec course (or another course on e-fast). despite this, 85.69% consider the atls course should be mandatory during residency, and 43.33% of those surveyed consider trauma care in their hospital as very bad or deficient. conclusions: according to this survey, specific training in trauma care is still deficient in spain and with many aspects that can be improved. only 40% of those surveyed have received specific training in definitive surgical management of severe trauma. despite this, a large percentage of surgeons take calls for the ed routinely, and face the challenge of managing these patients. exploring team leaders' decision-making challenges in civilian and military complex trauma introduction: in the nordic countries professionals may work in both civilian and military trauma care. timely and effective decisionmaking in complex trauma is essential in improving survival benefits. the mindset and management priorities differ among medical professionals, and correlate with different experience levels. trauma leaders are usually senior surgeons with extensive experience and well-developed decision-making skills. simulation training has been shown to be effective in practicing decision-making. the aim of this study is to explore the team leaders' decision-making challenges in complex trauma care and structure them with the activity theory framework (at). material and methods: video recordings at a trauma center in johannesburg and live observations of complex trauma training in gothenburg focusing on team leaders' decision-making challenges were analyzed and systemized using the at. results: the team leaders' activities were mapped onto the main elements of at ( fig. 1) whereby the decision making challenges were classified into six categories (table 1) . conclusions: the at framework may benefit and inform the design of educational interventions by structuring key issues of complex activities. introduction: trauma is one of the main causes of mortality worldwide and prevention stands out as one of the main ways to modify its incidence. a prime example of such initiatives is the prevent alcohol and risk-related trauma in youth program (p.a.r.t.y.). it aims to raise awareness of the population most at risk for trauma, young people from 14 to 18 years. the study objective was to evaluate the program impact on students' knowledge and behavior. material and methods: a quantitative, uncontrolled intervention cohort study was conducted through the responses of the p.a.r.t.y. in 2017 and 2018. data collection occurred through the application of a questionnaire to participating and non-participating students of public schools in the city of campinas, after a few months of participation in the program. results: among 697 answers, 53.9% were male, 87.2% between 15 and 17 years, and 22.7% program participants. time between participation and answers was 10.4 (± 3.7) months. regarding the first conducts when facing traffic trauma, 48.7% of those who participated chose the correct answer, against 14.8% of those who did not. about the first care while the service does not arrive, 85.5% of the first group answered correctly, compared to 35.1% of the second. concerning about the service that should be called in the event of a trauma, 66.4% of participants would call correctly against 28.0% of non-participants. in questions related to traffic laws, 74.3% of participants opted for the correct answer as to what should be done in the face of a running over, against 23.20% of non-participants. conclusions: students who had participated in the program had a higher rate of correct answers, a few months after the event, compared with students who did not attend. thus, it is concluded that there is a impact over the time caused by it. introduction: currently, intraosseous (io) devices are necessary for the resuscitation of severe trauma patients. however, opportunities to learn io device insertion are limited for residents. the aim of this study was to conduct a simulation of io device insertion for residents and to evaluate its effectiveness. material and methods: in this simulation, residents inserted io needles into the sternum of pigs under general anesthesia with the instructor's guidance. comprehension tests and questionnaires about satisfaction level and self-efficacy were conducted before and after the simulation. the objective evaluation was the io access success rate, and the subjective evaluation was obtained from points on comprehension tests and questionnaires. results: thirty-six residents participated in this study. just one resident had successfully obtained io access clinically. success rate of establishing io access in the simulation was 100%. the rate of test completion was 100% and that of questionnaire with survey response was 61%. the comprehension test results improved from 9.2 ± 0.94 to 9.6 ± 0.79 (mean ± standard deviation, p = 0.01739) out of 10 points. the questionnaires concerning satisfaction level changed from 7.4 ± 2.9 to 14 ± 1.3 (p \ 0.0001) out of 15 points. the questions specifically concerning self-efficacy dramatically increased from 1.8 ± 0.91 to 4.1 ± 0.64 (p \ 0.0001) out of 5 points after the simulation. conclusions: the simulation in this study improved the knowledge, satisfaction level, and self-efficacy of the residents for io access. the success rate of confirmation of io access in this study was 100%. this experience may positively affect their clinical performance in trauma care. case history: case 1. a 37-year-old white man presented to the ed complaining of intense abdominal pain and vomiting. he referred at least two previous episodes with associated fever which resolved spontaneously. case 2. a 35 years old white man consulted at the ed for intense abdominal pain, nausea, anorexia and constipation for the last 48 h. none history of abdominal surgery were registered. clinical findings: in both cases, the abdomen was distended without bowel sounds. investigation/results: case 1. abdomen xr: distended small bowel loops localized at the right side. ct scan: an encapsulated cluster of dilated small bowel loops into the ascending mesocolon. case 2. ct scan: an encapsulated nonrotated small bowel in the right side of transverse mesocolon and mesenteric vascular pedicle displaced. diagnosis: intestinal obstruction secondary right paraduodenal hernia therapy and progressions: emergency midline laparotomy that evidenced a rpdh which was reduced before closing the mesentery defect. the postoperative was uneventful. comments: paraduodenal hernias are a type of internal hernia and a rare cause of intestinal obstruction accounting for about 0.5% of all hernias. right paraduodenal hernias are far less common than left ones. symptoms of paraduodenal hernias are nonspecific. preoperative diagnosis of pdh by imaging techniques is difficult. contrastenhanced ct scan is highly recommended as the most specific method of diagnosis for pdh. with the increased use and improved enhancement of ct scans, paraduodenal hernias currently can be diagnosed preoperatively. this advancement in diagnostics coupled with increasing experience and facility of general surgeons in using laparoscopic techniques has led to the initiation of laparoscopic repair of internal hernias. case history: a 52-year-old female patient who goes to the emergency department due to vomiting and abdominal pain. since the accident, the patient reported post-prandial discomfort and gastroesophageal reflux, as well as self-limited abdominal cramps. clinical findings: soft, depressible abdomen. bowel sounds on left hemithorax. investigation/results: cxr: right hemidiaphragm elevation. lab test: leukocytosis. thorax and abdomen ct: right anterior diaphragmatic hernia and passive atelectasis secondary to ascent of dilated small intestine and colon. diagnosis: intestinal obstruction secondary post trauma diaphragmatic hernia. therapy and progressions: emergency laparotomy due to symptoms compatible with intestinal obstruction secondary to incarcerated diaphragmatic hernia. it is right diaphragmatic chronic rupture chronic with omental incarceration, antrum, small bowel and ascending colon with reversible signs of suffering. chelotomy and content reduction, herniorrhaphy with loose spots with non-absorbable material are performed. endothoracic drainage is left removed at 48 h. the postoperative course is uncomplicated. comments: trauma events should be considered in the diagnostic process to avoid delayed treatment. case history/clinical findings: we present a 61-year-old male patient with a history of large pelvic mass in the rectum-prostate space under study, since 4 months. he were admitted into the emergency unit, 3 days after the mass biopsy, with fever up to 40°c and rectorrhagia. the patient rapidly developed septic shock with hemodynamic instability and elevation of acute phase reactants. abdominal ct was performed: pelvic mass of 11 9 9.3 9 12.5 cm, of heterogeneous content, with areas of blood density. we decided doing an emergency surgical exploration of this mass as the only suspected origin of infection. investigation/results: in the surgical exploration the mass was protruding on the anterior rectum wall. the mass was drainaged with an output of 400 ml of purulent material mixed with clots and necrotic tissue. foley no. 22 probe was placed inside the cavity. in the postoperative period, the patient showed significant hematochezia, so he was reoperated performing hemostasis and rectal tamponade. it was effective and a new foley catheter was replaced at 24 h. when the purulent drain gave way, the catheter was removed and the patient evolved favorably. diagnosis: cytology analysis: mesenchymal type lesion, morphologically and immunophenotypically compatible with gist (gastrointestinal stromal tumor). ihq profile: cd34, dog1, c-kit positive. therapy and progressions/comments: the complications of gist are usually acute abdomen due to peritonitis secondary to perforation or hemorrhage. however, the formation of intratumoral abscesses is very inusual, although is described in the literature. emergency surgery is often necessary due to the significant affectation of the general condition of the patient and the difficulty of the diagnosis. fournier's gangrene (fg) is a surgical emergency defined by an obliterating endarteritis of the subcutaneous tissue arteries of infectious etiology, with progressive necrotizing fasciitis of the perineal, abdominal, thoracic or lower limbs, which can lead to multiorgan failure. a 75 years old woman was admitted in our er presenting with a 1 week worsening vulvar pain. clinical exam showed vulvar and mons venus erythema, without lesions, bp was 111/47 mmhg and she had a fever of 38.2°c. blood work showed leukocytosis (27.68 9 10 3 /ll), neutrophilia (25.8 9 10 3 /ll) and crp of 387 mg/ l. past medical history of obesity, right thp and total thyroidectomy. vulvar cellulitis was the initial diagnosis and empirical atb was implemented. on d2, due to an evolution into septic shock and spread of an emphysematous inflammatory process to the right thigh and buttock, the diagnosis of fg was made. during emergent surgery we observed extensive fascial and tissue necrosis from the asis and suprapubic region to the proximal third of the right thigh and perineum. extensive necrosectomy, drainage of purulent exudate and transversostomy were performed. empirical second-line broad-spectrum atb was started. she underwent new necrosectomies and surgical debridements on po days 2 and 4 and needed icu stay for 5 days. daily dressing changes were performed with povidone iodine and later with octenidine. microbiology sample showed polymicrobial infection with gram positive and negative organisms as well as anaerobes, thus confirming the diagnosis of fg type i of vulvar origin. after surgical and hd stabilization, the patient underwent plastic reconstructive surgery, with local flaps and partial skin graft. the postoperative period was uneventful and the outcome was great. introduction: appendicitis is not uncommon in the elderly but may often be mis-diagnosed [1] . the aim of this study was to explore the specific traits and treatments of this group in a swedish context to better understand where to optimize the management. material and methods: all acute appendectomies registered in the southern general hospital registry between january 2015 and june 2019 constituted the cohort (n = 2687). patients were stratified into two groups; c 65 and \ 65 years of age. significances were computed with pearsons chi2 and anova. results: the older group made up 8% of the study population (n = 214). the elderly population was female to a larger extent (or 1.57, p \ 0.05), triaged higher in the emergency department (p \ 0.05) and had higher asa classifications (p \ 0.05). the elderly were also perceived as sicker at the time of decision for surgery, expressed as having higher priorities for surgery (p \ 0.05). no significant difference between the groups in time from arrival to decision for surgery was found, nor for the time from arrival to surgery. there was a higher rate of perforations in the elderly group (53.8% vs 25.0%, p \ 0.05), twice the length of hospital stay (p \ 0.05) but no significant differences in complication rates (9.2 vs 5.8%, p = 0.71). twenty-eight day mortality rate was 0% in the younger group and 1.9% in the older group (p \ 0.05). conclusions: this study shows that an elderly group of appendicitis patients are more frail and more acutely sick when presenting to the hospital. in spite of higher priority for surgery, the elderly experience longer hospitalization and higher mortality rate, but not more complications. the findings are consistent with antecedent research. introduction: existing evidence points towards the notion that patients undergoing emergency surgery receive a poorer consenting quality when compared to their elective counterparts. with 70,000 cholecystectomies in england a year, cholecystectomy is one of the most frequently performed procedures both in the emergency and elective settings. however, to date, no studies have explored the relationship between consenting quality and the setting of cholecystectomy. we aimed to measure the quality of informed consent (ic) for patients who underwent emergency vs elective cholecystectomy. material and methods: the final review included the analysis of 174 ic forms completed between 2011-2017. percentage proportions were calculated to demonstrate the degree of completeness of consenting against a total of 57 components of information. binary regression was utilised for subgroup analysis. results: patients undergoing emergency surgery were more likely than elective patients to be warned of severe perioperative complications such as cardiac disorders (46.6% vs 25.9%, p = 0.038), fluid collection (46.6% vs 25.9%, p = 0.010), and infected bile spillage (8.6% vs 1.7%, p = 0.049). elective patients were more likely to be counselled about the risk of less serious side effects of cholecystectomy such as diarrhoea (19.8% vs 3.4%, p = 0.027). patients in asa 2-3 group were more likely to be counselled about the occurrence of pulmonary embolism. interestingly, patients were more likely to receive a patient information leaflet if they were females and under 60. conclusions: the results of this study demonstrate multiple inconsistencies in the level of disclosed information to patients undergoing cholecystectomy. the results suggest that the consenting physicians make assumptions regarding the information that the patient would like to receive based on patient demographics and clinical factors, highlighting the need for more consistent consenting procedures. acute calculous cholecystitis and the timing of cholecystectomy: advocating early surgery i. moutsos 1 , r. lunevicius 1 1 liverpool university hospitals nhs foundation trust, general surgery, liverpool, united kingdom introduction: cholecystectomy cures acute calculous cholecystitis (acc) in nearly all patients and, according to nice, augis, tokyo and wses guidelines, should be conducted at the earliest opportunity, within 7 days of the diagnosis. the present audit aimed to measure whether the care of patients with acc meets the standards of best practice and to assess whether early cholecystectomy was a more beneficial and safer intervention as compared to delayed cholecystectomy. material and methods: a ''snapshot'' sample of 50 patients operated on between 12/2018 and 06/2019 with an index admission diagnosis of acc was reviewed. the selected patients were divided into three subgroups according to the timing of their surgery: 1-7 (early), 8-28, and[ 28 days. the other measures used in this audit were the rates of conversion to open surgery, subtotal cholecystectomy (stc), perioperative complication-specific morbidity, secondary interventions, and admission to intensive therapy unit (itu). results: nine patients (18%) underwent early cholecystectomy-laparoscopic (n = 8) or primary open (n = 1); 40 of the other 41 patients-delayed laparoscopic cholecystectomy. the rates of stc were similar in both subgroups-11.11% (1/9) vs 9.76% (4/41). delayed cholecystectomy was related to five side effects: higher rates of postoperative collections (three patients, 7.32%), external bile leak (one patient, 2.44%), ercp (2.44%), emergency re-operations (two patients, 5.56%), and admission to itu (5.56%). they all occurred in the delayed [ 4 weeks surgery subgroup of 36 patients. conclusions: although no significant associations were found when comparing early to delayed cholecystectomy, this analysis shows that postoperative morbidity, the rates of secondary interventions and admissions to itu were higher when surgery was delayed. this audit advocates that early cholecystectomy should become a standard of practice as per national and international guidelines. esophagopericardial fistula following primary repair for chronic esophageal ulceration presenting with pericardial tamponade: a case report and outline of management and treatment case history: a 54-year-old man with chronic esophageal ulcerations presented with substernal pain, fever, and shortness of breath. a radiograph revealed a right pleural effusion and pneumomediastinum consistent with an esophageal perforation (fig. 1 ). he underwent a right thoracotomy, primary esophageal repair with intercostal muscle flap buttress, and gastrojejunostomy feeding access. a post-procedural gastrograffin study demonstrated an anastomotic leak (fig. 2) . a right thoracostomy drain was placed for diversion. the patient was discharged home and returned 10 days later. clinical findings: he presented with substernal pain, hypotension, and fatigue. thoracic computed-tomography (ct) revealed a pneumopericardium and an esophagopericardial fistula (epf) manifesting as pericardial tamponade (fig. 3) . diagnosis: epf. therapy and progressions: the patient underwent a subxiphoid pericardial window and mediastinal drain placement for decompression. an esophagogastroduodenoscopy revealed an exposed right atrium, thus precluding esophageal stenting. sepsis and antibioticassociated clostridium difficile colitis complicated his post-operative course. once resolved, the patient underwent a partial esophageal resection, epf ligation, and esophagogastrostomy. the postoperative gastrograffin study did not demonstrate an anastomotic stricture or leak. the patient tolerated a regular diet and was discharged home. comments: esophagopericardial fistula is a rare clinical entity most often caused by benign disease. prompt diagnosis and treatmentpericardial decompression and fistula ligation-is critical. due to wide use of proton pump inhibitors and development of interventional radiology (ir), causative reasons are changing. introduction: secondary peritonitis yields high morbidity and mortality rates. besides rapid source control, adequate antimicrobial therapy is essential to improve outcomes. thus initial empiric therapy has to take suspected germ spectrum as well as possible resistance rates into account. microbial selection and resistances may pose problems during prolonged administration of antibiotics. however, a possible negative effect of multi-resistant germs on mortality has not yet been clarified. the choice of a suitable antibiotic and the relevance of its efficacy on isolated germs as well as the relationship between germ spectrum and clinical condition of the patients need to be clarified. material and methods: intraabdominal swabs from consecutive patients from 2010 to 2018 requiring intensive care due to secondary peritonitis were evaluated retrospectively. patient characteristics and outcomes, germ spectrum and resistance rates were collected. changes over the course of therapy and development of resistance as well as influences on the clinical course were analyzed. introduction: complicated intra-abdominal infections (c-iai) represent challenging diseases with high mortality rates. depending on different selection criteria and therapy strategies the reported mortality rates vary between 7.6 and 36%. usually a distinction between community (cap) and hospital acquired peritonitis (hap) is made. hap can further be classified as postoperative peritonitis (pop) or non-postoperative peritonitis (hap-non-pop). we conducted a retrospective analysis of patients with c-iai requiring intensive care therapy. material and methods: all patients with c-iai requiring surgery and intensive care treated at the danube hospital in vienna from 2010 to 2018 were retrospectively analyzed. a total of 195 patients where included into the study and grouped as cap, hap-non-pop or pop. for each group comorbidity and patient characteristics, source and cause of infection, hospital and icu stay, apache ii, saps ii and sofa-scores, mortality and outcome were calculated and compared to each other, using fisher exact test or mann-whitney-u-test. results: a total of 195 c-iai were treated, consisting of 37.3% cap, 12.7% hap-non-pop and 50% pop. concerning the patient characteristics and comorbidities no significant differences were seen between the groups, except for malignant diseases which were significantly higher in pop. the postoperative (source control) apache ii and saps ii values did not differ between cap and pop (apache ii mean: cap 13.5, pop 13.29) whereas both were significantly higher in hap-non-pop (apache ii mean: 16.32). mortality rates were not significantly different in cap and pop (34.2% vs. 36.26%): however, hap-non-pop was complicated by a nearly doubled death rate (57.14%). conclusions: although patients with pop are described to have a higher mortality in the literature, this could not be shown in our study. postoperative survival was comparable between cap and pop patients. hap-non-pop demonstrated a significantly higher mortality. acute appendicitis and acute diverticulitis presenting concurrently treated surgically and conservatively clinical findings: on examination the abdomen was soft but there was tenderness and guarding in the right iliac fossa and suprapubic region. her observations were stable on admission and she was afebrile. investigation/results: laboratory tests demonstrated a wcc 24.79 (9 10 9 /l) and crp of 57.5 (mg/l). urinalysis was normal. a ct of the abdomen and pelvis with intravenous contrast demonstrated acute appendicitis with non-perforated sigmoid diverticulitis (fig. 1, fig. 2 ). diagnosis: concurrent acute appendicitis and non-perforated sigmoid diverticulitis. therapy and progressions: the patient underwent a laparoscopic appendicectomy. intraoperative findings included a retrocaecal inflamed appendix and diverticulitis in the pelvis which was not disturbed. there was no pus in the pelvis. she recovered well postoperatively and was discharged home to complete one week of oral antibiotics the following day. the histology demonstrated acute appendicitis. comments: there are very few reports in the literature of concurrent appendicitis and sigmoid diverticulitis despite these two pathologies being amongst the most common presentations of abdominal pain. this case demonstrates the value of cross sectional imaging, ct imaging is a helpful diagnostic tool and is highly sensitive and specific for both diverticulitis and appendicitis.the challenge in this case is balancing the two differing managements of these two conditions. most cases of diverticulitis are managed conservatively with dietary modification and antibiotics. operative management is only usually considered if there are associated complications such as intraabdominal perforation. this is in contrast to appendicitis where the standard treatment is to undergo surgery. references millions of people die from major trauma annually. 30-40% of these deaths are due to exsanguination, with nearly half dying prior to hospital arrival. when properly managed, these deaths are preventable. this paper summarizes data relating to the extent of hemorrhage as a cause of mortality in the traumatic arena. an overview of the pathophysiological steps occurring during massive bleeding and their clinical implication is presented. a variety of treatment options, both historical and current, is then discussed, including vascular occlusion methods and hemostatic dressings, along with their limitations and complications. finally, woundclot, a new hemostatic gauze, is introduced, which not only requires no compression when it is applied, but allows the first responder to rapidly and effectively treat more than one casualty within seconds. additionally, it is adaptable to a wide array of clinical applications, both traumatic and surgical, including situations where vascular occlusion methods are not practical or are contraindicated. i am the clinical research administrator for core scientific creations treating acute colonic diverticulitis with extraluminal pericolic air; a multi-centre retrospective cohort study background: since the emergence of acute care surgery as an entity encompassing trauma and emergency general surgery there have been several studies evaluating patient outcomes noting a higher unexpected survivorship and expedited operative times, shorter hospital stays, and fewer complications for patients undergoing procedures such as appendectomy; however, these superior outcomes have not been demonstrated across the array of emergency surgical cases. the aim of this investigation is to determine whether patients operated on by acute care surgeons in a trauma center benefit from the trauma model of in-house availability, earlier availability of surgical care, and care dictated by evidence-based protocol. we examined our health care system's data to determine if trauma centers were to able to provide more timely care with improved outcomes, by focusing on truly emergent general surgery cases. this was examined by identifying and quantitatively comparing time to operative intervention, need for re-operation, hospital length of stay, duration of stay spent in intensive care unit, and patient disposition at time of discharge. methods: this is a retrospective cohort study. patients presenting with emergency general surgery conditions (incarcerated hernia, perforated viscus, sbo, necrotizing soft tissue infection) who underwent surgery within 24 h of presentation were selected. outcomes were compared between patients presenting to our two trauma centers versus our two non-trauma centers. n = 1600 results: at this time we are nearing the finalization of our data interpretation. we are examining mean time to operation, los, icu los, need for re-operation, and disposition at discharge. discussion: although our data analysis is not complete we feel that the results of our data will shed valuable and needed light onto the care delivered to emergency general surgery patients by surgeons in this increasingly complex population. anastomosis leakage after hartmann removal, with conservative treatment at the beginning but after, bad evolution, a surgery was performed with colostomy and vac system. 3 patient. after 24 h, he develop a compartmental syndrome and a vac system was applied. investigation/results: 1 patient. after the first change the distance between the two layers was 18 cm and botulinum toxin was applied. 2 pat. the distance between the two layers of abdomen was 20 cm and botulinum toxin was applied. 3 patient. the distance between the two layers was 18 cms and toxin was applied. unfortunately, he suffered from a hepatorenal syndrome and died. diagnosis: open abdomen with distance between the two layers: 18 cm, 20 and 18 cm. therapy and progressions: we have added botulism toxin with doses of 20 units in each side of abdominal wall. 1 patient. three changes after, the abdomen wall was closed. 11 months later, the abdominal wall is ok. 2 patient. a reduction of 50% was got. comments: the use of open abdomen in patients suffer from septic shock or after an abdominal compartment syndrome often poses a challenge in the abdomen closure. we have developed a protocol, dividing our patients according to the distance between the two layers in two group: more than 10 cm or 10 cm or less. in the first group ([ 10), we present our first 3 cases in our protocol. conclusions: botulinum toxin can make easier abdomen closure when the distance between the two layers is more than 10 cms incidentally discovered splenic peliosis in a patient with no comorbidity clinical findings: a 51-year-old man with no comorbidities visited our emergency medical center based on a complaint of chest pain. the chest and abdomen radiographs, electrocardiogram, and cardiac markers showed no abnormalities; therefore, he was discharged from the hospital. two months later, he returned to our hospital with abdominal pain and distension. he was hemodynamically stable, and there were little tenderness and rebound tenderness on his abdomen, although he complained a slight abdomen discomfort investigation/results: no abnormalities were found on the laboratory examinations, including complete blood cell count, cardiac markers, and coagulation profile. an abdomen computed tomography revealed multiple hemorrhagic cysts on spleen with moderate amount of hemoperitoneum. diagnosis: ruptured splenic peliosis with hemoperitoneum. therapy and progressions: laparoscopic splenectomy was done because recurrent rupture of hemorrhagic cysts was strongly anticipated. on histologic examination, the blood-filled cysts were welldemarcated, distributed in red pulp congestion. no vascular-endothelial cells were observed, and normal lining cells were disappeared in the wall. comments: a peliosis is a rare disorder characterized by widespread, blood-filled cystic cavities within the parenchymatous organs. the liver is the most commonly involved organ, and an isolated splenic peliosis is extremely uncommon. patients are often asymptomatic; therefore, early recognition and withdrawal of offending agents is crucial. in cases with the rupture of surface lesions, which can occur spontaneously or by the minor trauma, prompt surgical management is necessarily required. splenectomy offers the advantage of a definite histological diagnosis with the complete elimination of the risk of recurrent hemorrhage. introduction: despite an evident success and advantages of endoscopic surgery, the discussion on reasonability of endoscopic surgeries in children with acute appendicitis is still going on. purpose: to assess the effectiveness of laparoscopic techniques for treating appendicular peritonitis in children. material and methods: 149 children with appendicular peritonitis were operated in our hospital (2016) (2017) (2018) . they aged 1-17 years (11 ± 3.5); 65.2% of boys, 34.8% of girls. appendicular peritonitis was registered in 7.7% cases of acute appendicitis. three ports were used for the approach: appendectomy was performed by the ligature technique with roder loop. results: laparoscopic surgery is indicated in all forms of appendicular peritonitis, except appendicular abscess stage 3, and total abscessing peritonitis. in appendicular abscess stage 3, we perform a puncture and drainage under ultrasound control. 3-6 months later appendectomy is made. total abscessing peritonitis is an indication for laparotomy. laparoscopic surgery in patients with peritonitis has the following stages: diagnostic laparoscopy; sanation of the abdominal cavity by the aspiration of purulent exudate; ligature appendectomy; in diffuse and combined peritonitis a pelvic aspiration drainage is made. in appendicular abscess stage 2, we additionally put the aspiration drainage in the cavity of destructed abscess. conclusions: laparoscopic technique applied for surgeries in children with acute appendicitis has considerably improved outcomes introduction: nighttime emergency surgery is associated with increased postoperative morbidity and mortality [1] , and delayed appendectomy due to acute appendicitis is not linked to a higher rate of postoperative complications (pc) [2] . the aim of this study was to determine whether appendectomy on-call (oc) was associated with higher risk of pc. (1) (2) (3) (4) (5) (6) (7) (8) . two patients underwent major thigh amputation. negative pressure wound therapy and hyperbaric oxygen therapy were used in 15 and 7 patients, respectively. three patients died (mortality rate = 12%). conclusions: the mortality and major amputation rates (12% and 8%, respectively) were lower than those reported previously. in this study, even when patients had multiple organ failure or septic shock, major amputation was not always needed because of effective communication between the infection control team and intensive care specialists, resulting in radical debridement without amputation. material and methods: a systematic search in pubmed/medline, embase, cinahl and central was performed. the primary outcomes were mortality and amputation. these outcomes were related to the following time related variables (1) time from onset symptoms to presentation; (2) time from onset symptoms to surgery; (3) time from presentation to surgery; (4) duration of the initial surgical procedure. for the meta-analysis, effects were estimated using random-effects meta-analysis models. results: a total of 109 studies (6051 patients) were included for qualitative analysis, of which 1277 patients died (21.1%). a total of 33 studies (2123 nsti patients) were included for the different quantitative analyses performed. mortality was significantly lower for patients with surgery within 6 h after presentation compared to when treatment was delayed more than 6 h (or 0.43; 95% ci 0.26-0.70). surgical treatment within 6 h resulted in a 19% mortality rate compared to 32% when surgical treatment was delayed more than 6 h. also, surgery within 12 h reduced the mortality compared to surgery after 12 h from presentation (or 0.41; 95% ci 0.27-0.61). patient delay (time from onset of symptoms to presentation or surgery) did not significantly affect the mortality in this study. none of the time related variables assessed reduced the amputation rate. conclusions: average mortality rates reported remained constant (around 20%) over the past 20 years (fig. 1) . surgical debridement as soon as possible lowers the mortality rate for nsti with almost 50%. thus, a sense of urgency is essential in the treatment of nsti. altemeiers procedure in an emergency setting case history: three patients with irreducible incarcerated rectal prolapsed were referred to our department for treatment. all patients were female and their age was 57, 82 and 85 years old. all patients suffered from severe co-morbidities. clinical findings: all patients presented with incarcerated rectal prolapse. in one patient there was macroscopic evidence of mucosal necrosis, whereas the other two patients had evidence of ischemia. the former patient was febrile whereas the latter did not exhibit signs or symptoms indicative of sepsis. investigation/results: blood panels demonstrated leukocytosis and elevated levels of c-reactive protein (crp) in all patients. apart from routine imaging upon admission (e.g. chest radiography), no other imaging modalities were performed. diagnosis: irreducible incarcerated rectal prolapse. therapy and progressions: initially manual reduction of the prolapsed was attempted without success. all patients were evaluated as high risk surgical candidates. altemeier's procedure was selected as a safer alternative to an abdominal approach. all patients were successfully discharged after resumption of bowel function. comments: incarcerated rectal prolapse is a rare clinical condition. initial management involves manual reduction of the prolapse. when this is not feasible, urgent surgical management is mandatory. in patients with severe co-morbidities, altemeir's procedure is a safe and effective treatment when performed by an experienced practitioner. introduction: treatment options for sigmoid volvulus are decided by its severity. uncomplicated cases are usually treated by endoscopic detorsion followed by elective surgery and complicated cases or cases can't be detorsioned are treated with emergency surgery. in this study we aim to review a single center experience in long term management of sigmoid volvulus cases. material and methods: data of the sigmoid volvulus cases between 2009-2018 were collected using hospital database. files of 57 patients were reviewed for treatment modalities, demographic info and complications. 4 patients were dropped from the study due to inadequate long term follow-up. results: 37 were men and 16 were women. mean age was 54,9. endoscopic detorsion was attempted in 30 cases. success rate was 90% (n = 27). 10 of these patients were followed up with elective surgery. 23 patients with complicated cases and 3 unsuccessful detorsion patients were managed by emergency surgery. 16 hartman procedures, 10 anterior resections, 2 left hemicolectomies, 1 subtotal colectomy and 2 transverse loop colostomies were done. a stoma was created in 28 cases. 22 patients had their stoma created in the primary surgery and an additional of 6 stomas were created due to anastomosis leakage. mortality rate in the first 7 days was 25% (n = 7) in patients with a stoma (n = 28). asa and charlson co-morbidity scores were exceptionally high in the mortality group. in the remaining patient group, stoma closure rate was 57.1%. conclusions: endoscopic detorsion is a powerful and highly successful management option in uncomplicated cases when done by an experienced staff. emergency surgery shouldn't be delayed in complicated cases or after unsuccessful detorsion attempts. introduction: esophageal perforation has high mortality rates when not treated aggressively. treatment options are conservative approach, endoscopic intervention and surgery. purpose of this study is to review cases of esophageal perforation in a single center and to evaluate types of diagnosis and treatment options. material and methods: using hospital database we collected data of 26 patients diagnosed with esophageal perforation between 2009-2018. we reviewed treatment modalities, demographic data and complications. 1 patient was removed from the study due to insufficient long term data. results: 13 were female and 12 were male. average age was 59.9. average time between the onset of symptoms and admission was 2.2 days. the most common etiology was iatrogenic (n = 16) followed by consumption of corrosive substances in 2 patients, spontaneous perforation in 2 patients, esophageal tumour in 3 patients and foreign body ingestion in 2 patients. 11 patients were treated surgically, 8 patients were treated with endoscopic stenting and 1 patient was treated with surgery following stenting. 5 patients were managed conservatively with antibiotherapy. average time in intensive care was 8.4 days and average hospital stay was 26.6 days. mortality was seen in 3 patients treated with surgery and 2 patients treated with stents. conclusions: esophageal perforations are mainly iatrogenic but also can be caused by multiple reasons. especially in cases developed after endoscopy, rapid intervention can be a significant factor that can decrease both mortality and morbidity rates. introduction: spontaneous rupture of liver tumors (rlt) is a rare but potentially life-threatening condition. damage control techniques, namely perihepatic packing (php), is a resource for the most physiologically compromised patients, with more stable patients undergoing transarterial embolization (tae) or immediate resection. decision algorithm depends on patient status, available resources and liver function. the authors present their center experience in managing rlt and propose a management algorithm. material and methods: eighteen consecutive patients who underwent surgery for rlt in our department (january 1988-october 2019). inclusion criteria: spontaneous rupture and evidence of intraperitoneal bleeding. fourteen patients were male. mean age of 62.6 years (35-86). thirteen patients (72%) presented in hemorrhagic shock. mean tumor size was 6.72 cm (3) (4) (5) (6) (7) (8) (9) (10) (11) (12) (13) (14) (15) (16) (17) . most frequent pathological diagnosis were: hepatocellular carcinoma in 12 cases (67%); adenoma in three cases (17%); metastases in two cases (11%); liver sarcoma in one case (5.6%). median of seven units transfused by patient (0-25). statistical analyses with spss tm version 23.0 results: six patients (33%) needed immediate surgery (php in three and resection in three). five (28%) underwent urgent ([ 2 h and \ 24 h) and seven (39%) delayed ([ 24 h) resection. hepatectomy was performed on all (fifteen minor and two major) but one patient php only. eight patients (44%) underwent tae prior to resection, two of them (11%) between php and hepatectomy. median length of stay 10 days . major morbidity in three patients (17%); mortality in three patients (17%). number of transfused units associated with increased risk of complications (p = 0.009). conclusions: rupture of liver tumors is a severe complication. although hepatic resection, with or without preoperative tae, should be considered gold standard, damage control techniques such as php are the only option for physiologically compromised patients (fig. 1) . seasonal variability of cellulitis: a five year retrospective cohort study introduction: it is commonly purported that the incidence of cellulitis is highly seasonal but there is little empirical evidence supporting this assertion. this 5 year retrospective cohort study set out to identify whether there is a statistically significant relationship between an increase in temperature and incidences of cellulitis. as a corollary to this proposition, length of hospital stay for cellulitis was examined in relation to the level of inflammatory markers upon admission and micro-organism identified on culture. material and methods: this is a 5 year retrospective single centre cohort study of all patients admitted with cellulitis to tallaght university hospital from 2014 to 2018 inclusive. the patient cohort was identified via the use of a prospectively managed database of all surgical admissions and corroborated via examination of clinical chart records. dates of admission were correlated with the average temperature of dublin as provided by the meteorological office of ireland. site of infection, inflammatory markers and the prevalent micro-organism were also identified whilst the length of admission was extrapolated from hipe (hospital inpatient enquiry) records. results: there were 710 admissions for cellulitis with 3 cases of necrotising fasciitis. there was a statistically significant (p \ 0.05) relationship between temperature and cellulitis with admission peaking in late summer/autumn. age correlated significantly with readmission. furthermore, the level of crp had a statistically significant prognostic value as an independent predictor for the length of hospital stay with a high level resulting in a prolonged admission. conclusions: there is a statistically significant relationship between a rise in temperature and the incidence of cellulitis. furthermore age is an independent risk factor for re-admission with same whilst inflammatory markers at time of admission can be used as a prognostic marker for length of stay. case history | clinical findings: a 88-year-old female patient, with history of type ii diabetes, high blood pressure and major depressive syndrome, was admitted in the emergency room department complaining of abdominal pain. based on the patient's history and physical examination, a presumptive diagnosis of renal colic was initially made. however, after 2 days, the patient showed signs of fever, aggravated abdominal pain and vomiting. investigation/results | diagnosis | therapy and progressions: a ct scan showed the presence of a radiopaque foreign body near the duodenum, the presence of air bubbles outside the intestinal lumen and an hepatic abscess. we agreed to perform a laparoscopy, drainage of hepatic abscess and fish bone removal after successfully identification. after 4 days, the laboratory findings showed persistent leukocytosis and raised cpr, which led to a second ct scan with maintenance of the hepatic abscess. the decision was to perform a percutaneous drainage. after the second drainage, the patient had an uneventful recovery. comments: foreign body ingestion into the gastrointestinal (gi) tract is rare and typically accidental in adults. most ingested foreign bodies pass through the gastrointestinal tract without the need for any intervention. gi perforation is rare and can occur at any site. surgical intervention is required in less than 1% of the cases. fish bones are the most commonly ingested objects. preoperative diagnosis, when possible, is made with ct scan, identifying a linear high-density structure. high level of suspicion is of paramount importance. in cases of delayed diagnosis, perforation may lead to intraperitoneal abscess formation. reports of hepatic abscess secondary to fish bone perforation has been limited to isolated case reports in the literature. case history: description of two cases of appendicular goblet cell carcinoid tumors, which debuted as acute appendicitis. patient a was a 54-year-old woman with a 24-h evolution of classic symptoms of acute appendicitis. patient b was a 70-year-old female that consulted for chronic abdominal pain in rlq that recently increased pain intensity and fever. clinical findings: patient a had pain and defense in rlq without a fever. patient b had a chronic painful fluctuating mass in rlq, with fever over 38°c. investigation/results: patient's a lab test showed leukocytosis and us findings of acute appendicitis. the patient's b ctscan showed an intra-abdominal abscess fistulized to the abdominal wall, along with formation of a phlegmonous mass related to appendicular plastron. diagnosis: the anatomopathological reports for both patients were informed as appendicular goblet cell carcinoid tumor. therapy and progressions: both underwent laparoscopic exploration. after appendicectomy in patient a, when the diagnosis of gcct was made, the case was discussed at our mdt meeting and a right hemicolectomy was indicated and performed shortly after. in the patient b a right hemicolectomy was performed in the initial surgery due to the magnitude of tissue involvement. currently, both are receiving chemotherapy with xelox without signs of recurrence or tumor spread on follow up. comments: the gcc is a rare entity of appendicular tumors with a less favorable prognosis than the appendicular pure neuroendocrine tumors. it behaves like a low-grade adenocarcinoma and often presents as disseminated disease. therefore, sometimes surgical treatment with appendicectomy is not enough, needing the right hemicolectomy to avoid recurrence. this is recommended for tumors [ 2 cm, pt3 or t4 and higher grade histology. introduction: among the post-pancreatoduodenectomy complications post pancreatoduodenectomy hemorrhage (pph) is the least common complication, but severe form may be life-threatening without an urgent treatment. late pph are more likely due to a complex physio-pathological pathway secondary to different etiologies. the understanding of the etiology and such a pathway could therefore be of great interest to guide the treatment of potential lifethreatening late severe pph. results: during the aforementioned period 347 patients underwent pd, of whom 18 (5.18%) developed pph. early pph was reported in one patient (5.6%) with severe bleeding from the gastric stapler line. late pph were reported in 17 of these patients (94.4%). the most common causes were bleeding from a vascular pseudoaneurysm reported in 6 patients of which, one had mild and 5 had severe hemorrhage and bleeding from gastro-enteric anastomosis marginal ulcer in 6 patients, all with mild hemorrhage. no etiology was fond in 5 patients with mild hemorrhage. a significant association was found between the severity of late hemorrhage and the vascular pseudoaneurysm as a cause of bleeding (p \ 0.001). all pseudoaneurysm bleeding occurred in cases complicated by a postoperative pancreatic fistula (popf) with a significant statistical association (p \ 0.001). conclusions: the most common cause of pph was bleeding from a vascular pseudoaneurysm, most of them were severe bleeding with late presentation and all were associated with a popf. in these cases, early detection by cta is mandatory, allowing an urgent treatment by angiography of such a bleeding vascular complication following pd. ventral hernia in hostile situation introduction: there is no consensus about the benefit or harm derived from adding a mesh hernioplasty at the same time as an urgent intraperitoneal surgery for another cause. the use of a prosthesis in contaminated fields is controversial, but suture repair has a high risk of recurrence. the main objective has been to analyze the impact of the simultaneous repair of uncomplicated midline hernias at the same time as emergency surgery for another cause, in relation to the presentation of complications, the surgical site infection rate (isq) and recurrences. material and methods: retrospective, observational study of all urgently operated patients (surgery open and laparoscopic) in the period between 2015-2018 who underwent a simultaneous midline primary ventral hernioplasty. the background, circumstances of the surgery and postoperative complications during the first month and long term through the basis of prospective data of emergency surgery and complications of our surgery department. results: a total of 94 patients (50 female) met the inclusion criteria with a mean age of 57.2 years (sd = 17.5), average bmi of 28.7 kg/ m 2 (sd = 5.1). the most frequently performed interventions were: appendectomy (38.3%); cholecystectomy (48.9%); and lysis of adhesions (4.3%). the 89.4% of all interventions were performed by laparoscopic approach. they presented associated peritonitis in 12.8% of the cases. the 41.5% of patients presented some complication, in 13.8% surgical site infection (3.2% organ space). during the followup three recurrences were detected (3.2%), no patient has presented chronic infection related to the use of prostheses. conclusions: in our series the simultaneous performance of hernia repair of the midline in the context of emergency surgery for another cause has been safe and not associated with long-term complications and low recurrence rate. the open abdomen: our experience introduction: ''open abdomen'' refers to a solution in which the abdominal content is left deliberately exposed under a temporary cover for a variable amount of time. since 1970 this method has been used more and more for the treatment of severe intra-abdominal infections. starting from the 80s the concept has been also applied in trauma surgery. material and methods: between 2002/2019 we have treated 200 patients with this technique. in 45 cases the etiology was traumatic, in the remaining cases the abdominal pathology was inflammatory. in the last years we also started to use it in some cases of treatment of surgical complications. the techniques we used were different and changed during the time. at the beginning of the experience we've completed 4 drainages of the abdominal cavity according to mickulizt, 5 laparostomies with mesh, 18 bogota bags. these techniques have been abandoned since the negative pressure therapy came out. we started with the barker vacuum pack (36 cases), followed by the vac (vacuum assisted closure) and ab thera kci ò (33 patients) systems and in the last three years we used the cnp suprasorb ò of lohmann and raucher (104 patients case history: 79 year old lady presented at the a&e with few days history of constipation, faeculent vomiting, abdominal distension and pain in the lower abdomen. she had hysterectomy many years ago through a lower midline incision. her urgent ct scan of the abdomen and pelvis confirmed an incarcerated right obturator hernia containing a small bowel loop causing bowel obstruction. clinical findings: elderly, frail patient with mild tachycardia, distended abdomen and lower abdominal tenderness with guarding in the left iliac fossa. per rectal examination was unremarkable. investigation/results: inflammatory markers were raised, lactate, liver and kidney function was in normal limits with only mild hypokalaemia and hyponatraemia. ct abdomen and pelvis confirmed small bowel obstruction at the mid ileal level due to right obturator hernia. diagnosis: incarcerated right obturator hernia causing small bowel obstruction. therapy and progressions: patient was taken to the operating theatre for urgent laparotomy. dilated small bowel loops and incarcerated right obturator hernia was found with proximal ileal loop in it. after blunt stretching and dilatation of the obturator foramen, the involved ileal loop was reduced. it was deemed viable, therefore no bowel resection was required. the defect at the right obturator foramen was closed with suture. post-operatively the patient was transferred to the intensive care unit for further management. comments: obturator hernias are a rare type of pelvic hernias. their real incidence is unknown but it is thought to be less than 1% of all hernias worldwide and due to its non-specific symptoms and late diagnosis, they require bowel resectional surgery in nearly 50% of the cases. howship-romberg sign is helpful in diagnosing such a hernia, but the ultimate diagnostic choice is ct scanning which is the only way to find this condition early and avoid bowel ischaemia. case history: a 21-year-old woman without previous medical history presented to the emergency department with abdominal pain and dysphagia associated with nausea, vomiting and absolute constipation. during previous months, she reported having ingested hair. clinical findings: abdominal examination revealed a distended abdomen with rebound tenderness and tinkly bowel sounds. investigation/results: ct-scan showed a distended stomach with a mussel-shaped, heterogeneous and non-enhancing mass. an esophagogastroduodenoscopy revealed hair inside the lower esophagus and the stomach. diagnosis: high intestinal obstruction due to a gastric trichobezoar. therapy and progressions: the patient underwent laparotomy, gastrotomy and trichobezoar removal (fig. 3) . the postoperative period was uneventful and she was discharged home on the 8th pod with a psychiatric evaluation scheduled. comments: bezoars are rare conditions consisting of compacted material that is unable to pass through the gastrointestinal tract. 1 this condition usually involves the stomach; rarely, it can extend into the small bowel and even the colon, giving the so-called rapunzel syndrome. 2 bezoars could be composed by vegetable material (phytobezoars), hair (trichobezoars), drugs (pharmacobezoars), or other materials. 1, 3 a trichobezoar is the result of trichotillomania, trichophagia or other psychiatric disorders. 3 always consider bezoars in differential diagnosis. introduction: the effectiveness of different step-up approaches is increasingly evaluated but results are controversial. we assessed the results of a standardized step-up approach protocol in the treatment of acute severe necrotizing pancreatitis, with a special focus on patient stratification to obtain an early identification of those deserving a more aggressive strategy. matherials and methods: this is a retrospective analysis of patients with acute severe pancreatitis over a period of 10 years. the variables taken into account were: etiology and severity of the disease, sepsis, organ failure, hemodynamic stability, treatment, los, morbidity, mortality. since 2016, patients with infected necrosis underwent a standardized step-up approach: percutaneous drainage only; percutaneous and endoscopic procedure; surgery. the results were compared with the standard care delivered from 2009 to 2015. results: among 142 patients, 51 (35.9%) were identified as affected by severe necrotizing disease. overall mortality was 29.4%. the initial management was non operativein all patients. mortality in the step-up group was 20% (3/15) vs 25% (9/36) in the standard care group. conclusion: a standardized step-up approach protocol offers better results than standard care in the management of acute severe necrotizing pancreatitis. however, a better stratification of patients. introduction:the appendix stump closure in complicated appendicitis has been widely practiced in different ways such as metal clip, hem-o-lok clip, endoloop and endostapler. the treatment of complicated appendicitis with necrosis and perforation of the appendix base is controversial. we aimed evaluate the efficacy of laparoscopic partial caecum resection with endostapler in complicated appendicitis with necrosis and base perforation. material and methods:from january 2015 to october 2019, we evaluated 28 consecutive patients who underwent a laparoscopic partial caecum resection in complicated appendicitis with necrosis and perforation of the appendix base. partial caecum resection was performed with the endostapler to close the appendix base at ileocaecal junction. results:the laparoscopic partial caecum resection with endostapler was used in %92.8 of the cases. the mean operative time was 100.07 ± 34.12 min. there were necrosis of appendix base in 12, perforation of appendix base and diffuse peritonitis in 9, perforation of the appendix base and localized peritonitis in 7 of the patients. the wound and intra-abdominal infection rates were 9.8% and 7.2%, respectively. there were no operative complications and the conversion rate was 7.2%. the average length of hospital stay was 4.46 ± 3.10 days. there was no leakage on the stapler line. conclusions:the laparoscopic partial caecum resection with endostapler in complicated appendicitis with necrosis and perforation of the appendix base, is a safe and effective technique. introduction: the term ''''volvulus'''' comes from the latin ''''volvere''''meaning twist. if left unattended, sigmoid volvulus can compromise the blood supply of the involved segment,leading to ischemia,gangrene,perforation and death. the mainstay of sigmoid volvulus management has been through proctoscopic or colonoscopic decompression when feasible, followed by surgery either during the same admission or electively. the aim of our study is to identify patients which can benefit of immediate surgical approach and prognostic factors associated with failure of conservative/endoscopic treatment. materials and methods: charts of 27 patients admitted for sigmoid volvulus to our institute were retrospectively analysed. we revised ct scan images and laboratory tests of all the patients to identify risk factors for conservative treatment failure. results: 18 patients underwent surgical procedures; in 9 cases after a failure of an initial conservative approach; 9 patients were managed with endoscopic approach only. elective surgery was performed in 2 patients. case history: we report a 32-year-old male case presenting left hand middle finger pain after pressured paint gun shot in volar proximal phalanx clinical findings: on physical examination swelling and tenderness on the volar side of the hand was observed (fig. 1 ) investigation/results: pain was remarkably more intense with passive finger extension. distal nerurovascular status was unscathed. there was no fracture reported on radiography. leukocytosis and acute phase reactants rise was observed on laboratory examination diagnosis: after physical, radiological and laboratory examination the diagnosis of acute flexor tenosynovitis was made. therapy and progressions: open debridement and irrigation following bruner incisions on middle finger was undertaken within 4 h of injury. paint impregned in tissues could be observed in subcutaneous tissue, palmar fascia and flexor tendon sheath. paint affected tissues samples were analysed in microbiology laboratory (fig 2, 3) after checking nerurovascular indemnity, 14g drainage was left in deep tissues and skin suture was performed with 4-0 monofilament non absorbable suture. the patient followed 3 days intravenous antibiotical therapy followed by 4 weeks oral treatment. he attended physiotherapy program postoperatively, reporting no functional disability or wound complications after 3 weeks. comments: chemical flexor tenosynovitis is an important emergency which must be correctly diagnosed and treated due to quick progression and potential morbidity if not treated effectively (1) in our experience, case was managed by open debridement and irrigation but different treatments can be followed depending of patientsclinical situation, such as iv antibiotics with serial examinations or percutaneous drainage. it should also be noted that australia does not have a specific subspecialty in emergency surgery. the acute surgical unit at the tch was set up in 2010 in order to provide a dedicated acute unit to service the ever increasing demand acute surgery. previous model was that the acute surgical service was integrated into the elective work. 16 additional beds were provided to the unit including the positions of a dedicated director and chief nurse. the achievement of the unit has been the decreased time to theatre, less after-hours operating, standardised treatment approaches, and dedicated emergency surgery medical staff. the difficulties have included clinician engagement, competing resources with elective surgery, emergency surgical presentations increasing by 3-6% each year, and the unit''s beds being used for non-acute patients as the hospital approaches regular 100%. the acute surgical unit has evolved into a specialised acute care that enables rapid assessment and treatment of patients with staff dedicated with skills in this area. treating pyogenic liver abscesses secondary to diverticulitis in a patient using immunosuppressants for crohns disease by performing a sigmoid colectomy introduction: pyogenic liver abscess (pla) formation due to microbial contamination of the liver parenchyma is often seen secondary to intra-abdominal infections. pla formation due to crohn''s disease (cd) is a rare complication and not well-documented in current literature. as symptoms often mimic a cd exacerbation, diagnosis is often delayed and severe disease may develop. optimal treatment for this group of patients remains debatable. case presentation: a 54-year-old man was admitted to the hospital with a 2-week history of overall malaise, fever and night sweats. patient''s history solely stated a 6-year treatment of cd that was stable over the past period with infliximab and azathioprine. investigations and treatment: biochemical analysis revealed a c-reactive protein of 314 mg/l and a white blood cell count of 15.3 9 109/l. an abdominal ct scan showed multiple abscesses in the right lobe of the liver and a thickening of the wall in the transition of the descendent colon to sigmoid. the patient''s immunosuppressants were paused, intravenous antibiotics were administered and a percutaneous drainage of the biggest pla was performed. however, the clinical condition of the patient did not improve. colonoscopy and pet-ct scan did not reveal any other sites of infections. as patient remained septic and previous imaging revealed mild diverticulitis rather than active cd, an emergency hartmann''s procedure was performed. hereafter, the patient recovered rapidly and the plas resolved completely. conclusion: diverticulitis of the sigmoid colon should be considered as causative pathology in patients presenting with multiple pyogenic liver abscesses and a history of crohn''s disease that is in full remission with immunosuppression. when the abscesses exceed 3 cm in size and are multilocular, resection of the inflamed colon can be a treatment option of value. clinical findings: epigastric pain and recent episode of hematemesis. pain at deep palpation of the epigastrium, no signs of peritoneal irritation investigation/results: abdominal x-ray and ct showing a large right sided strangulated paraesophageal peh, with pneumatosis of the gastric wall diagnosis: right sided strangulated peh therapy and progressions: emergent laparotomy. peh reduced, ischemic portion of the stomach recovering viability. closure of diaphragmatic defect with non-absorbable suture, reinforcement of lower esophageal sphincter with round ligament (ligamentum teres hepatis) and anterior partial fundoplication (dor). postoperative course uneventful, patient discharged on 10th pod. comments: peh are mediastinal displacements of abdominal organs, most often the stomach, associated with laxity or a hole in the phrenoesophageal membrane, large enough to allow the gastric fundus to herniate. because the stomach is attached to the gastroesophageal junction, it tends to rotate around its axis leading to organoaxial volvulus. occurrence and size increases with age. peh account for 5-15% of all diaphragmatic hernias. in patients without prohibitive operative risk, they should be surgically corrected, avoiding the risk of acute and potentially life-threatening complications when emergent surgical repair is required. the risk of developing these complications is less than 2%/yr and associated mortality rate is approximately 5%. case history: patient was a previously healthy 40-year-old female with an unremarkable past medical history, non-smoker with a high body mass index (bmi [ 30). she first presented to a level 2 medical facility with acute left upper leg pain and swelling. one week prior to this she had a progressive cough, swinging fever, and malaise. clinical findings: patient was transferred to our hospital haemodynamically unstable, acidotic, hypoxemic and delusional. tachypnea and oliguria were present. she continued to deteriorate clinically with pyrexia (t 39,3 oc), resistant shock, and toxaemia. on examination her left leg was found to be paresthetic below the femoral-inguinal fold. investigation/results: abg samples showed lactic acidosis with a ph of 7.32 and lactate of 3.2 mmol/l. hypoxia and hypocapnea were present.her biochemical profile showed acute kidney injury (aki) with raised creatinine kinase (cpk) 850 and serum creatinine (cr) 2.08. chest x-ray illustrated bilateral lung infiltrations (ards image). diagnosis: patient was urgently referred to a ct scan of the left femur with i.v. contrast for suspected necrotising fasciitis. ct findings highlighted a deep muscular femoral abscess with multiple regional fluid collections and necrotizing inflammation from the femur diaphysis to the patella. therapy and progressions: the patient was immediately transferred to or for emergency surgical exploration and debridement. almost the entire anterior compartment of the femur was necrotic and hence an extensive excision of the dead tissues and packing with npwt was performed. comments: severe snm can cause marked systemic toxic effects, namely, the streptococcal toxic shock syndrome (stss). stss secondary to snm is a life-threatening host response to gas superantigens with a mortality rate as high as 80%. clinical findings: patient had a diffusedlty tender abdomen and had not passed flatus proceeding his admission to the a ? e department and was vomiting. investigation/results: ct abdomen showed small bowel dilatation with abrupt cut-off point proximal to the icv diagnosis: a diagnosis of small bowel obstruction was made based on the clinical and ct findings. therapy and progressions: patient was taken to theatre for laparoscopy ? -proceed and a 'slipped' bowel lopp was noted within the peritoneal flap that had been created a week prior during the original hernia repair. the 'v lock'' suture line was found to be loose which is thought to have led to this complication. the bowel loop was reduced, deemed viable and an internal hernia repair was performed. post-operative period was unremarkable and the patient was discharged day 3 posy-operatively. comments: during lap tapp hernia repair, there are currently at least 3 options avaiable for peritoneal flap closure; (sutures, tackers and glue.) suregons prefernce prevails over the chosen approach. when sutures are chosen, most surgeons prefer the self-locking v-lock stitch. by adopting this technique, meticulous periotneal closure is impoartan, as loose suturing of the peritoneum can lead to post operative complications of internal herniation and small bowel obstruction, as described in this case. a multi-centre prospective study would be welcomed, to compare efficacy and safety of all types of peritoneal closure devices. introduction: peer review assessment of medical treatment has been shown to be a robust way of improving quality of care in trauma in our institution and globally. in 2016 we introduced regular morbidity and mortality meetings at the department of gastrointestinal surgery. severe complications (revised accordion classification [ 3) after surgery were identified on a weekly basis, evaluated and data included in a local quality registry with the aim of revealing suboptimal surgical quality and continuously improving our results. material and methods: retrospective analysis of collected data from the described quality registry. all adult patients who had undergone gastrointestinal surgery in 2018 were assessed. results: of 2091 surgical procedures performed, 70% were emergency procedures. a total of 11% (239/2091) experienced a severe complication after surgery and 6% (125/2091) required reoperation. in the group of upper gastrointestinal surgery [n = 570 (27%)] 59% were emergency procedures. anastomotic leak (al) was identified in 15% (9/59) undergoing thoraco-laparoscopic esophagectomy and in 8% (3/36 patients) after gastrectomy. of 190 laparoscopic cholecystectomies, 79% were emergency procedures with 1% (1/151) reoperation. of 106 hernia repairs, 5% required reoperation. in the group of lower gastrointestinal surgery [n = 1521 (73%)] 74% were emergency procedures. al was diagnosed in 5% of 257 colonic resections and 11% of 87 patients after rectal resection. in emergency colorectal resections(n = 30) there were no al. of 497 appendectomies, 5 patients (1%) required reoperation. the most frequent cause of reoperation was revision of stoma (26), followed by reoperation for al (25), abscess (19), and wound dehiscence (13). 17 patients died after surgery of which 15 were emergency surgical patients. conclusions: systematic assessment of all severe complications helps reveal surgical procedures which can be improved but also to identify surgical procedures with low complications rates. plans are being developed to improve the quality of the identified procedures. all surgical departments should have regular and thorough assessment of their activity. acute surgical patients operated by emergency surgeons has less risk of post-operative complications and mortality d. gumaa 1 1 east kent hospitals university nhs foundation trust, general surgery, ashford, united kingdom introduction: in england and wales, we perform over 300,000 emergency laparotomy every year. 30 days mortality rate is around 10-11%. in our study we are trying to demonstrate if have dedicated emergency surgery service will make a difference in the outcome of emergency laparotomy. material and methods: retrospective study on prospectively collected data from nela database done in a large district general hospital. all patients over 18 years old who underwent emergency laparotomy for acute surgical condition between november 2017 and january 2019 were included in the study. mortality and post-operative complications were the primary outcomes. results: total of 191 patients were included in the study, 114 operations were performed by emergency surgeons (es). 30 days mortality rate was 9%, while it was 12.8% for the none emergency surgeons group (nes) post-operative complications were 13.1% compared to 15% for patients operated by nes. there was shorter itu stay with average of 2.8 days, while the itu stay for the other group was 3.3 days, but the es group had higher chance of unplanned return to theatre. 7.6% of the patients went back to theatre compared to 6% of the other group. reasons of unplanned return to theatre was mainly post-operative collection or wound dehiscence. conclusions: emergency surgeons has better outcomes when they perform emergency laparotomy, may be because they perform higher number of laparotomy compared to their peers. emergency surgery has been a growing subspeciality recently, and with no doubts having surgical emergency units has improved the patient's care around uk. the advantage of 2 g over 1 g of prophylactic cefazolin in surgical site infections in trauma surgery below the knee introduction: the rate of surgical site infections(ssi) after foot/ankle surgery remains high, despite the implementation of antibiotic prophylaxis (1) . recently guidelines suggest a single dose of 2 g instead of 1 g of cefazolin for implant surgery, this decision is largely based on pharmacokinetic studies (2) . however, the clinical effect of this higher dose has never been investigated in this region. this retrospective cohort study therefore investigated the effect of 2 g compared to 1 g of prophylactic cefazolin on the incidence of ssis in foot/ankle surgery. material and methods: all patients undergoing trauma-related surgery of the foot, ankle or lower leg between september 2015 and march 2019 were included. primary outcome was the incidence of a ssi. ssis were compared between patients receiving 1 g and 2 g of cefazolin as surgical prophylaxis. results: a total of 293 patients received 1 g and 126 patients received 2 g of cefazolin. the groups did not differ in gender, age, weight, co-morbidities or intoxications. the overall number of ssis was 19 (6.5%) in the 1 g group and 6 (4.8%) in the 2 g group. corrected for the confounders ''age'', ''smoking'' and ''blood loss'' this was not statistically significant (p = .705). conclusions: even though the decrease in ssi rate from 6.5 to 4.8% was found not to be statistically significant, it might be clinically relevant considering the reduction in morbidity, mortality and healthcare costs. research linking pharmacokinetic and clinical results of prophylactic cefazolin is needed to establish whether or not the current recommendations and guidelines are sufficient for preventing ssis in foot/ankle surgery. introduction:right-sided colonic diverticulitis (rd) is much rarer than left-sided (ld) and subsequently, controversies concerning the most appropriate treatment remain unsolved. our experience let us believe that mild rd can benefit from an outpatient management. material and methods: we performed a single center retrospective comparative study in which we included all our diverticulitis patients that were treated as inpatient in our unit. we divided in two groups:rd and ld group. the ld group was created by randomization from a prospective ld patients database. results: we included 24 rd and 94 ld patients treated in our unit from july 2016 to july 2019. median age was 53.9 in rd and 57.2 in ld, with a 52.2% of females in rd vs 45.2% in ld. asa classification was significantly lower in rd (asai:58.3% vs 33%, asaii:41.7% vs 46,8, asaiii:0 vs 18.1%, asaiv:0 vs 2.1% p = 0.005). the presence of neumoperitoneum in ct scan was significantly higher in ld 16.7% vs 59.6% p = 0.001) surgery was performed in 26.5% of the left-sided diverticulitis compared to 0 of the rd group (p = 0.0019). antibiotics of third line (imipenem and meropenem) were only required for ld (0 vs 26.1% p = 0.003). length of hospital stay was significantly shorter (p = 0.001) in rd (3.58 ± 1.35) than in ld group (6.11 ± 3,47) conclusions: in our series, patients with right diverticulitis had fewer perforations in the ct scan, they required lower spectrum antibiotics and did not required any surgical treatment with a shorter length of hospital stay. we consider that mild right diverticulitis could benefit from an outpatient treatment with oral antibiotic following similar recommendations to those followed for mild ld patients. when surgery should not be immediate, a night of hospitalization in a specialized environment is performed and surgery deferred overnight. in some selected patients, a return home is possible with a scheduled emergency surgery the next day. the pa.r.c.o.ur protocol is set up in the surgical emergencies of the university hospital of lille after a suitable medical treatment and enlightened information. this retrospective study assesses whether this deferred surgical management allows a return home on the day of the operation. methods: between 1/01/2015 and 1/09/2018, 3468 records of patients operated for an abscess, appendicitis, cholecystitis or symptomatic inguinal hernia were reviewed. 321 patients who did not have criteria for immediate surgical management (peritonitis, occlusion, sepsis, cellulitis, intravenous treatment need) agreed to return to their home for an os the next day. results: 286/89% interventions were performed in os and allowed a return home at day 0, within a median time of 7 h [iqr 6-9]. conclusions: the pa.r.c.o.ur protocol makes it possible to reserve the availability of the entire technical platform (operating rooms and beds) to the most serious pathologies with a failure rate of 11%. the medico-economic benefits, the efficiency in the management of the beds and the satisfaction of the patient and medical staff of this protocol must be evaluated prospectively. a 69 years old woman was admitted in our er presenting with a 12 h sharp epigastric and ruq pain, fever, nausea and vomiting, hd stable. the patient had a past medical history of tachyarrhythmia, open-angle glaucoma and lower limb venous insufficiency. her past surgical history included an hysterectomy and bilateral salpingooophorectomy, appendectomy and left inguinal hernioplasty. during clinical examination, signs of peritoneal irritation were present. ct scan revealed a small pneumoperitoneum in the luq and multiple small and large bowel diverticula, without free peritoneal fluid. blood work showed mild leukocytosis and neutrophilia. we performed an urgent exploratory laparoscopy in which dozens of small intestine diverticula were found, increasing proximally in number. one of them, 20 cm distally from the treitzs angle, showed signs of perforation, with a small abscess and surrounding fibrin. the affected bowel was externalized through a 4 cm laparotomy for segmental resection and a manual double-layer terminoterminal jejunojejunostomy was performed. in the perforated jejunal diverticulum, a 25 mm cod fishbone was identified as the cause of the perforation. the histopathological examination of the extracted 6 cm tissue sample, found several diverticular structures of the muscular wall, one of which with a 2 mm perforation and a granulocytic infiltrate with serosa involvement. complicated cases of small bowel diverticulosis are best managed by segmental resection surgery. despite being quite rare, every surgeon should be aware of such acute abdomen presentation. asymptomatic cases benefit from a watch-and-wait approach. case history: a 47-year-old female consulted to the emergency department for a 24 h epigastric pain. it was accompanied by nausea without vomiting. clinical findings: the patient was hemodynamically normal and the abdomen was soft with minimal distention. investigation/results: x-rays showed large gastric dilation. the abdominal ct scan showed mesenteric axial gastric volvulus with minimal free fluid. suddenly, the patient presented diffuse abdominal pain with diaphoresis, mucocutaneous pallor, hypotension and tachycardia. diagnosis: a gastric volvulus with gastric ischemia was suspected. broad-spectrum antibiotic therapy and resuscitation measures were started. emergency surgery was indicated. therapy and progressions: a decompressive gastrostomy, gastric reduction and devolvulation, transverse colon resection due to ischemia and splenectomy were performed. after 12 h, she required total gastrectomy and right hemicolectomy due to ischemia secondary to severe septic shock associated with disseminated intravascular coagulation. comments: the gastric volvulus is an uncommon entity, being the mesenteric-axial type so rare. there are very few cases described whose manifestation is accompanied by hypovolemic shock secondary to splenic laceration, which occurred due to the great gastric distention. early diagnosis is the key to start treatment as quickly as possible, due to high mortality the main mechanism of death is usually vascular involvement, perforation and multiorgan failure. results: we analyzed 13,621 pediatric ogis, and 23.3% of pediatric cases occurred in the 0-5 age group, 20.1% in 6-10, 19.9% in 11-15, and 36.7% in 16-20. the average age of the cohort was 11.5 years and 76.5% of cases occurred in boys. racial distribution revealed 35.8% of cases in caucasians, 17.0% in african americans, and 17.3% in hispanics. most (39.9%) cases were documented in the southern united states. of our 13,621 cases, 12.6% underwent vitrectomy, 4.2% underwent enucleation, and 1.8% developed endophthalmitis. the rate of endophthalmitis development after ogi was highest (4.6%) in the asian/pacific islander group. the average length of stay for the entire cohort was 3.51 days, and the average cost per day was $11,724.01. table 1 contains a breakdown of our statistics. conclusions: as documented in the nis, ogi occurs more commonly in boys than in girls at a ratio of approximately 3:1. the rates of vitrectomy and enucleation are higher in boys. we noted a higher of rate of enucleation in asian/pacific islanders and african americans. the plurality of ogis occur in the 16-20 age group; this age group also has the highest relative rate of enucleation. with respect to location, ogis occurring in the western united states had the highest average cost per day of inpatient stay. autologous tissue from intramedullary channel parietes for femur nonunions management introduction: a reamer-irrigator-aspirator (ria) method is deeply reliable for getting high volumes of bone graft/mscs. high rates of successful outcomes have been reported after the use of ria bone fragments to cure non-unions. material and methods: being supported by histomorphological examination of the material acquired while drilling intramedullary channels of 41 patients with femur nonunions (20-hypertrophic, 21oligotrophic), we have discovered that nevertheless, expressions of the dystrophy and necrosis in bone tissue and marrow in pseudoarthrosis areas depend on time since fracture occurrence, the microscopic study of the material 5 cm above and below a fracture line has demonstrated ordinary structures of bone tissue and marrow in all cases. introduction: this study aimed to evaluate the outcomes of ankle fractures with posterior malleolus fragments (pmfs) involving \ 25% of the articular surface treated with or without screw fixation. material and methods: among patients with ankle fractures and pmfs who underwent surgery between march 2014 and february 2017, 62 with type 1 pmfs involving \ 25% of the articular surface were included. of these 62 patients, 32 underwent screw fixation for pmfs and lateral and/or medial malleolar fracture fixation (group a) and 30 underwent internal fixation for malleolar fractures without screw fixation for pmfs (group b). ankle joint alignment and fracture healing were measured using plain radiography and computed tomography (ct). clinical outcomes were determined using the american academy of orthopaedic surgeons foot and ankle questionnaire, short form-36, and american orthopaedic foot & ankle society scale. results: nonunion was not noted in either group. however, we detected union with a step-off of 2 mm or more in 2 cases from group b. with regard to ankle joint alignment, 1 case in group a and 3 cases in group b showed mild asymmetry of the medial and lateral clear spaces on ct at 12 months. clinical outcomes at 6 and 12 months after surgery were better in group a than in group b. conclusions: screw fixation of pmfs was effective for fracture healing and maintaining ankle alignment. additionally, it improved short-term clinical outcomes, which we believe was due to stabilization of ankle fractures with pmfs involving\ 25% of the articular surface. references: level ii, prospective comparative study. how accurate can gaps and step-offs be determined in acetabular fracture treatment? introduction: the assessment of gaps and steps in acetabular fractures is challenging. studies evaluating the value of various imaging techniques to enable accurate quantification of acetabular fracture displacement are limited. this study aimed to assess the inter-and intraobserver variability of gap and step-off measurements using pelvic radiographs, intraoperative fluoroscopy and computed tomography (ct). material and methods: sixty patients, surgically treated for acetabular fractures, were included. five observers measured the gap and step-off on all the pre-and postoperative pelvic radiographs and ct scans. intraoperative fluoroscopy images were reassessed to determine the presence of gaps and/or step-offs. the inter-and intraobserver variability were calculated for the measurements using pelvic radiographs or ct scans. kappa was calculated for the intraoperative fluoroscopy assessment. results: for the preoperative displacement, the intraclass correlation coefficient (icc) was 0.4 (gap and step-off) using pelvic radiographs, and 0.4 (gap) and 0.0 (step-off) using ct scans. for the postoperative displacement the icc was 0.4 (gap) and 0.2 (step-off) using pelvic radiographs and 0.3 (gap) and 0.4 (step-off) using ct scans. the average kappa for the intraoperative gap and/or step-off assessment using fluoroscopy was 0.2 (-0.36 to 1) both for the inter-and intraobserver assessment. conclusions: there is little agreement between the observers regarding the measurements of the preoperative displacement, the presence of gaps and step-offs intraoperatively and the measurements of the postoperative displacement. a possible explanation for this is that the acetabulum has a three-dimensional spherical shape with multiple fracture lines and fragments going in different directions. single radiographic or ct-based gap or step-off measurements do not seem to be representative for the fracture characteristics, therefore the use of 3d measurements should be considered. introduction: long-term intake of glucocorticoids leads to pathologic changes in bone and cartilage tissues. material and methods: to understand how to prevent the occurrence of the pathology, we studied the use of vitamin d, vitamin e and a combination thereof on the background of the intake of prednisolone, 0.5 mg/ 100 g of body weight. the experiment involved 68 male rats of wistar linear breed. the animals were 2 months old and weighted 100.0 ± 5.0 g. the experiment included 4 series of animals, 17 rats in each, namely: the first group-intact animals; the rest of the animals received prednisolone, 0.5 mg/100 g of body weight. the rats of the third series received additionally 100 iu of vitamin d3. the animals from the fourth group also received 0.726 iu (0.6 mg) of vitamin e. results: long-term administration of prednisolone to the experimental animals has caused significant structural and functional disorders in their bone and cartilage tissues. they can be construed as simulated glucocorticoid-induced osteochondropathy. the combination of the vitamins d3 and e has demonstrated its ability to promote restoration of histomorphologic features of bone and articular cartilage in proximal femur epiphysis and epiphyseal cartilage of proximal femur epimetaphysis in animals with simulated glucocorticoid-induced osteochondropathy. the combination of the vitamins d3 and e has demonstrated a better effect on the background of the glucocorticoid-induced osteochondropathy, compared to the vitamin d3 alone. conclusions: preventive administration of the vitamins d3 and e while treatment with prednisolone leads to avoidance of the majority of pathologic changes, resulting otherwise from glucocorticoid-induced osteochondropathy. konyang university hospital, orthopaedic, deajeon, south korea introduction: the purpose of this study was to evaluate clinical, radiological and functional outcomes of patients had osteochondral autograft harvested from the ipsilateral femoral head for a femoral head defect after posterior hip fracture dislocation material and methods: this study was approved by irb at our institution. a retrospective chart review of a prospectively performed operation was performed at two university hospital between march 1, 2014, and june 30, 2018 . all fracture was classified by the ao/ota classification. we included the patients had minimum 6 months of follow up periods. ten displaced head fractures were addressed through posterior surgical dislocation and two patients had no posterior dislocation was operated using smith-peterson approach. an osteochondral graft was harvested from inferior non-weight bearing articular surface and grafted to osteochondral defect. all patients were full weight bearing by 3 months results: we had 86 femoral head fracture dislocation. 5 patients were excluded due to lost to follow up. twelve of 81 with type i/ii pipkin fracture dislocation with the articular defect and reduced within 12 h of injury was identified for review. the patients were followed up for a mean of 13.2 months. there was no osteonecrosis. decreased joint space was identified in two patients. all fractures achieved union. the mean harris hip score of last follow up was 89.1 (56-98) one patient who operated using the smith-peterson approach had femoral nerve palsy. conclusions: the clinical and radiological results after treatment of femoral head fracture dislocation with articular defect by osteochondral autograft harvested from its own non-weight bearing articular surface show good outcomes. hospital universitario fundacion jimenez diaz, madrid, spain, 2 hospital universitario 12 de octubre, madrid, spain, 3 hospital universitario la paz, madrid, spain introduction: preoperative computerized tomography scan provides important information about ankle fractures associating posterior malleolus, helping us distinguishing fractures affecting distal tibiofibular joint. the aim of our paper is to describe our series of patients suffering an ankle fracture with posterior malleolus involvement. methods: fifty-two consecutive patients, with ankle fracture involving posterior malleolus were evaluated prospectively. all of them were assed with a preoperative ct scan, demographic data, fracture mechanism, surgical approaches, posterior malleolus size measured classification and treatments were analyzed. results: most frequent posterior malleolus pattern according to bartonicek classification was type ii, twenty-two patients (42.3%). an alternative surgical approach was performed in thirty-three patients (63%) as a consequence of information provided by ct scan. no statistical differences were observed when measuring posterior malleolus in conventional x-rays or ct scan. analysis of variance showed a p value less than 0.05 when comparing pm size and haraguchi and bartonicek classifications. discussion and conclusion: ct scan is required to perform an adequate preoperative study of ankle fractures involving posterior malleolus, using this information to provide a better outcome to our patients. effect of atorvastatin and losartan on gene expression and cell count in a rat model of posttraumatic joint contracture of the knee-a blinded and randomized animal study introduction: myofibroblasts have been associated with increased posttraumatic joint contracture, which has a massive impact on articular function. atorvastatin and losartan have shown to reduce the proliferation of cardiac, hepatic and pulmonary myofibroblasts. the aim of this study was to evaluate the effect of atorvastatin and losartan on gene expression, cell count and collagen deposition in the posterior joint capsule 2, 4 and 8 weeks after trauma in a rat model of posttraumatic joint contracture of the knee. material and methods: posterior capsular injury and kirschner-wire immobilization of the knee were performed in 72 sprague-dawley rats. atorvastatin, losartan, or placebo was administered daily orally. the rats were sacrificed at either 2 (n = 24), 4 (n = 24) or 8 (n = 24) weeks after initial surgery. rats euthanized at week 8 had their k-wire removed at week 4, followed by a remobilization period of another 4 weeks. the results were evaluated via qpcr and immunohistochemistry. results: losartan reduced the number of myofibroblasts in comparison to the control at week 2 and 4, whereas atorvastatin lowered myofibroblasts only at week 2 (p \ 0.05). atorvastatin reduced the collagen deposition at week 2, whereas losartan had no effect on collagen deposition. losartan decreased gene expression of connective tissue growth factor (ctgf) at week 4 and of tgf-b at week 8. clinical findings: positive anterior drawer test, grade iii valgus instability, and a palpable gap below the patella were assessed. no neurovascular alterations were found and ankle-brachial index scored [ 0.9. investigation/results: initial immobilization with a splint was performed. radiographs showed a high patella with no other lesions. mri revealed a complete rupture of the patellar tendon and a complex multiligamentous injury with complete anterior cruciate ligament (acl) tear, avulsion of distal medial colateral ligament (mcl), and a complex rupture of both meniscus. diagnosis: knee dislocation with patellar tendon rupture. therapy and progressions: definitive treatment was performed 7 days after the initial lesion, with arthroscopic resection of the posterior horn of the external meniscus and reconstruction of the acl with posterior tibial tendon allograft, as well as open repair of the patellar tendon and the internal meniscus, with subsequent mcl distal reinsertion. immediate partial weight-bearing with an extension orthosis was allowed. the patient is currently progressing with rehabilitation. comments: knee dislocation is a rare injury, and most cases are due to highenergy trauma. concomitant rupture of the patellar tendon is very unusual, and most cases are described in the context of open injuries. surgery is mandatory in order to restore full stability of the knee, with either one intervention or a staged surgery, including repair of the collateral ligaments and the patellar tendon followed by arthroscopic reconstruction of the cruciate ligaments. postoperative management consists on early rom restoration and weight-bearing as tolerated. introduction: apophyseal anterior inferior iliac spine (aiis) fractures are rare injuries. they most commonly occur in athletes in adolescence period. because the ossification of pelvis is not completed, apophyses are the weakest part of musculo-tendinous unit during this period, thus avulsion fractures are more frequent than muscle ruptures. aiis avulsions are the result of sudden and forceful contraction of rectus femoris muscle concentrically or eccentrically. material and methods: we report a clinical case of a aiis avulsion fracture in a young male football player, after being misdiagnosed as muscle strain. results: our patient was treated with conservative treatment including bed rest, analgesia, using crutches and toe-touch weight bearing, progressing to full weight bearing as tolerated and nonsteroidal anti-inflammatory drugs. at follow-up, he showed relief from his pain and mechanical symptoms and regained full range of motion and returned to his previous levels of activity. conclusions: diagnosis requires careful attention to the physical examination and imaging. in this case, the fracture was managed successfully with a conservative approach. good results and return to previous levels of activity can be achieved with conservative treatment. when misdiagnosed as a simple strain, the late diagnosis may cause chronic pain with decreased sportive performance in the future. therefore, a carefully taken anamnesis and physical examination with comparative anterior-posterior pelvic x-rays are needed not to miss avulsions in adolescents; also in some instances, more advanced scanning methods must be considered. introduction: the problem of meniscus damage in children is due to unsatisfactory treatment results, which is associated with the frequent execution of meniscectomies. amount of unjustified meniscectomies and the incidence of osteoarthritis can be reduced if menisci are repaired. material and methods: during the period january 2018-august 2019 66 children with injuries of the meniscus were treated in morozov children's clinical hospital. 59 children underwent meniscus repair by suturing using three techniques: ''all inside'', ''inside out'' and ''outside to inside''. meniscus suture decision was made taking into account the assessment of the severity of the damage. the period from the moment of injury wasn't taken into account. the technique of meniscus suture was determined depending on the location and type of damage. we met 4 children with damage to the discoid meniscus who underwent partial resection and meniscus suture. 7 children underwent a meniscectomy due to severe traumatic and degenerative changes. children had mri of the knee after 6 months and x-ray after 12 months. results: 30 children achieved a satisfactory functional result; 28 operated children are at the rehabilitation stage. we faced a complication-limitation of flexion in the knee joint in 1 child. in all children on the control mri, the absence of synovitis, the safety of the reconstructed meniscus contour and the decrease in the intensity of the hyperechoic signal in the gap zone in dynamics are determined. conclusions: the introduction of a technique for repair meniscus integrity in the daily practice of an arthroscopist makes it possible to reduce the number of meniscectomies, which will reduce the number of unsatisfactory treatment results for this pathology and prevent the development of early osteoarthritis of these, 97 children revealed a fracture-dislocation of the patella. in 64 children, a tangential fracture of the lateral condyle of the femur was noted. in 110 children, the dislocation was repeated. we met 89 children with bilateral damage. all children with complete damage to the medial patellofemoral ligament, fracture-dislocation of the patella and dysplastic dislocation were performed tendon plastic using the quadriceps femoris tendon. the technique includes: transplanting a graft quadriceps tendon graft without cutting off the patella. next, the transplant is subfascial carried out in the medial direction and is fixed with a bio-integrated screw in the femur. results: the rehabilitation period was 4 months. 10% of children have a satisfactory result (there is a limitation of flexion in the knee joint to 90°). 90% have an excellent clinical result: the full range of motion in the knee joint, the absence of pain and a return to sports. none of the operated children had relapses of dislocation. conclusions: it is recommended to consider the technique of tendon plasty of the medial patellofemoral ligament using the quadriceps femoris tendon as a method of choosing the treatment for patellar dislocation in children. case history: a 13-year-old boy who was injured while playing baseball. he was playing as a catcher and was bumped into the runner, therefore his ankle got twisted. he was immediately taken to the hospital. clinical findings: x-ray the distal tibial epiphyseal growth plate was irregular. although the ankle joint was not dislocated. in the ct, the proximal fibular fragment was caught behind the posterior edge of epiphysis of the distal tibia and was trapped there. investigation/results: the patient must be operated in order to repair the ankle. but the reduction of the entrapped distal tibia epiphysis was not easy without open. diagnosis: we diagnosed with bosworth like fracture. therapy and progressions: reduction was not easy, however we performed it by the pulling the fibula towards to outside, pulling out the curled anterior tibiofibular ligament, and then pushing into the tibia. we performed screw fixation after reduction of distal tibial epiphysis. furthermore, we fixed the fibula with plate. we made him to do range of motion exercise and toe touch gait from next day, and full weight bearing from 6 weeks. we removed the implant 5 months after the surgery. he did well subsequently, and at 3 years after injury, he had normal function of the ankle, and normal x-ray. and he has returned to sports without pain. introduction: judo is the most popular martial art in the world and the first martial art recognized since 1964 as an olympic sport. worldwide, the international judo federation has registered 200 countries with about 40 million judo practitioners. like martial arts, judo mainly involves grip and throwing techniques. the competition rules in judo have been subject to constant adjustment and optimization in recent years. injuries prevalence is an important factor in the contact martial arts. material and methods: a prospective cohort study of all registered international athletes (1023) at three different european judo contests in germany were accomplished with the aim to investigate the injury rate as well as the pattern of injury. the age of the athletes ranged between 15 and 20 years. injury incidence rates were calculated per 1000 athlete-exposures (iirae) and per 1000 min of exposure (iirme). independent variables were sex and weight division. subgroups were compared by calculating the injury incidence rate ratio. results: severe injuries by judo tournaments are rare. the most frequently injured regions were the hand and head. the fights of the main block are riskier than the finals. the incidence of injury in heavyweight division differed with lightweight competitors. the risk of injury for female and male competitors differed slightly. conclusions: further studies are needed to determine a judo specific injury patterns and factors especially in the pre-competitional phase. investigation of prevention-strategies like the adaptation of competition rules etc. makes sense. does garden''s classification of femoral neck fracture match between orthopedic specialist and clinical resident? t. inoue 1 , s. inoue 1 , t. muraoka 1 1 prefectural miyazaki hospital, orthopedics, miyazaki, japan introduction: garden''s classification is the most popular classification of femoral neck fractures. femoral neck fracture should be operated^24 h; however poor agreement make waiting time longer because it takes more time to prepare implants and biological clean room. we investigate the agreement of the garden''s classification (non-displacement type or displacement type) between clinical resident and orthopedic specialist. material and methods: the examiner are a clinical resident (2nd year) and an orthopedic specialist (19th year). the subjects were 55 cases of femoral neck fractures treated at our hospital between january and december 2018. first, the examiners classified them into a non-displacement type and a displacement type (test 1). second, the examiners studied the literature about unclassifiable type. third, the examiners classified 55 cases 1 month later once more (test 2). finally, we compared the first test with the second test using the agreement (the number of matched patients/total) and kappa coefficient. results: the test 1 showed that the agreement and kappa coefficient were 81.8% and 0.337. the test 2 showed agreement was 90.9%, 0.614. the intra-observer agreement of clinical resident was 90.90% and kappa coefficient was 0.6520. the orthopedic specialist was 98.18%, and kappa coefficient was 0.930. at test 1, 10 cases did not match. 4 cases of those were unclassifiable type, which were valgus type with medial fracture line. with slight displacement, agreement will get lower; some doctors consider it displacement type. conclusions: unclassifiable type makes us confused. it makes agreement better to discuss about unclassifiable type. introduction: the aim of this retrospective study was to describe the profile of missed hand and foot fractures in multitrauma patients and to elucidate risk factors for the delayed diagnosis. material and methods: from 2005 to 2017, there were included 279 patients. missed fractures were defined as fractures, which were not diagnosed during primary and secondary survey. patients were assessed for age, sex, glasgow coma scale, injury severity score, and length of stay in hospital (los). timing of hand or foot diagnosis related to admission date (measured in days) was noted. results: overall, 5.9% of patients had a delayed diagnosis of hand fracture, 7.3% ha a delayed diagnosis of foot fracture. the mean gcs for patients with delayed diagnosis was 11, whereas patients with diagnosis the day of admission had and mean gcs of 14 (p \ 0.001). patients with delayed diagnosis had a mean iss of 13.4 versus 9.1 for those diagnosed the day of admission (p \ 0.001). furthermore, patients with delayed diagnosis had a mean los of 9.8 days, whereas those diagnosed at the time of admission had a mean los of 5 days (p \ 0.001). concerning delayed diagnosis hand fractures, metacarpal and phalangeal fractures were the most common injuries overall (46.9% and 25.8%, respectively). concerning delayed diagnosis foot fractures, metatarsal fractures (52 cases) and calcaneus fractures were the most common injuries overall, followed by talus fractures and toe fractures. conclusions: this study revealed that with a decreased gcs and increase in iss, polytrauma patients are increasingly at risk for delayed diagnosis of hand and foot fractures with a concomitantly increased los. as a delayed diagnosis has significant impact on the final functional outcome, correct and careful primary, secondary and tertiary survey is essential. introduction: the aim of this study was a) to determine the methods of hemorrhage control currently being used in clinical practice and b) to analyze pelvic fracture mortality rates before and after initiation of a multidisciplinary pelvic fracture protocol. material and method: between 2005 and 2017, we included 98 trauma patients with pelvic fractures (group 1). a similar retrospective examination was performed on a number of 85 trauma patients without pelvic fractures (control group). there were collected injury severity score (iss), the highest abbreviated injury scale (ais) score in each anatomic region and methods of pelvic hemorrhage control. there were also recorded hospital lengths of stay (los) and in-hospital mortality. results: the average follow-up was 24-months. the average iss in group 1 and group 2 was respectively 13.8 and 9.7. in both groups the commonest mechanism of injury was motor vehicle crash (40.5%). in group 1, angioembolization and external fixator placement were the commonest used method of hemorrhage control. 8 patients underwent diagnostic angiography with contrast extravasation noted in 4 patients. patients with pelvic fracture had a mean hospital los of 17.3 days. the overall in-hospital mortality rate of patients with pelvic fractures was 11.7%, while in group 2 the overall in-hospital mortality was 6.5%. age, shock, severe head injury and increasing iss, are all significantly associated with mortality in the pelvic fracture group. conclusions: the findings from this study demonstrate no clear relationship between the choice of hemorrhage control intervention used and the patient's clinical status. in healthier patients with unstable pelvic fractures, the mortality rate was similar to that of patients with stable fracture patterns. introduction: various percutaneous screw placement for pelvic and acetabulum fractures is often difficult because of complex anatomical morphology, however, it becomes very beneficial to set enough fixation stability if we can insert the long screws. 3d-ct navigation system for the screw placement is beneficial for precise screw insertion. we investigated the accuracy of screws with 3d-ct navigation. material and methods: our retrospective case series were assessed by the accuracy of screws with 3d-ct navigation for pelvic and acetabulum fractures. twenty-six patients who sustained pelvic fractures and thirteen patients who sustained acetabular fractures were included in this study and 3.5 mm cortical screws or 6.5 mm cannulated screws were inserted with 3d-ct navigation. we investigated the number of screws and screw positions which is measured by postoperative ct scan and classified by smith criteria. results: we inserted 13 tits (transiliac-transsacral) screws and 31 is (iliosacral) screws for pelvic fractures. 43 of 44 screws (97.7%) were placed in correct position (grade0 or 1). 1 screw for s1 lesion was placed in incorrect position. meanwhile we inserted 1 antegrade pubic screw, 5 anterior column screws, 27 posterior column screws and 6 infra-acetabular screws. 35 of 39 screws (89.7%) were placed in correct position (grade0 or 1). 4 screws were in incorrect position and they were all cortical screws. and there was no complication related to screw insertion. conclusions: our study highlights that 3d-ct navigation system reduced the malposition rate of screw insertion for pelvic and acetabular fractures. however, we sometimes had difficulty in inserting tits screw for s1 lesion and cortical screw for acetabular fractures. we assumed that this was caused by narrowness of s1 corridor and flexibility of drill or inserting cortical screws in wrong position manually. we should pay much more attention even using 3d-ct navigation. is operative therapy still warranted for dislocated acetabular fractures in elderly patients? introduction: the incidence of acetabular fractures in elderly patients is increasing. there is no consensus about the right treatment for the impaired elderly patient with an acetabular fracture. the aim of study was to investigate acetabular fractures in the elderly patient and the risk of a secondary tha. material and methods: a retrospective study was performed from 2004 till 2014 in the radboudumc nijmegen. all patients with an acetabular fracture were reviewed. they were divided into two groups, younger than 65 and 65 or older. ct scans were used for classification according to letournel and for the quality of the reduction according to matta. there was a follow-up of minimal 2 years. results: in total, 267 patients attended at the radboudumc with an acetabular fracture, of which 68 were 65 years or older. in the younger group, 156 patients received surgery and 40 elderly patients. according to matta, an anatomical reduction was achieved in 15% of the young patients and 8% of the elderly patients. imperfect reduction was achieved in 46% of the younger patients and 49% of the elderly patients. thirteen percent of younger group and 30% of the older group needed a tha based due to the posttraumatic arthritis, the younger group after 32 months and the older group after 22 months on average. one younger patient with anatomical reduction needed a tha, none of the elderly patients. twenty-three percent of the younger patients and 50% of the elderly patients, all with a poor reduction, needed a tha. age, the complexity of the fracture and the quality of the reduction were important factors leading to a secondary total hip arthroplasty. conclusions: elderly patients are two times more likely to need a secondary total hip arthroplasty. after an anatomical reduction, the risk is very low, even in the elderly. surgery for dislocated acetabular fractures is a good option when there is a possibility for a good reduction. references: letournel e. matta jm. introduction: in japan, as a definition of basicervical fractures of the proximal femur, a fracture line is placed into and out of the joint capsule of the hip joint. however, in fact there are various fracture types.we classified these fracture types based on treatment methods and reported on these results. material and methods: 958 cases of proximal femoral fractures treated in our hospital from january 2011 to december 2017. basicervical fractures occurred in 25 cases (2.61%). all cases diagnosed with x-ray and 3d-ct, and observed for 3 months or more after surgery. results: there are two types of basicervical fractures: the fracture line exists around the just inside of the intertrochanteric part: normal type(n type); 5 cases (0.52%), and fracture line exists subcapital at ventral side, the coronal plane in the center of the neck and the trochanteric fossa at the dorsal part: coronal shear type(c type); 20 cases (2.09%).c type was further classified by treatment method depending on existence of posterolateral fragment and anterior wall fracture. c type without comminution (2 part:c-2 type) was 12 cases (1.25%). with posterolateral fragment (3 part:c-3 type) was 5 cases (0.52%), with posterolateral fragment and anterior wall fragment (4 part:c-4 type) was 3 cases (0.31%).n type and c-2 type were treated by sliding hip screw (shs) with anti-rotation screw. c-3 type: shs with trochanteric stabilizing plate, c-4 type because of the bony contact area is very small: hemi-arthroplasty with calcar replacement was performed. cut out occurred in 3 cases of c-2 type and 1 case of c-3 type, but others obtained union.. one case of c-4 type occurred peri-prosthetic fracture intraoperatively. conclusions: we classified 25 cases of basicervical fractures, and according to its classification, treatment method was decided and good clinical results were obtained. strategies aimed at preventing chronic opioid use after trauma: a scoping review c. cô té 1 , m. berube 2 1 université laval, faculty of nursing, québec city, canada, 2 chu de quebec research center, université laval, trauma, emergency, critical care medicine, québec city, canada introduction: a high incidence of chronic opioid use (up to 58%) has been documented after trauma. 1 solutions are urgently needed considering the importance of this public health issue. we aim to identify strategies to prevent chronic opioid use in the trauma population and to assess their level of evidence. material and methods: we initiated a scoping review of literature to identify research articles and guidelines on preventive strategies. several databases and websites of trauma were searched. strategies were classified according to their types and targeted trauma populations. the level of evidence was summarized according to an adaptation of oxford center for evidence-based medicine classifications and strategies effectiveness. results: close to 10 000 items have been screened until now from which 3 studies 2-4 and one guideline were found eligible. 5 two studies 2-3 combined education with mandatory limit of opioid prescriptions (level iii) in the orthopaedic trauma population and the other study used tailored physical training after whiplash injury 4 (level i). findings showed reduction of opioid use or complete weaning at 6 and 12 weeks after trauma, however the effect was not maintained beyond 12 weeks. guidelines on orthopaedic trauma 5 made the following recommendations: prescribe the lowest effective dose for the shortest period (strong, high-quality evidence), avoid long-acting opioids in the acute setting (strong, moderate-quality evidence), and prescribe precisely (avoiding ranges of dose and duration) (strong, low-quality evidence). conclusions: chronic opioid use is an important issue in trauma patients. findings highlighted the need for more research to reduce the burden associated with chronic opioid use in this population. references material and methods: we analyzed 85 clinical cases: men-32 and women-53, mean age 53 years. trauma circumstances: habitual trauma-60 cases, traffic accident-15, precipitation-6, sport-3, aggression-1. for cohort analize schatzker classification was used: especially type i was meet in 9 cases, ii-22, iii-11, iv-3, v-26, vi-14; 81 close, 4 open. for paraclinic examination were used x-ray and ct. surgical management consisted of: close reduction, internal fixation-10 cases (8-percutaneus canulated screws arthroscopic assisted, 2-external fixator), open reduction, internal fixation-75 cases. bone graft was done in 15 cases. results: postoperative follow up was performed at 6, 12, 18, 24 weeks. patients were evaluated according to the lysholm knee scoring scale, obtaining an average score of 88 points. bone healing was achieved in a period of between 12 to 18 weeks. postoperative complication developed in 11 cases. results were depending on the stability of osteosynthesis, precocity, rightness of functional reeducation and patient compliance. conclusions: favorable functional results and less complication were met in cases of individual approach of surgical management, a good choice of implants and minimally invasive surgical techniques. fractures of the shoulder processes-a case report case history, clinical findings and diagnosis: 17-year-old male, low-speed motorcycle crash with subsequent polytrauma. he presented with right shoulder pain, swelling and pain to the touch. articular ct revealed a type i fracture of the coracoid base, type iii acromion fracture and scapular body fracture without displacement. results, therapy and progressions: he was submitted to surgical treatment 7 days later. a superior ''sabercut'' approach with open reduction and osteosynthesis of the coracoid process was performed with a cancellous screw and washer and fixation of the acromion with 2 k-wires and tension band wire. fracture of the scapular body followed a conservative treatment. immediate postoperative period was uneventful and he presented with favourable evolution in the subsequent 6-week, 12-week and 6-month follow-up. at present time, at 14-month follow-up, maintained anatomical reduction in radiological control, complete arm abduction and no limitation with efforts. comments: conservative treatment is generally indicated for all shoulder body fractures without displacement. fractures of the coracoid or acromion with [ 1 cm displacement are described as an indication for surgical treatment. fractures of the acromium without displacement may follow conservative treatment with sling immobilization. surgical fixation can be achieved with screws, plate and screws or tension band wire. although controversial, surgical treatment for coracoid fractures is preferred, especially in active young patients with open reduction and fixation with screws or, if necessary, with plate and screws. the treatment applied in the present case, all approaches described in the literature as being effective and with good results, is in agreement with the options described in the literature and constitutes a corroborative example of its efficient results. case history: a 49-year-old male, hand worker, attended to our emergency department after a traffic accident complaining about pain and swelling in his left wrist. initial radiographs revealed an isolated dorsal dislocation of the lunate that went unnoticed. two and a half months later he was referred to our clinic. clinical findings: findings included dorsal wrist deformity and pain. he presented a decreased passive wrist flexion and extension range of motion, with normal finger tendinous function. investigation/results: plain x-rays showed persistence of the lunate dorsal dislocation without any associated injuries. diagnosis: chronic isolated dorsal dislocation of the lunate therapy and progressions: open reduction was performed using a dorsal approach. the scapholunate, lunotriquetal and scaphocapitate spaces were stabilized with a compression screw and kirschner wires respectively. the patient persisted with pain and functional limitation after the surgery, showing an insufficient reduction of the scapholunate space on the x-ray. nine months after the initial surgery, he developed a purulent fistula on the ulnar edge of the carpus. after it was resolved, a total wrist arthrodesis was performed using the mannerfelt technique. at the 3 months follow up, he was clinically stable, consolidation of the arthrodesis was documented and he had returned to his previous normal activities. comments: isolated dorsal dislocation of the lunate is a rare lesion. the delay in the diagnosis of carpal dislocations is frequent. this compromises the final outcome of reconstructive techniques and the risk of residual instability, hence increasing the risk of chronic pain associated with posttraumatic osteoarthritis. in the case of chronic lesions, treatment with palliative techniques such as proximal carpectomy or joint arthrodesis should be taken into consideration. references: siddiqui n., sarkar s. isolated dorsal dislocation of the lunate. open orthop j. 2012;6:531-4 is ultrasound-guided regional anesthesia safer than landmark technique? one-hospital experience introduction: according to the literature the application of ultrasound (us) in performing regional anesthesia had a significant impact on patient safety by increasing the success rate [1] . in 2006 a donated ultrasound device became available in the institute of emergency medicine, chisinau, republic of moldova. due to lack of equipment both us guided and landmark techniques have been performed. the aim of this study was to analyze the two methods of performing regional anesthesia, in order to estimate the potentials benefits of of us guided techniques (succes rate and doses). results: the bivariate analysis showed that, out of 100 anesthetics in lmg, a number of 13 were reported as unsuccessful, compared with a number of 20 in usg. the v 2 test with corrections for continuity did not determine significance (test value 1.306, df = 1, p = .253, effect size = .007), rr being 1.67 (95% ci 0.78-3.58). linear regression for dose (lidocaine) modeling, in patients included in the research, showed a decrease of the dose by 57 mg in lmg, the confidence interval being quite wide (95% ci -.938, -.192). that is, the actual decrease is within the limits of 19 and 94 mg. conclusions: the tendency towards higher failure rate in successfully performing an us guided regional anesthesia and relative ''uncertain'' decreasing of dosage are in contradiction with the international statistical data. this in turn evidenced probable deficiencies in the training of the practitioners in field of ultrasound guided techniques in our country. the prospective research to confirme/infirme these results and estimate the complication rate follows. references: 1. barrington mj, uda y. did ultrasound fulfill the promise of safety in regional anesthesia? current opinion in anaesthesiology 2018; 31 (5) results: average age 41 years old (34-62).all were active labour patient. the most frequent mechanism was high energy trauma (traffic accident), 2 of who presented gustilo grade iiib open fractures operated in the country of origin. most frequent pattern of fracture was 23-c.2 (2 cases) and 23-c.3 (2 cases). initial conservative treatment was performed in 2 of the cases. one persistent pseudoartrhosis with osteosynthesis material failure. in every case, preoperative ct and early surgical intervention were carried. in 3 cases, an additional procedure was associated at the radioulnar distal joint. in all cases consolidation occurred. one patient required reintervention for persistent pseudoarthrosis. average consolidation time 6 months (3) (4) (5) (6) (7) (8) (9) .average follow-up of 61 months (22-116). average active joint balance: flexion 49°(15°-70°), extension 38°(10°-65°), pronation 68°(40°-70°), supination 82°(70°-85°). average dash 21.56 (0-50.8).force reduction greater than 50% compared to contralateral in 2 of the cases. radiological parameters:radial height 8.7 mm (7-12),radial inclination 15°(9-19°),volar angulation 11.8°( 0.2°-21°), ulnar variance 2.85 mm (1) (2) (3) (4) (5) . conclusions: malunion of the distal radius is an uncommon and severe complication with increasing incidence that requires early and personalized surgical treatment to achieve the correction of the deformity, preserving mobility acquiring consolidation with acceptable functional results case history: isolated ulnar translocation of the carpus is unusual. when the translation occurs without injury of the radius, ulna or carpal bones are often misdiagnosed. early diagnosis is key, to avoid further complications such as redislocation of the carpus (1). clinical findings: in our case a young male patient suffered a high energy motorcycle accident. he had no a b c d problem investigation/results: the ulnar translation of the left carpus was evident but comparison x-rays were taken on both wrist for further evaluation. the distance between the line, drawn through the axis of the radius and the center of the capitate bone was measured bilaterally. the results were 14.3 mm vs 4.7 mm. diagnosis: isolated, open ulnar translocation of the radiocarpal joint, dumontier type i, was diagnosed. treatment: the primary treatment was debridement, reposition and fixation with ex fix. after the wound healing on 18th days we made reconstruction. volar approach was used, we re-reponate the carpus and fixated the position with two 2 mm smooth kirschner wires. the radioscaphocapitate and long radiolunate and radioscaphoid ligaments were reattached to the volar margins of radius using mitek mini anchors. we put the ex fix and left the bended wires percutaneously. after 10 weeks the ex fix and the k wires were remove. wrist motion exercises were initiated under supervision of physiotherapist. comments: after 16 weeks the wrist was in good alignment, the flexion-extension were 20-20, the deviations were 15-20°. the radiographic signs of this injury are unusual and often misdiagnosed. it can be useful to compare with contralateral x-rays. the radiolunate and radioscaphocapitate ligaments is considered crucial in prevention of ulnar translation. in our opinion the radiolunate arthrodesis can be reserved for failed ligament repairs. introduction: within the orthopaedic paediatric population, there is a distinct paucity of literature in regard to post-operative paediatric analgesic regimes. supracondylar humeral fractures account for 33% of all paediatric limb fractures and there has been a marked divergence in recent literature concerning the most appropriate choice of analgesia for this cohort with recent studies recommending the routine inclusion of an opioid agent post-operatively on prescription. opioids have deleterious side effects pertinent to paediatrics. in our institution, patients'' only receive a prescription for acetaminophen and nsaids upon discharge. our study assessed postoperative analgesic satisfaction rates in all paediatric patients who underwent crpp for supracondylar humeral fractures in our institution from january 2018 to december 2018. material and methods: this is a retrospective multi-surgeon case series of all paediatric patients who underwent crpp from january 2018 to december 2018. patient data was extrapolated from theatre records and clinical charts. for each patient, all analgesic agents given were identified, the dosage, route and frequency of administration in addition to the length of their hospital stay and time from injury to operation. following discharge, patients'' guardians were contacted retrospectively and a questionnaire was administered which ascertained the efficacy and duration of analgesia used by the patient postoperatively. results: fifty patients were identified for inclusion within the study who met the inclusion and exclusion criteria. there was a 92% satisfaction rating amongst the responders with the analgesic regime recommended-acetaminophen & nsaids. conclusions: in stark contrast to papers which we discuss throughout our paper, our study conclusively demonstrates that opioid prescriptions are not required upon discharge for supracondylar fractures within a paediatric population case history: a 57-year old man suffered an isolated injury of his right hand in a motorcycle accident. clinical findings: the patient presented with a swollen hand, a subtotal amputation of the middle finger at the level of the middle phalanx and lacerations to the other fingers (fig. 1) . investigation/results: after excluding injuries to other body regions, radiographs and a ct of the hand were performed (fig. 2) . diagnosis: closed fracture dislocation of cmc joints from ii. to v. finger, comminuted fracture of the middle phalanx of the middle finger, closed fracture of the proximal phalanx of the middle finger, other lacerations to the iv. and the v. finger. therapy and progressions: urgent open reduction and internal fixation (orif) with k wires of the cmc joints. exploration of the middle finger reviled heavy contamination and comminution of the phalanx, with injury to one neurovascular bundle. a phalangectomy with acute finger shortening was performed with creation of a new ip articulation (distal to proximal phalanx) (fig. 3, 4) . progression after the surgery was uneventful. there was no sign of infection. the shortened finger was sufficiently perfused and the patient reported a sense of touch. k wires were removed after 6 weeks and physical therapy was started. the patient has limited rom in his neo ip joint with minimal pain (vas 2-3) (fig. 5) . comments: middle phalangectomy of the hand was described in the literature only in two papers which report treatment of chronical or congenital diseases. the authors propose this method as an alternative to amputation in selected trauma cases. results: 29 patients (15 m, 14 f, mean age 43 y) with 40 fractures were included. 13 kidney-tpl, 6 lung-tpl, 5 liver-tpl, 3 heart-tpl, 2 kidney/pancreas-tpl. all patients got treated with at least two immunosuppressive drugs. cause of accident: 37.5% sports/leisure, 35% work/household, 12.5% traffic accidents, 5% without trauma. the operation was performed under perioperative long-term antibiosis, often with a combination of two or three drugs. patients were hospitalized for an average duration of 11.3 days and were also examined by the particular organ specialists. osteosynthesis: in 90% primary operative fracture treatment, in 10% two-step procedure. 11 plates distal radius and ulna [healing period (h) conclusions: the fracture healing was possible but significantly delayed. the wound healing took longer. the immunosuppressive therapy may be responsible for these problems. the rehabilitation of movement and weight bearing has to be adapted to the slowed fracture healing. introduction: the prevalence of fragility fractures of the pelvis (ffp) increases, including in up to 90% a lesion of the posterior pelvic ring. an operative therapy is indicated in cases of prolonged or immobilizing pain or in a displaced dorsal fracture. methods: patients suffering an ffp treated with a minimal-invasive trans-sacral bar through s1 from 2009 to 2017 were included. the patients or their relatives were contacted to ask about mortality, the present mobility and place of residence. 96% of all patients still alive could be included in follow-up. results: 73 females and 6 males with a mean age of 76.7 ± 9.5 years (50-95) were included. concomitant stabilization of the anterior pelvic ring was performed in 53%. 16.5% underwent an operative revision (5% evacuation of hematoma, 5% peri-implant infection, 10% hardware removal-combinations possible). the trans-sacral bar was removed in one case due to malpositioning. the length of stay was 20 ± 12 days. at discharge, 46% were mobile on the ward, 14% in their room, 35% for transfer to sitting position and 5% were bedridden. 24% were discharged to their home, 49% in geriatric rehabilitation unit, the remaining to other rehabilitation or to a nursing home. during follow-up, mortality was 27%, one patient died during hospital stay. the patients died in average 158 ± 109 weeks after discharge. after a follow-up of 206 ± 151 weeks, 52% lived at their home, thereof one-third with assistance. 63% needed a walking aid, 16% were mobile without walking aid, 21% were bedridden or only mobile to sitting position. conclusion: the trans-sacral bar in s1 is a valuable minimal-invasive stabilization method to recover mobility in elderly with an ffp. a relatively long in-hospital stay could be explained by the initial trial of conservative treatment and due to intra-and inter-departmental cogeriatric services. the high mortality and need for assistance reflects this geriatric, multi-morbid patient collective. case history: a 58-years-old woman was admitted in the emergency room after being run over by a bus. clinical findings: at the emergency room, she was conscient and hemodynamic stable. head, thoracic or abdominal trauma were excluded. the patient presented with an open wound in left popliteal area with massive bleeding with exposure of gastrocnemius and soleus muscles and achilles tendon investigation: radiologic images didn't show any fracture. a limb angiography showed complete perfusion of the leg, without any lesion on major arteries. diagnosis: open aquilles tendon avulsion through the popliteal fossa therapy and progressions: the patient was taken to the operating room. we approach the popliteal area and found a small laceration of popliteal vein, which was sutured with prolene 6/0. then, we reference the achilles tendon, and tunneled the posterior face of the leg, and passed the tendon through the tunnel. a distal approach, above the insertion of achilles tendon was done, and two suture anchors preloaded with 2 sutures were inserted in the medial and lateral sides of the calcaneal tuberosity, then we did an krackow suture. we also did a fasciectomy on the lateral side of the leg, to prevent compartmental syndrome. the patient was put in a posterior cast with 208 of flexion for 4 weeks. the immediate post-operative time was in an intermedia unit care, to control possible multiorgan failure. in 2 days, she was discharged to orthopedics nursery. due to the degloving of subcutaneous tissue, she evolved with some blisters which made her stay inpatient about 4 weeks. after some time, she developed some areas of skin necrosis, which needed some intervention by plastic surgery with skin graft. now, she has skin completely healed, some loss of strength in the leg, with loss of plantarflexion, and is under prolonged rehabilitation program. therapy and progressions: she was rushed into the or and submitted to external fixation of the humerus and bones of the forearm, debridement, and primary closure of the forearm and hand. successive dressings and debridement was maintained and, at 19th postoperatory day(po) the external fixator of the left humerus was removed and a nailing was performed as well as an osteosynthesis of the clavicle fracture with anatomical plate. at 40thpo the external fixator of the forearm bones was removed and an open reduction and internal fixation of the radius with lcp plate and closed reduction and internal fixation of the ulna with an anterograde ten nail was performed. at 49thpo, she underwent an autologous skin graft of the forearm and hand wounds. good clinical evolution of the wounds and fractures, all of which evolved to consolidation, although m3 fracture malunion was verified as well as deficit of thumb abduction and extension of 3rd-5th fingers. uefi of 65/80. comments: the approach of polytrauma patients should be sequential, according to the atls protocol, preserving life, limb and function. treatment of these lesions is complex and, if poorly managed, can be associated with high morbidity, as most patients combine severe and contaminated lesions, extensive skin loss, open fractures, postoperative infection. a sequential approach is required, which involves injury assessment, infection prevention, soft tissue treatment and fracture stabilization. introduction: pelvic fractures, though rare (3-8%), are often associated with high mortality (5-20%). the factual outcomes in polytrauma patients with the additional burden of pelvic fractures are unknown. the purpose of this study is to provide an in-depth analysis of pelvic fractures in seriously injured patients. material and methods: this is a retrospective analysis of prospectively maintained trauma registry from 2012 to 2018. we included all trauma patients with iss c 16. group i, which had an additional burden of pelvic fractures, was compared with group ii, consisted of patients without pelvic fractures. a double-adjustment propensity score match (psm) analysis was utilized to minimize confounding and unbiased estimation of the impact of pelvic fractures. 24.68 ± 10.86, asmd = 0.15).patients in group i had higher number of genitourinary surgery (p = 0.04), exploratory laparotomy (p = 0.03). therequirement of angio-embolization was similar in between two groups (p = 1.00). while there were no difference in mortality (or 0.69, 95% ci 0.31-2.15, p = 0.82), group i had higher odds of severe sepsis (or 1.42 95% ci 1.19-2.92, p = 0.03) and ventilator-associated pneumonia (or 3.64, 95% ci 1.74-9.72, p = 0.01) conclusions: pelvic fractures in polytrauma patients did not translate into higher mortality. however, there was an increased risk of sepsis and vap. evidence-based management at tertiary care specialized centers can further enhance the outcomes. investigation/results: ap pelvis x-ray reveals a complex left proximal femur fracture with neck and trochanteric extension. a ct-scan was obtained and showed a complex fracture pattern with subcapital and trochanteric extension. blood analysis showed a hemoglobin of 8.6 g/dl. diagnosis: therapy and progressions: at admission, patient refused erythrocytes'' concentrate transfusion and was hospitalized for pain control and hemodynamic stabilization. despite alternative measures such as intravenous iron supplementation and erythropoietin, hemoglobin values remained lower than 7.8 g/dl, thus preventing any surgical procedure. at day 12, patient finally decided to accept packed red blood cells and was then transfused. at day 14 and with a hemoglobin of 11.8 g/dl, the patient was finally submitted to a total hip arthroplasty with an uncemented revision femoral stem. at day 15, the patient initiated the rehabilitation protocol with hospital discharge at day 21 with a hemoglobin of 10.2 g/dl. comments: proximal femur fractures arise as one of the major problems of present traumatology. comorbidities frequently prevent surgical treatment within the golden hour (first 48 h) and thus limiting the postoperative results. in this particular case, a timely surgical approach would have made it possible to try a more conservative procedure with femoral osteosynthesis. the surgical delayed due to low hemoglobin values limited the surgical options and forced a more aggressive procedure. routine versus on demand removal of the syndesmotic screw; a multicenter randomized controlled trial on functional outcome introduction: syndesmotic injuries are common, being present in approximately 15-20% of surgically treated ankle fractures 1 . one of the most commonly used ways of fixation is the syndesmotic screw (ss). traditionally, this screw is removed after 8-12 weeks as it is thought to hamper ankle function and cause pain. however, a recent study showed that implant removal does not always result in improvement of functional outcome 2 . with the relatively high complication rate of implant removal in mind, retaining sss could be beneficial. we therefore aimed to investigate the effect of retaining the ss on functional outcome. material and methods: in this multicenter rct, patients were randomized between routine and on demand removal (upon patients request). the primary outcome was functional outcome at 12 months after ss placement, measured by the olerud-molander score (omas) with a non-inferiority limit of 10 points (90% power, a = 0.025). secondary outcomes include quality of life, range of motion, complications and costs of ss removal. results: a total of 197 patients were randomized, of which 93 for routine removal and 104 for on demand removal. the mean age was 45 years old and 63% was male. follow up of all participants will be completed in march 2020. results of the primary outcome analysis are therefore not yet available, but will be at the conference. conclusions: if on demand removal of the ss is non-inferior to routine removal in terms of functional outcome, this will offer a strong argument to adopt this as standard practice of care. this means that patients will not have to undergo a secondary procedure, resulting in fewer complications and subsequent lower costs. introduction: treatment options for pertrochanteric fractures of the hip are extra-or intramedullary fixation. the aim of this study is to identify risk factors for the development of complications: varus deformity, neck shortening, revision and cut-out. material and methods: retrospective cohort study in which radiographs of patients with pertrochanteric fractures, treated at the uz brussel between 2008 and 2016, were reviewed. fracture type, type of the device, cut-out and revision where noted. measurements for the centrum-collum-diaphyseal angle (ccd) of the two hips, impaction, tip apex distance (tad), parker''s ratio were realized. statistical analyzes were made with logistic and multiple linear regression analyzes. results: 248 patients were included. bmi (p = 0,043), type of osteosynthesis (p = 0,024), dhs ? plate (p = 0,006), short nail (p = 0,011) and the tad (p = 0,000) are independent risk factors for the development of varus deformity after consolidation. for impaction are bmi (p = 0,005), short nail (p = 0,000), long nail (p = 0,000) and fracture type a1 (p = 0,001) independent risk factors. we identified a marginal statistical significant risk factor for cut-out: tad (p = 0,051). conclusions: 31,4% of the patients had varus deformity after consolidation. the risk of varus deformity rises with a higher bmi and a higher tad. the risk for this complication was higher when using a nail. neck impaction was shown more together with a high bmi and less in fracture type a1 and with the use of a short or long nail. in the prevention of cut-out, it is important to keep the tad low. case history: 85-year old female with previous distal femoral plating (17 years ago) and ipsilateral proximal femoral nailing (2 months ago) presented with a diaphyseal femur fracture. clinical findings: extremity was swollen, painful, neurocirculatory intact, no shortening or external rotation was seen. she was unable to lift her leg. scars showed no sign of infection. investigation: x-ray revealed a spiral fracture including distal pfna locking screw, unhealed proximal femur fracture without loss of reduction, protruding pfna blade and a healed distal femoral fracture. diagnosis: peri-implant fracture classification proposed by the singapore group presented a discrepancy between nail type 1 subtype b and plate type 2 subtype. by simplification, we disregarded the distal (healed) fracture to choose the first option. therapy: firstly, the distal femoral plate was removed as the preoperative simplification dictated. secondly, pfna distal locking screw was removed and the pfna blade shortened. after open reduction 2 cerclage wires were applied. a long lcp plate was initially fixed through the plate and pfna locking hole, adjusted in line, fixed proximally with 8 screws through a locking attachment plate and 1 cerclage, distally 5 locking screws were used. comments: distal femoral callus prevented the use of a long nail. as the proximal fracture was not yet healed, we avoided full implant removal. as the pfna was unstable, fixation through the plate and pfna distal locking hole enabled implant coupling to strengthen the construct. the plate covered the entire bone to bridge the possible loci minori left by the plate removal and minimize stress risers. background: we have been reported the usefulness of intra-medullary antibiotics perfusion (imap) and intra-soft tissue antibiotics perfusion (isap) for suppressing open fracture and bone infection. imap and isap was a method of antibiotics delivery with the continuous administration of high-dose aminoglycosides. however, the best dose was not obviously. the purpose of this study was to evaluate translation of aminoglycosides from imap or isap. as follows: 11 males and 8 females, average age was 54.9 years old, 10 intramedullary nails and 9 plates. one dialysis patient was including. we measured concentration of gentamicin from imap, isap and in blood, outflow. results: average administration concentration of all cases was 1236.67 lg/ml. average blood concentration of all cases was 1 lg/ml and outflow concentration were 1107.77 lg/ml. average blood and outflow concentration of each dosage were shown as follows: 600 lg/ ml: 0.6 lg/ml, 868 lg/ml, 1200 lg/ml: 0.83 lg/ml, 1135.1 lg/ml, 1600 lg/ml: 1.9 lg/ml, 4800 lg/ml, 2400 lg/ml: 1.03 lg/ml, 547.5 lg/ml. in dialysis patient case, 1200 lg/ml administration lead concentration of blood as 2.46 lg/ml, outflow as 822 lg/ml. side effect were not observed. discussion: local antibiotic administration using imap and isap showed increasing blood concentration depend on administration dose. under 2400 lg/ml administration dose showed safe blood concentration(\ 2 lg/ml). on the other hand, 2400 lg/ml administration dose achieve trough concentrations over 100-1000 times of minimum inhibitory concentration. furthermore, we need to pay attention for administration dose in dialysis patient case. conclusion: 2400 lg/ml administration dose achieved safe and effective local concentration. introduction: distal radius fractures and supracondylar humerus fractures are two of the most common fractures seen in children. most can be treated with non-operative treatment but a small number require operative reduction and surgical stabilisation, often with percutaneous kirschner wires. this study aims to identify whether an early review is required before planned removal of the wires. materials and methods: retrospective review of paediatric patients undergoing surgical reduction and stabilisation with percutaneous kirschner wires for upper limb injuries. data collected over threemonth period (june-august 2019). number and type of outpatient reviews, imaging episodes and clinical interventions recorded. results: 45 consecutive patients with mean age 9 years (range 4-15). 35 distal radius fractures and 10 supracondylar humerus fractures. 3 patients transferred to another unit. 41/42 patients received a 2 week check and then a second review where the wires were removed. mean time to first outpatient review 10.5 days (sd 7.6). at initial appointment all patients had a change of cast and a satisfactory radiograph. mean time to second outpatient review was 26.9 days (sd 7.9). at the second appointment 33/41 patients had the wires and cast removed and subsequent satisfactory radiograph. 8/41 required a further period of casting. 19/41 had a third appointment. 4/41 required formal physiotherapy after cast removal. there was one transient anterior interosseous nerve palsy after supracondylar fracture stabilisation. clinical union of the fracture and good functional outcome was seen in all cases. conclusion: the initial outpatient review at 1-2 weeks allows a lighter weight cast to be applied but in this series the radiograph taken after the cast was changed did not alter management. our findings support a cast change alone at 2 weeks and then clinician review with radiographs at the time of wire removal. introduction: the aim of this study was to describe surgical technique, report on patient-based functional outcomes and complications following open reduction and internal fixation in patients with scapular fractures. methods: the study comprised 14 patients who were treated with open reduction and internal fixation (orif) of a scapular fractures between september 2010 and july 2018. surgical indications were as follows: medial/lateral displacement greater than 20 mm; shortening greater than 25 mm; angular deformity greater than 40°; intraarticular step-off greater than 4 mm and double shoulder suspensory injuries (including fracture of clavicle, coracoid or acromion with displacement greater than 10 mm). all patients underwent x-ray examination (true ap, y scapular view) and computed tomography (ct) scans. fractures were classified according to the revised (ao/ota) classification system. functional outcome were measured using the constant-murley score. results: seven patients had glenoid fossa fracture, six patients had scapular body fracture and one patient had acromion process fracture. all glenoid fossa and scapular body fractures were exposed via the judet approach. eleven of 14 patients were reviewed with constant-murley score at the final follow-up examination, three patients were lost for follow-up. the mean follow-up after injury was 44 months (6-92 months). we found in four patients infraspinatus muscle hypotrophy. mean constant-murley score was 93.45 (± 8.93) for injured arm and 98.36 (± 2.91) for uninjured arm. mean score between injured and uninjured arm was 4.91(± 6.49) which is excellent functional outcome according to grading the constant-murley score. conclusions: open reduction and internal fixation of displaced scapular fractures is a safe and effective treatment option that results in reliable union rate and good to excellent functional outcome. introduction: the aim of this study was to evaluate clinical and radiological results of intramedullary radius and ulna nails in treatment of adult forearm fractures. methods: the retrospective study included 21 patients who were treated with intramedullary nailing of forearm fractures between january 2010 and september 2017. the medical records and radiographic images of all patients, taken preoperatively and postoperatively, were reviewed. fractures were classified according to the ao/ota classification system by reviewing the radiographs. we analayzed time to union, union rate, clinical outcome and complications. results: primary intramedullary osteosynthesis were performed in 17 patients with forearm diaphyseal fractures. the average time to union was 2 months (range, 2-4 months) in primary osteosynthesis cohort. secondary intramedullary osteosynthesis were performed in four patients following removal of plates and screws due to pseudoarthrosis. the average time to union was 4 months (range, 2-6 months) in secondary osteosynthesis cohort. overall union rate was 95,24% in 21 forearms with fractures or pseudoarthrosis of the radius, ulna, or both bones, which were treated with intramedullary nail with compression screw. overall complications were one nonunion, one postoperative rupture of the extensor pollicis longus tendon and one postoperative transitory radial nerve palsy. conclusions: intramedullary nailing of adult forearm fractures is a safe and effective treatment option that results in reliable union rate and good to excellent clinical outcome. key words: forearm fractures, intramedullary nailing, biological fixation, union rate results: transverse or short oblique fractures of the middle third of the humeral shaft were treated using a retrograde approach. spiral fractures of the middle third of the humeral shaft were treated through the antegrade approach. comminuted fractures of the proximal third of the humeral shaft were treated mostly through the antegrade approach. comminuted fractures of the distal third of the humeral shaft were usually treated using the retrograde approach. whenever possible, we prefer retrograde insertion because the approach through the shoulder joint is avoided. reduction with retrograde nailingnis easier because upper arm was placed on the radiolucent operating table extension. interlocking screw insertion by freehand techique is also easier to perform because there is no danger of radial nerve injury. nonunion was found in eight patients (1,8%). there were five patients (1,1%) with postoperative transitory radial nerve palsy that fully recovered within 6 months. conclusions: the choice of approach to the medullary canal depends on the fracture type and the fracture site. therefore, antegrade nailing should be performed for proximal third humeral shaft fractures and complex middle third humeral shaft fractures, while retrograde nailing should be perforemd for distal third humeral shaft fractures and simple transvese or short oblique middle third humeral shaft fractures. keywords: humeral shaft fractures, intramedullary nailing, radial nerve palsy, nonunion the diaphyseal aseptic tibial nonunions after failed previous treatment options managed with the reamed intramedullary locking nail i. kostic 1 , m. m. mitkovic 2 1 clinical center nis, university hospital, orthopaedics and traumatology, nis, serbia, 2 university of nis, serbia, orthopaedics and traumatology, nis, serbia introduction: in this article, we present our approach to the surgical treatment of noninfected tibial shaft nonunions. material and methods: between 2014 and 2016, 33 patients with aseptic diaphyseal tibial nonunion was treated by reamed intramedullary nailing and were retrospectively reviewed. all patients, preoperatively, were evaluated for the signs of the infection, by the same protocol. results: the time that elapsed from injury to intramedullary nailing ranged from 9 to 48 months (mean 17 months).open intramedullary nailing was unavoidable in 25 cases (75,75%), while closed nailing was performed in 8 patients (24,25%). all patients were followed up in average period of 2 years postoperative (range 1-4 years), and 31(93,9%) patients achieved a solid union within the first 8 months. conclusions: in conclusion, a reamed intramedullary nail provides optimal conditions for stable fixation, good rotational control, adequate alignment, early weight-bearing and a high union rate of tibial non-unions. percutaneous figure of 8 suture as a novel technique for treating closed tendinous mallet injuries following failed splinting therapy. t. eltantawy 1 , a. yousif 1 , k. maheshwari 1 , a. hartpinto 1 1 bedford hospital, plastic surgery, bedford, united kingdom introduction: mallet injuries are common injuries affecting the hand. majority of them are managed using conservative method, however a small percentage of patients that do not do well on conservative treatment need an operative intervention. we wish to evaluate the efficacy of percutaneous figure of 8 suture as a new technique for treating closed tendinous mallet injuries resistant to splinting therapy, as a minimally invasive treatment option. material and methods: we present a case series of 5 patients who had persistence of more than 30 degree extensor lag, despite splinting minimally for 9 weeks. all of these were treated with a percutaneous figure of 8 suture placed across the dorsum of dipj, which provided splinting for further 4 weeks. this technique provides fixation for the dipj in hyperextension position by going through the periosteum on both sides and was done under local anaesthesia. results: the mean age of our patients was 40 years, with a single digit involved in all patients. all the five cases had nearly fully straight dipj with less than 10°extensor lag following 4 weeks of percutaneous stitch placement. there was no further recurrence with mobilisation or overlying skin necrosis. conclusions: percutaneous figure of 8 suturing technique can be an effective, minimally invasive and safe technique to treat closed tendinous mallet injuries not responding well for conservative splinting. introduction: osteosynthesis of pertrochanteric fractures (pf) is a frequently performed procedure in orthopaedic trauma care. dynamization of the osteosynthesis during fracture healing can lead to dynamization of the lag screw. which can cause debilitating complaints. a spontaneous femoral neck fracture (sfnf) after implant removal was seen in 5 patients over a 6 month period. based on these 5 cases we evaluate the different aspects of the pathophysiological and mechanical mechanisms of lag screw dynamization, complaints and complications in pf healing. material and methods: pubmed search on incidence of chronic pain, gait impairment associated with dynamization of osteosynthesis, risk factors for dynamization and complications after implant removal. based on research data preventive recommendations are suggested. results: literature describes complaints as reduced mobility, gait impairment and chronic pain in association with lag screw dynamization. an important risk factor is the ao-classification of pf, a2 type fractures are significantly associated with more dynamization and the onset of trochanteric pain and gait disturbances. partial implant removal can reduce complaints in the majority of symptomatic patients, and induce symptoms in 20% of asymptomatic patients. literature study shows a sfnf after lag screw removal with an incidence of 15%, affecting mostly vulnerable elderly patient resulting in a high mortality rate. risk factors associated with an increased risk of this complication are pre-existing systemic osteoporosis, stress-shielding, pre-loading of the implant. most importantly the removal itself, a sfnf with the implant in situ is very uncommon. conclusions: the clinical indications for implant removal in healed pf are not well established, and should be restricted to specific cases. after removal, partial weight bearing and good patient counselling is extremely important. replacement with shorter lag screw should be considered. metal osteosynthesis of pathological bone fractures with metastatic lesion of plates with a spray on their surface of hydroxyapatite and 1% silver v. protsenko 1 , a. abudayeh 2 , v. chornyi 2 , y. solonitsyn 1 1 institute of traumatology and orthopedics of nams of ukraine, onco-orthopedics, kiev, ukraine, 2 bogomolets national medical university, kiev, ukraine introduction: surgical intervention in the case of pathological bone fracture against the background of metastatic lesion involves performing osteosynthesis. for more effective integration of the metal plate with the bone, a material based on bioactive glass was sprayed on their surface. bioactive glass-based material is an osteoinductive and osteoconductive biomaterial that integrates quickly with bone, forms a bone-ceramic complex, and is transformed into bone over time. material and methods: metal osteosynthesis of pathological bone fractures with metastatic lesion of plates with spraying on their surface of hydroxyapatite and 1% silver was performed in 12 patients. the functional result of the operated limb was calculated on the msts scale. evaluation of pain was performed on the scale of r.g. watkins. the quality of life of patients was evaluated using the eortc qlq-c30 system. the evaluation of the integration of the plate with the bone was performed by radiological examination and by osteoscintigraphy. results: postoperative complications were found in 1 (8,3%) patient, recurrence of metastatic tumor was noted in 2 (16,7%) patients. the functional result of the operated limb after metal osteosynthesis was 76,8%. the degree of pain decreased from 92,2% to 24,6%. the quality of life of patients after metal osteosynthesis improved from 38 to 74 points. x-ray examination revealed the formation of callus within a shorter timeframe, as evidenced by the more intense accumulation of radioisotope during osteoscintigraphy. introduction:the aim of this study was to evaluate the results in patients who had heal intertrochanteric fracture but did not receive adequate mobilization and rehabilitation support. material and methods:sixty patients over 70 years old age were included in our study. the rehabilitation emphasized pain relief, muscle strength, range of motion, endurance, balance challenges, and proprioceptive enhancement for all patients. it started postoperative first day and was delivered twice a day by the physical therapist until discharge. patients were discharged on average 7.4 days (2-20 days) after surgery. the mobilization of patients was evaluated with the parker and palmer mobility scoring system, the clinical evaluation was performed with the haris hip scoring and daily living activities were evaluated with the barthel life index before and at the end of the fracture. results:34 female 26 male patients were included in our study. the mean age was 75,2 (70-84) years and the mean follow-up period was 25,5 (10-40) months. 35 patients had a1 type, 25 patients had a2 type intertrochanteric femur fracture. in the last follow-up, all patients had fracture union. patients' mobility, daily life activity and clinical evaluations were found to be statistically significantly worse in the last control than before surgery. conclusions:the success of the surgical treatment and the union of the fracture after fixation are not sufficient for the successful mobility,daily life activity,and clinical results.the success in the functional results are significantly related with the ambulatory ability.although early mobilization and rehabilitation support are important in intertrochanteric femur fractures after surgery,the continuity of mabilization and rehabilitation support after hospital discharge is more important.the rehabilitation which administered by the patient''s ralations after hospital discharge is not sufficient.therefore,the importance of home-based rehabilitation is increased. the prognostic value of the hip screw position in trochanteric fractures i. gárgyán 1 , î csonka 1 , t. ecseri 1 1 university of szeged, department of traumatology, szeged, hungary introduction: in our study, we analyzed one of the hungarian population's most frequent injuries, the hip fracture, focusing mainly on the lateral femoral neck and the pertrochanteric fractures. according to the classification of the swiss association for ostheosynthesis (ao), we focused on 31-a1 and 31-a2 fractures, the incidence of which increases by ageing. material and methods: between 2010 and 2016, we analyzed the data of 1179 patients. all of the fractures were stabilized with intramedullary nails. 992 patients received stryker gamma3 ò , whereas 187 patients' fractures were solved with synthesis pfna ò nail. in all cases, closed reduction method was used with fluoroscopy on an extension table. the surgeries were done in general or epidural anesthesia and performed by traumatology residents or specialists using standard lateral exploration. data were collected using gepacs software and statistical analysis was done with ms excel. results: cut-out occurred in 33 cases (2,79%): out of that 21 (1.78%) were left sided and 12 were (1,01%) right sided. 29 (87.87%) patients were treated with gamma3 nail, and in 4 (12,12%) cases pfna nail was used. the average tad-index was 18 mm. conclusions: according to recommendations of the tad-index value, when using dynamic hip screw, it should be 20 mm or lower. the average index value was 18 mm which was equal in the complicated and non-complicated groups. our study shows that the cutout is independent from the tad-index value, thus this recommendation cannot be applied for intramedullary nails. oita university hospital, acute trauma, emergency, and critical care center, yufu, japan, 2 oita university, orthopaedic surgery, yufu-city, oita, japan introduction: dome impaction fragments (difs) in acetabular fractures are typically accompanied with anterior column fragments and recognized as the gull sign on plain radiographs. meanwhile there are some difs which do not fit into typical difs. the aims of this study were to define atypical dif and describe tips for diagnosis and intraoperative visualization. material and methods: this study was a retrospective case review. we defined atypical difs as the fragments which were independent of anterior column fragments and did not show the gull sign on plain radiographs. from jan 2012 to july 2019, there were 68 patients of acetabular fractures, and 15 patients (22.1%) had difs. among them, 3 patients (4.4%) were identified as the cases with atypical difs. all of them were male. the ages were from 55 to 68. results: the atypical difs were not obvious on x-rays (fig. 1) . all three atypical difs were located at posteromedial weight bearing zones of the acetabulum. case 1 and 2 were displaced in accordance with posterior column fragments, and were visualized clearly on the sagittal view of ct images (fig. 2) . case 3 was impacted posteriorly into a posterior part of the ilium as a free fragment, and well visualized on ct sagittal and coronal views. anterior intrapelvic approach was chosen in all patients to treat atypical difs. the iliac oblique view was useful to visualize the atypical difs intraoperatively in case 1 and 2. in both cases, the reverse gull sign appeared after reduction of posterior column fragments (fig. 3) . in case 3, the inlet view was useful to visualized the atypical dif intraoperatively.the fragments were reduced and fixed with supra-acetabular screws (fig. 4) . results: we found prospective two to 10 years after acetabular osteosynthesis 64,04% complications. avn of the femoral head was present in 5,55% of the hips reduced within 24 h and 27,77% of the hips reduced more than 24 h after the injury [p = 0,013; 9 2=4,94; or = 25 (95% ci = 1,29-1121,5) ]. post-traumatic oa of the hip we found in 23,07% (fig. 1 ) infections we found in 5,1% (1 deep, 1 superficial), iatrogenic nerve palsy in 1 (2,56%), traumatic nerve palsy in 15,38% (6), dvt in 5,12% (2) , and ho in 10,25% (4) cases. in one case (2,56%) revision surgery was done. conclusions: acetabular fractures are followed with complications. some complications depend on surgery, meanwhile others cannot be affected on (type of fracture, impaction of acetabulum, injury of the femoral head, dislocation of femoral head). good knowledge of acetabular anatomy, surgical technique, experienced surgical team, early surgery, anatomical reduction and stable orif, early mobilization, can significantly influence excellent/good functional outcomes and reduce possibility for complications. introduction: reduction is one of the important factors in surgical treatment of femoral trochanteric fractures. in this study, postoperative reduction status was examined and the relationship between this reduction status and unsatisfactory cases was investigated. material and methods: 135 cases of femoral trochanteric fractures over 65 years treated with pfna-ii were investigated. postoperative reduction status was evaluated in ap and lateral view of x-ray and ct. anatomical reduction means medial or anterior cortex is reduced anatomically (abbreviation am and aa). intramedullary reduction means medial or anterior cortex of proximal fragment is inside the shaft (im, ia). extramedullary reduction is medial or anterior cortex of proximal fragment is overlapped to cortex of shaft (em, ea). unsatisfactory cases were ununited cases until 6 months and excessive sliding cases over 10 mm. reduction status of these cases was evaluated. results: postoperative status was classified with combination of medial and anterior reduction status. so there are nine groups and number of each group are as follows; im-ia:6 case, im-aa:5 cases, im-ea:0 case, am-ia:14 cases, am-aa: 46 case, am-ea:4 cases, em-ia:17 cases, em-aa:32 cases, em-ea:12 cases. non-united cases until 6 months were 29cases. reduction status of non-united cases were; im-ia:2 cases, im-ea:3 cases, am-ia:4 cases, am-aa:6 cases, em-ia:8 cases, em-aa:6 cases. there was no case in extramedullary reduction of anterior cortex. excessive sliding of blade over 10 mm was 11cases. there was also no case of extramedullary reduction of anterior cortex in these 11 cases (2 cases were cut out). conclusions: our results show there are no ununited cases and excessive sliding cases in extramedullary reduction of anterior cortex. this means extramedullary reduction of anterior cortex is important to reduce unsatisfactory results in surgical treatment of femoral trochanteric fractures. male injured open lateral condyle fracture of femur by to be bitten by a pig. after 5 months from initial debridement, i confirmed the size of bone defect was 3 cm(2) 9 3 cm in depth. the same size of bone was harvested from iliac crest and transplanted in the bone defect area of lateral condyle of the femur. after 7 months from bone transplantation, i confirmed bone union and two 6.5 mm diameter osteochondral grafts and 4.5 mm diameter osteochondral graft were transplanted for the chondral defect lesion. case 2; seventy year old male injured open lateral condyle fracture of femur by traffic accident. after 3 months from first debridement, i confirmed the bone defect (size 7 cm(2) 9 3 cm in depth) and the same size of bone was harvested from iliac crest and transplanted in the bone defect area. and simultaneously two 10 mm diameter osteochondral grafts were transplanted for the chondral defect lesion. case 3; 37 year old male injured open lateral condyle fracture of femur by traffic accident. i confirmed the size of bone defect was 6 cm(2) 9 3 cm in depth. the same size of bone was harvested from iliac crest and transplanted in the bone defect area of lateral condyle of the femur. after 1 month from bone transplantation, he had undergone autologous chondrocyte implantation. investigation/results: at last follow-up, average flexion angle of knee was 147 degrees. in all cases, lysholm knee scoring scale was good. diagnosis: large traumatic osteochondral defect of the weightbearing articular surface of the knee comments: treatment of large traumatic osteochondral defect of the weight-bearing articular surface of the knee is a difficult condition to treat. combination of bone transplantation and osteochondral autograft transfer or autologous chondrocyte implantation is useful strategy for the injury. references: tegner y., lysholm j., clin orthop relat res., 198, 43-108, 1985 pr 264 treatment of double tension band wiring method with ai wiring system for transcondylar distal humeral fractures m. uchino 1 1 hakujikai memorial general hospital, orthopaedic surgery, tokyo, japan introduction: as ai wiring system is united the pin with the cable due to compressed sleeve, the pin is never deviated. we review the treatment of transcondylar distal humeral fractures with ai wiring system in geriatric patients. patients and methods: 6 were identified as receiving this surgery. all patients were female and their mean age was 68 years. they were assessed union rate, range of motion for elbow joint, postoperative complication and functional outcome for japanese orthopedic score. results: union rate was 100%. the mean arch of motion was 95°at latest follow-up. the complications were detected 3 cases which were temporary ulnar palsy for 2 cases and hardware failure for 1 case. the average of functional outcome was 73 points (73/100). conclusion: tension band wiring of transcondylar distal humeral fractures with ai wiring system provides stable fixation for osteoporotic bone and tiny fragment. introduction: the purpose of this study was a comparative evaluation of the complications related to the treatment of trochanteric fractures using 2-screw proximal femoral nail (pfn) versus proximal femoral anti-rotational blade nail (pfna). material and methods: a retrospective review was conducted between march 2013 and march 2019. the study included 519 patients treated surgically for trochanteric fractures. the mean age was 79,8 ± 12,0 (24-100) years. patients were treated by pfn (393 patients, 75, 7%) or by pfna (126 patients, 24,3%). implant related complications were the primary objectives. infection and revision surgery were also recorded. results: complications were observed in 38 (9.7%) patients in pfn group and 7 (5,6%) patients in pfna group (p = 0.15). screw backout (n = 11) and cut-out (n = 11) occurred in 5,6% patients treated with pfn. in the pfna group, cut-out occurred in 1,6% (n = 2) of cases. infection (n = 3) represented 2,4% in pfna patients and 2,3% (n = 9) in pfn group. there were no statistically significant differences in both groups considering implant-related complications (p = 0,14) and infections (p = 1.0). revision surgery was performed in 7 (1,3%) patients. soft tissue problems are more likely in fractures due to high energy impact than low energy type fractures. high energy type present with horizontal fractures of tibia and fibula (i.e. on the same level), whereas in low energy type tibia fractures they present with spiral or oblique fracture patterns often associated with concomitant fractures of the posterior rim of the distal tibia (i.e. volkmann's triangle). posterior malleolus fractures occur regularly but are often missed and seen only on ct scans obtained either for preoperative planning or to verify postoperative rotation. in literature these mostly undisplaced fractures are treated with screw fixation mostly from anterior. but is this really necessary? material and methods: we retrospectively analysed 21 consecutive tibia shaft fractures operatively treated over the past 2 years at our regional hospital analysing the fracture pattern. results: out of 21 patients with tibia shaft fractures 9 patients presented with a posterior rim fracture of the tibia. no routine stabilisation of the volkmann fragment was performed, in all cases the posterior rim fragments healed uneventful. angles of 60°and above seem to present themselves with a concomitant fracture of the posterior malleolus. they are mostly undisplaced and the trauma mechanisms is low energy and torsion. none out of the 9 patients had known osteoporosis. conclusions: low energy and torsion-type tibia fractures with an angle of [ 60°seem to have an accompanying undisplaced fracture of the posterior malleolus. these fractures are usually undisplaced and do not need to be addressed. as a consequence there seems to be no need to actively rule them out with ct scans prior to surgery. concomitant ankle fractures including posterior rim fractures should be addressed like isolated ankle fractures. the dangers of bouncing: a prospecive cohort study of injuries associated with trampolines and bouncy castles over a 3 month period in a paediatric population. introduction: within the orthopaedic paediatric population, there is an increasing incidence of presentation of fractures associated with both trampolines & bouncy castles. whilst this phenomenon has been depicted frequently within the media in recent years given the dramatic upsurge in trampoline and bouncy castle usage, there have been few studies documenting either the incidence of fractures associated with either. materials and methods: this was a prospective cohort study conducted within our institution over a 3 month period june to august inclusive 2019. all paediatric patients who sustain a fracture and present to the national childrens'' hospital are referred to the orthopaedic department either whilst as an inpatient or as an outpatient depending on the assessment of the severity of injury. a standardised mixed questionnaire was given to all parents''/guardians which recorded the type of injury, type of trampoline/bouncy castle, inherent awareness of safety precautions governing the usage of either and application of same was recorded. the type of fracture was corroborated via examination of x-ray in addition to the recording of any complications via examination of clinical chart records. results: there were 88 patients who sustained a fracture directly related to the usage of either a trampoline or bouncy castle for which the majority required operative intervention. there was wide variability in the nature of injuries recorded; supracondylar/radial fractures were the most common whilst more complex injuries such as an open fracture of the femur was rarer. conclusions: awareness and application of necessary safety precautions was low (38%) amongst parents'' supervising parents''/guardians highlighting the need for greater public awareness of same. furthermore, the incidence of severe injury relating to usage of trampolines/bouncy castles is not uncommon highlighting the high risk activity that trampolining is. introduction: conventional plate fixation (pf) of distal fibular fractures in elderly patients is associated with a high risk of wound and implant related complications. intramedullary fixation (imf) using a fibular nail is a minimally invasive alternative to pf that provides superior biomechanical strength and allows immediate full weight-bearing postoperatively. aim: to compare the postoperative complications of minimally invasive intramedullary nail fixation to conventional pf for lauge-hansen supination external rotation type 4 fractures in patients aged 65 years or older treated in a single geriatric trauma unit in the netherlands. methods: a retrospective cohort study was performed including unstable ankle fractures in patients aged 65 years or older treated with either imf or pf between 1 january 2017 to 1 january 2019. the primary outcome measure was the total number of wound related complications. results: a total number of 58 patients were included with a mean age of 73.9 years (range 65 to 95). the imf-cohort (n = 13) had a significantly higher mean age (82.5 versus 71.4 years, p = 0.002) and charlson co-morbidity index (4.7 versus 3.6, p = 0.005) compared to the pf-cohort (n = 45). the total number of postoperative complications was lower after imf (31%) compared to pf (53%), although this relative difference was not statistically significant (p = 0.152). all 4 complications observed in the imf-cohort were wound related but demanded no debridement or implant removal. wound related complications did not differ significantly from pf (31% versus 44%, p = 0.378). no implant related complications, hospital-acquired complications or mortality were observed after imf. conclusion: despite the higher mean age and co-morbidity status of patients treated with a minimally invasive intramedullary nail, the total number of postoperative complications was lower after imf compared to pf. this technique might be a promising alternative in a selected group of patients. the authors declare that they have no commercial associations that might pose a conflict of interest. no funding or other compensation was received for the research, authorship or publication of this article. gustilo type ii and 4 gustilo type iii fractures. the treatment protocol was external fixation at admission and definitive osteosynthesis with plate at 15 ± 7 days. a single approach to the tibia was performed in 32 patients, and a combined anterior and posterior approach was used in 9. the incidence of complications was 50%: 15 cases of poor soft tissue evolution, of which 7 were infections. 9 patients evolved to nonunion. osteoarthritis appeared in 100% of patients (70.73% grade 3), and only one patient needed arthrodesis. 15.91% had a valgus ldta (\ 86°) and 38.64% a varus deformity ([ 92°). we found a significant relationship between the history of open fracture and the development of complications (p \ 0.05). we found no relationship between the incidence of complications and the approach. conclusions: tibia ao43c fractures have a high percentage of complications and evolve to well-tolerated osteoarthritis. open fracture seems to significantly influence the poor postoperative outcomes of these patients. clinical findings: a 24-year-old male, who suffers a closed chest trauma with pneumothorax, right pulmonary contusion and poor pneumoperitoneum. also a grade iiia open fracture of the right femur, with a 10 cm bone defect. investigation/results: upon arrival at the hospital, he needs orotracheal intubation, as well as blood transfusion with 9 red blood cell concentrates. external fixator is placed on the right femur. diagnosis: a iiia grade diaphyseal open fracture of the right femur with 10 cm bone defect, bearing external fixator with one broken proximal pin and positive culture for s maltophila in the distal pin. therapy and progressions: antibiotic treatment and medical optimization are performed, cemented intramedullary nailing (t2-stryker) with antibiotic (vancomycin-tobramycin), as well as cement spacer with antibiotic (masquelet's first stage) in the defect area. in second time, withdrawal of spacer and contribution of ria autograft of contralateral femur and allograft respecting membrane. the patient begins the protected weight bearing with two crutches immediately, without using them 3 months after the surgery. bone consolidation without pain or limitation after 1 year. comments: the induced membrane technique is a simple and effective technique for the reconstruction of segmental bone defects and can be used as a first time technique together with the initial stabilization, leaving the defect ready for graft delivery in the second time. introduction: carpal metacarpal dislocation is a rare entity that accounts for less than 1% of all carpal injuries. dorsal dislocations are the most common and occur most frequently after violent trauma in young individuals and are easily overlooked and may lead to longterm sequelae. material and methods: we present the case of a carpal metacarpal dislocation from d2 to d4. male, 40 years old, no relevant personal history. brought to the emergency service after a motorcycle accident with projection. he had a symphysis pubis diastasis, a distal radius fracture on the right wrist and a fracture of the left forearm bones. no other apparent injuries associated. at week 4, he presented edema and dorsal deformity of the left hand associated with limited finger movements. neurovascular assessment was normal. the radiological evaluation showed a carpal metacarpal dislocation from m2 to m4. it was an unstable reduction so open reduction was performed, with debridement of fibrous material, until exposure of the articular surfaces, and reduction and fixation with k wires of the three metacarpals (from d2 to d4). similarly, m5 was stabilized with a k-wire due to clinical instability observed intraoperatively. results: it is necessary to reduce and stabilize these lesions to avoid vasculonervous compression and skin distress. open reduction is indicated in irreducible cases allowing debridement and excision or os of small osteochondral fragments and fixation of associated fractures. conclusions: combined dislocation of multiple metacarpals is a rare lesion that compromises the functional prognosis of the hand in the absence of adequate treatment. instability and post traumatic arthrosis are among the sequelae of this lesion. identify the lesion to allow the appropriate treatment usually leads to good results. case history: 16-year-old suffered direct trauma to his right hand after falling off his bicycle. clinical findings: on physical examination showed edema and bruising from the base of the thumb and thenar eminence, tenderness over the cmc joint and functional disability speacialy in pincer grasp. no neurovascular injuries investigation/results: the x-ray revealed a comminuted fracture of the base of the thumb metacarpal. diagnosis: we identifed a rolando fracture. therapy and progressions: on the day after the trauma, he was submited to open reduction and osteosinthesis with lateral-palmar plate and screws, through radiopalmar aproach of the thumb base. intra operatively no dorsal fragments werefound to be left undisplaced. two months after surgery, the patient went back to the hospital for sudden pain and inability to extend the thumb. clinically with rupture of the long extensor of the thumb. on the x-ray, the fracture was aligned. the latero-lateral tenorrhaphy with kessler suture was preformed and intraoperatively a bony spicule was identified in the proximal stump of the tendon, which was removed. 6 months after the initial trauma, the patient has a consolidated neck and no limitation of the mobility of the thumb. comments: rollando fracture is relatively rare in adolescents. the aim of treatment should be exact reduction usually with open technics. the main complications are stifness and early arthrosis. there are also records of conflicts with the plates and even rupture of the extensor tendon, so the radiopalmar placement of the plate was chosen. nevertheless, the rupture occurred due to conflict with an unidentified bone fragment during surgery causing an unexpected complication in this case. the immobilization necessary after tenorrhaphy could have caused joint stiffness, but in this case the teenager fully recovered after physical therapy case history: periprosthetic and periimplant femoral fractures are an increasingly frequent pathology. in many cases they are a challenge with limited or too aggressive therapeutic options. it is important to investigate new approaches that increase the arsenal of the orthopedic surgeon. the recently described mipo (minimally invasive plate osteosynthesis) approach for the medial aspect of the femur may seem like a dangerous procedure because of the anatomical structures that run along the medial aspect of the thigh, but it is a viable and useful option in selected cases. clinical findings: we present the case of a 54-year-old patient with a total hip replacement who presented a first periprosthetic vancouver b1 fracture of the femur that was treated with a lateral blocked plate. subsequently the patient presented a second supracondylar femur fracture below the first plate (vancouver c). investigation/results: after thinking over the possible therapeutic options, we decided to treat our patient by means of the medial femoral mipo approach with a long medially placed blocked plate, managing to stabilize the fracture and superimpose the plate on the previous implants without the necessity of removing the previous lateral plate. diagnosis: periprosthetic and periimplant supracondylar left femoral fracture. therapy and progressions: we used the surgical technique of the medial femoral mipo approach as described by apivatthakakul 1 . comments: we consider that the medial femoral mipo approach is a useful therapeutic tool to consider. it seems a safe and low-invasive option for the resolution of cases in which the lateral mipo approach is not a feasible option. references: 1 c. jiamton y t. apivatthakakul, « the safety and feasibility of minimally invasive plate osteosynthesis (mipo) on the medial side of the femur: a cadaveric injection study » , injury, vol. 46, n.o 11, pp. 2170 » , injury, vol. 46, n.o 11, pp. -2176 » , injury, vol. 46, n.o 11, pp. , nov. 2015 . posterior knee dislocation with neurovascular injury associated-a case report case history, investigation and diagnosis: a 58-year-old male was brought in after 4 h following a heavy straw bale fall. he presented with a posterior knee dislocation that had already been reduced and an open wound in the popliteal fossa. the limb was flushed and pale on the extremity, with absence of the pedis and posterior tibial pulses. stability tests revealed unstable knee in all axes. an anterior shoulder dislocation was diagnosed and reduced. therapy and progressions: an emergent surgery was performed, involving a transarticular external knee fixation and a femoro-popliteal bypass above the knee (angiogram revealed a stop sign at the level of the interarticular popliteal artery). he developed circulatory shock and was admitted to the intensive care unit. on the 1stpostoperative day(po) was diagnosed a compartment syndrome that was treated with fasciotomies. these incisions showed a slow but progressive evolution, that required vacuum dressings and underwent autologous skin graft on the 34thpo day. the external fixator was removed on the 41stpo day and rehabilitation was started. on a 5-month follow-up, the patient had a good evolution of the wounds, but a knee with valgus and anteroposterior laxity and severe complete peroneal, tibial and sural neurological injury, confirmed with electromyography, and neuropathic pain. introduction: isolated iliac wing fractures represent only a small part of all pelvic fractures. these fractures are associated with severe injuries, but are considered benign. the literature lack information about the function and quality of life of these patients. our objective was to evaluate the long-term effects of isolated iliac wing fractures. material and methods: patients with pelvic fractures treated at oslo university hospital, ullevaal, in the time period 2006-2016, were extracted from the local fracture registry. 403 patients were registered in this period. a search was also made in the hospital''s administrative electronic database for patients registered with diagnose code s32.3 in icd-10 in the same period. 37 patients were identified. in total, 13 patients had an isolated iliac wing fracture, and these were invited to a follow-up examination, including proms (eq-5d-3l and majeed score), clinical examination, and pelvic x-ray. results: nine patients agreed to participate in the study, median 7 years after the fracture (range 4-13). all of them were injured from high energy trauma, with mean niss 18, 3 (range 5-66) . four of the fractures were open, and seven of the patients had associated injuries. five were treated with internal fixation. the mean eq-5d vas was 84 (range 75-99). five patients reported pain, one of them related to the pelvic fracture. the mean majeed score was 87 (range 64-100). seven patients had sensory deficit in the lateral thigh. one patient had difference in range of motion between the two hips. the x-rays showed healed fractures in all the patients. eight of them showed ectopic ossification. conclusions: our study confirms previous studies that isolated iliac wing fractures are results of high energy trauma with severe associated injuries. however, the majority of this group of patients seem to have a good general state of health, which is in accordance with the general assumption of the injury as a benign one. fenton's syndrome-a case report of a common underdiagnosed entity case history: a right handed 54-year-old male, construction worker, was admitted in our emergency department, after a 3 meters fall. the authors report a case of fenton's syndrome in a politrauma scenarium. clinical findings: both right elbow and left wrist were painful, swollen and with a remarkable restriction of the range of motion (rom). patient also reported lower back pain. no neurovascular injuries were detected. investigation/results: x-ray and ct scan confirmed a fracture of a lumbar vertebra, fracture of the right olecranon and, on is left wrist, a carpal fracture-luxation mayfield 4 of both scaphoid and capitate associated with rotation of the last one proximal pole-fenton''s syndrome. diagnosis: this syndrome is an atypical presentation of perilunate fracture dislocation and, therefore, difficult to diagnose. few reports were found in literature. after an open reduction of the fractures, a definitive fixation with headless herbert screws was achieved. percutaneous kw and immobilization of the wrist were performed to further stabilization of the lunotriquetral joint. 12 weeks later consolidation was noted. a decrease of 15°in extension and flexion were detected when compared with the contralateral wrist. grip strength test was similar on both hands. osteosynthesis of the right olecranon was also realized. comments: a careful neurovascular assessment is important. although it is rare, injuries of median nerve were already reported associated to this complex fractures. open reduction and osteosynthesis are necessary due to the great instability and the risk of nonunion and osteonecrosis of the rotated proximal segment. introduction: intramedullary nailing has been popularly applied for the femoral shaft fractures. the current study aimed to analyze the femur geometry for development of implant design with 3 dimensional skeletonization. material and methods: we acquired computed tomography (ct) images of both femur reviewed in a single center from 2015 to 2017. the total 1400 participants were enrolled and they were divided into subgroups according to age (decades) and gender. each subgroup included 100 persons, respectively. these images are used to produce 3d samplings. with the skeletonization, we obtained the geometry parameter; (1) femur shaft length from the tip of the greater trochanter to the bicondylar line, (2) the minimum diameter of the medullary canal and its location, (3) anteroposterior (ap) diameter and lateral diameter of the entire femur, (4) radius of curvature (roc) of the femur (bowing). we compared all parameters according to sex and age. results: the average age of the participants were 54.0 years (range 20-89 years) and the number of each gender was exactly same. the femur length was 425.5 ± 37.6 mm (range, 337.4-516.0 mm) and the femur shaft length was 383.0 ± 35.6 mm (range 301.3-466.5 mm), both of them were longer in male (p = 0.002, \ 0.001). the minimum diameter of the medullary canal was 9.4 ± 1.9 mm (range 5.0-18.1 mm). the roc was 810.7 ± 202.5 mm (range 338. 3-1491.8 mm) . the rate of the minimum diameter less than 8 mm and 7 mm was 26.0% and 9.4%, respectively. the rate of roc with less than 750 mm and 700 mm was 28.5% and 21.3%, respectively. conclusions: this geometry analysis showed that there are mismatch problem between the current nail and the medullary canal in 9.4% and the roc of the femur was smaller than that of the current nail systems (1000-1500 mm). the result indicates potential mismatch problem in clinical cases and the problem can be resolved with newly designed nail system. the study was funded by national reserach foundation of korea (nrf-2018r1d1a1b07050224). safe zone of the infracacetabular screw: virtual mapping of 362 three-dimensional hemipelvises for quantitative anatomic analysis introduction: an infra-acetabular screw can provide increased stability in fixating acetabular fracture. we conducted this study to define the incidence of the safe corridor for infra-acetabular screw and to determine the correlation between the safe corridor and other demographic factors such as age, sex and height. material & methods: pelvis computed tomography (ct) of 182 participants was extracted with evenly age-and sex-allotted. 362 virtual three-dimensional (3d) model was generated. a search was performed to find the maximum-with corridor connecting two points. the entry and exit point was displaced in the template. the maximum diameter of each corridor was measured in automatic procedure. a minimum 5 mm corridor diameter, sate corridor, was defined as a cutoff for placing a 3.5 mm cortical screw in clinical setting. all data were presented as mean and range or mean and standard deviation. two-sample t test and regression analysis were used to compare difference between groups based on sex, age, and height. results: among 354 hemipelvis, 250 hemipelves (70.6%) satisfied a minimum safe corridor diameter of 5 mm. when divided into a subgroup by the patient's gender, the incidence of the safe corridor of a male group was statistically higher than a female group (82.0% vs 59.1%), with the mean corridor diameter of 6.24 mm (95% ci, 0.2) and 5.44 mm (95% ci, 0.2), respectively (p \ 0.001). in correlation analysis, only the height showed a positive correlation with the diameter of the safe corridor of a total population (r = 0.25; p \ 0.001). conclusions: the study provided the safe corridor was found in 81% of male and 69% of female, and the taller had the higher incidence of the safe corridor. the patient''s height was correlated with the corridor diameter of the infra-acetabular screw, whereas the patient''s age did not correlate with the corridor diameter. introduction: femoral neck fractures in middle-aged and older patients represent one of the most common orthopedic conditions. osteosynthesis, as a primary treatment option for femoral neck fractures has shown to have successful outcomes. however, this is not the case for old fractures. the purpose of this study was to evaluate the outcomes of treatment of femoral neck fractures in which cementless total hip arthroplasty was indicated. the aim of our study was to analyze the prosthetic failure, i.e., the reasons for unsuccessful outcome, in order to suggest the indications for primary osteosynthesis which could guide the femoral neck fracture management. material and methods: a total of 120 patients were analyzed in this study, with femoral neck fracture treated with osteosynthesis. reviewing the radiological findings, as well as the course of the treatment, we set up the criteria, on the basis of which we could advice the immediate implantation of total hip prosthesis for the femoral neck fracture. results: old fractures, varus deformity of the femoral head and neck, dislocation, as well as the comminuted fractures, are all factors affecting the surgical outcomes of osteosynthesis. additionally, medical and technical equipment of medical institution, personnel competence, and minutious surgical technique affect the treatment outcomes. introduction:proximal ulnar fractures are usually osteosynthesized by means of angle stable plate osteosynthesis. despite good functional results of this procedure, complications such as high access morbidity and disruptive osteosynthesis material with a high rate of material removal are described. the aim of our study was the development of a new locking nail and test setup for comparison with a plate osteosynthesis on artificial bones. material and methods: in our biomechanical laboratory, a jupiter 2b fracture of the proximal ulna was standardized on 20 sawbones and stabilized by means of the newly developed nail or anglestable posterior plate osteosynthesis. a servopneumatic testing machine, the specimens were flexed under a cyclic load (30-300 n) in the physiological range of movement of the elbow from 0°to 90°.the maximum elastic deformation of the specimens and the loosening of the implants were evaluated after 608 test cycles. results: the primary stability of the constructs at the anterior cortical bone after nail osteosynthesis was significantly greater (0.29 ± 0.13 mm) than in the angle-stable plate osteosynthesis (0.97 ± 0.30 mm, p \ 0.001).after passing through the test cycles, both implants showed a low loosening rate. in the area of the anterior cortex, the locking nail showed a significantly lower rate of loosening (nail 0.08 ± 0.06 mm, plate 0.24 ± 0.13 mm, p \ 0.001). at the dorsal cortex, there were no differences between plate and nail in both series of measurements. conclusions: intramedullary implants provide biomechanical benefits in fracture stabilization. good biomechanical results have already been shown in the literature after nailing olecranon fractures2. nevertheless, due to the complex anatomy and the resulting difficult implantation technique, ulnar nails could not prevail in practice. the presented nail allows a safe stability with simple surgical technique. introduction: adequate treatment of tibial plateau fractures is crucial to minimize patient disability, development of posttraumatic arthritis and subsequent need for a total knee arthroplasty (tka). however, due to the complexity of the fracture, adequate reduction cannot always be achieved which could result in the early conversion to a tka. in this study we introduce a quantitative 3d fracture assessment method and investigate whether it could help to identify patients that are at risk of conversion to a tka. material and methods: we retrospectively included 135 patients, who were treated for a tibial plateau fracture between 2003 and 2017. 16 patients developed severe posttraumatic arthritis and underwent conversion to a tka. from all patients, 3d models were created using the pre-operative ct-scans. for each patient, the 3d gap area between the fracture lines, representing an innovative combined gap and step-off measurement in 3d, was determined in order to quantify the displacement (figure 1 ). roc curve analysis was performed to determine a critical cut-off value for the 3d gap area. kaplan-meier survival curves were created to assess the association between 3d fracture anatomy and risk on a tka at follow up. results: a critical cut-off value of 700 mm 2 was found to give highest combined sensitivity and specificity for 3d gap area and the risk of tka at follow-up. kaplan-meier survival curves showed 98.9% knee survival (no tka) at 2 year follow up in the group with a gap area of \ 700 mm 2 , whereas in the group with a gap area of c 700 mm 2 a knee survival of 82.5% was found. at 10 year follow up knee survival was 97.9% and 63.8%, respectively, for the two groups (\ 700 mm 2 and c 700 mm 2 ). conclusions: we developed an innovative method to quantify the amount of displacement in 3d. pre-operative 3d fracture assessment could be used as an addition to the current fracture classification methods to help identify patients who have a high risk on conversion to tka at follow-up. introduction: soft tissue sarcomas (sts) in the anterior compartment of the thigh are frequent. the extent of quadriceps resection is controversial. the aim of the present study is to communicate our results in complete quadricectomies due to high-grade sts. material and methods: we present 8 sts, in stage iiib of the ajcc, with a mean craniocaudal diameter of 15 cm (9-25). there were 4 women and 4 men, with a mean age of 58 years (35-79). six were undifferentiated pleomorphic sarcomas, 1 myxofibrosarcoma and 1 clear cell sarcoma. in every case, total quadricectomy was performed with wide margins. posterior reconstruction with local muscle transfers was performed, expect for the younger patient, who received a vascularized contralateral vastus lateralis transplant. in all cases, complementary radiotherapy was indicated, and in 4 patients adjuvant chemotherapy. results: three patients required friedrich due to necrosis of the edges of the surgical wound. one patient died 50 months after the intervention as a result of multiple metastasis, and two due to medical complications after 1 week and 4 months, respectively. the average follow-up time for the rest was 28 months , with no local recurrence. as for functional outcomes, mean msts score was 20 (14-30), with deficit of active knee extension in most of them. the functional result of the patient with the vascularized muscle transplantation was excellent. all of them were satisfied with the results of the treatment. conclusions: quadricectomy provides good functional and acceptable cancer results, although it is not exempt from complications in frail patients. vascularized muscle transplantation, though complex, can improve functional results, especially in younger patients. introduction: operative treatment is a valuable option in displaced proximal and/or middle one-third diaphyseal humeral fractures. although plate osteosynthesis is preferred to intramedullary nailing, surgery can be complicated by radial nerve palsy. a helical plate could avoid this high-impact complication. to date there is however a lack of published evidence in literature, although recent asian case reports show promising results. material and methods: we retrospectively reviewed 16 patients who were treated with open reduction and internal fixation with a helical plate consecutively from october 2016 until august 2018 at az groeninge, kortrijk. a deltopectoral approach was used in combination with a distal anterolateral incision, whether or not in continuity. a self-molded long philos plate was used in the first 9 patients, while in our last 7 patients the a.l.p.s plate (zimmer ò ) was used. standard radiographs were obtained pre-and postoperatively. we retrospectively searched for complications, e.g. radial nerve palsy, infection and/or loosening. in autumn 2019, 12 patients were reassessed. patient''s general health status was evaluated using the eq-5d-5l score. constant-murley scores and dash scores were used for evaluating shoulder function and disability measures consecutively. results: all humeral fractures consolidated at 3 months. there were no radial nerve palsies due to surgery. one plate was removed after 1 year due to a late infection. with a minimum follow up of 1 year, the mean dash score was 22 (0-93) and the mean constant-murley score was 68 (33-95). the dash score was inversely proportional with the constant-murley score and patient''s general health status. conclusion: a helical plate avoids neurological complications with similar healing rates and good to excellent shoulder function at 1 year follow up in the treatment for proximal and/or middle one-third diaphyseal humeral fractures. the use of antibiotic-impregnated cancellous bone grafts in onestage surgery for chronic orthopaedic infection: preliminary clinical results k. dendoncker 1 , g. putzeys 1,2 1 az groeninge, tissue bank, kortrijk, belgium, 2 az groeninge, orthopaedic center, kortrijk, belgium introduction: the use of cancellous bone allografts is an established technique in reconstructive orthopaedic surgery. unfortunately, its use is generally avoided in the presence of a local infection. antibiotic impregnated cancellous bone grafts has shown its effectiveness as an local antibiotic delivery system [1] [2] [3] . in this clinical study, we report our first personal experience with the use of vancomycin-impregnated cancellous bone grafts in one-stage surgery for periprosthetic joint infections (pji) and fracture-related infections (fri). material and methods: between december 2015 and march 2019 nine patients were treated during a one-stage surgery with vancomycinimpregnated cancellous bone grafts, containing 1 g vancomycin per 10 cc bone. regular clinical, laboratory and radiographic follow-ups were performed for at least 6 months after surgery. results: the procedures included revision of 5 pjis (hip and humerus) and 4 fris (tibia, femur and clavicula). one tibia required further revision because of recurrent infection and one hip has an uncertain infection state, however the remaining 7 patients stayed free from infection during a follow-up of at least 6 months. interestingly, in one patient the vancomycin concentration could be determined in the drainage fluid from the wound. radiographic examination revealed no signs of osteolysis or loosening, good incorporation of the bone graft and progressive consolidation. conclusions: within the limits of the study, the use of vancomycinimpregnated cancellous bone grafts in one-stage surgery to treat pji and fri yielded positive outcomes in terms of clinical, laboratory and radiographic follow-up. this technique might offer new treatment strategies in often devastating injuries. references: 1. putzeys g., et al. orthopaedic proceedings. 2015; 97-b:supp_16, 145-145. 2 with the modified arthroscopic approach (group b). the prospective follow-up included the lysholm score, the subjective questionnaire of the ikdc score and the specifically extended oak score for clinical evaluation. the rolimeter ò was used to test the translational mobility of the knee joint. the statistical significance level was set at 5%. results: the follow-up was 28.5 ± 19.60 months and 30.6 ± 26.26 months postoperatively in group a and b, respectively. the subjective scores were tested. group a and b achieved a mean lysholm score of 70.3 ± 5.32 and 69.6 ± 19.82 points respectively. in the subjective ikdc assessment, group a achieved 67.3 ± 7.76 points and group b 65.9 ± 12.35 points. the clinical oak score was 77.5 ± 6.10 points in group a and 75.3 ± 11.31 points in group b. the following values could be recorded for the stability of the posterior cruciate ligament: the side difference in the rear drawer test was 1.75 ± 1,192 mm in group a and 2.50 ± 2.160 mm in group b. in the reversed lachman test, a difference of 2.37 ± 2.175 mm and 3.22 ± 2.059 mm was measured in group a and b, respectively. all values mentioned were comparable between the two evaluated groups. conclusions: the results of the two surgical techniques were comparable. therefore the arthroscopic approach is the preferred method in our institute. simple correction technique of femoral malrotation after pfn-a osteosynthesis of trochanteric fracture k. pavotbawan 1 , p. stillhard 1 , c. sommer 1 1 kantonsspital graubünden, department of trauma surgery, chur, switzerland introduction: malrotation after intramedullary nailing in femoral shaft fractures are well known. but malrotation after nailing of trochanteric fractures is an underestimated problem. during surgery the axial alignment can easily be evaluated by fluoroscopy in both planes. but the torsional alignment is difficult to assess especially with the patient placed on the traction table. in literature a malrotation after pfna is described in up to 25% of the cases. a revision with replacement of the blade, especially in patients with poor bone quality, may result in a reduced stability. to our knowledge there is no publication till to date to give a treatment pathway for this problem. we developed a rather easy technique to derotate a malrotated femur after pfna fixation. material and methods: the basic idea is to leave the usually well placed blade insitu in the femoral head, just rotating the distal main fragment around the nail. therefore, a small u-shaped osteotomy with a chisel is performed in the femoral cortex just anterior of the entry site of the blade. the length (l) of this osteotomy can be calculated, following the formula: l = d x p x a/360 (d = diameter of femur, a = angle of malrotation). then the distal locking bolt is removed, the leg derotated and finally locked again. the procedure is controlled by two schanz''screws separately inserted in both main fragments angulated to each other in the angle ''a''. results: since 2014 3 patients were detected with a clinically relevant femoral malrotation. all patients had an internal malrotation from 30 to 40 degrees confirmed and measured by ct scan. all of them were successfully revised in the above described technique 5-9 days after initial fixation. conclusions: first, we believe that malrotation after trochanteric fracture fixation is an underestimated problem. and second our method is a simple salvage procedure for malrotated trochanteric fractures after pfna, leaving the blade in situ in the femoral head. optimal intramedullary nailing for trochanteric fractures: the importance of distal locking screw and reduction position t. waki 1 , t. yano 1 , k. ito 1 , s. matsushima 1 1 akashi medical center, orthopaedic surgery, akashi, japan introduction: distal locking issue for trochanteric fractures is still controversial. therefore, the purpose of this study was to investigate the complications between distal unlocked group and distal locked group. further, the relationships were evaluated between these complications rates and their reduction positions after operation. material and methods: 365 operations were performed for trochanteric fracture (ao 31a1 ?a2) from 2012 to 2018. of these, patients with f/u periods [ 3 month were 218. gamma3 im nailing system (stryker) was used for all patients. 146 patients (unlocked group) from 2012 to 2016 operated without distal locking screw. 72 patients (locked group) from 2016 to 2018 operated with distal locking screw. we retrospectively analyzed those patients who suffered complications such as delayed healing and postoperative periimplant fractures and cut-out of the lag screw. further, in lateral view of their radiographs, we evaluated the position of the proximal fragment compared with distal fragment. the reduction positions were divided into 3 groups: anterior (subtype-a), neutral (subtype-n), and posterior (subtype-p). results: in unlocked group, complication was shown in 94 patients (complication group). delayed healing was shown in 94/146 (64.4%) in unlocked group and 12/72 (16.7%) in locked group. peri-implant fracture was shown in 3/146 (2.1%) in unlocked group and 0/72 (0%) in locked group. cut-out of the lag screw was shown in 4/146 (2.7%) in unlocked group and 1/72 (1.3%) in locked group. in complication group, subtype-p was more than non-complication group. conclusion: in the current study, higher number of complications was seen in the distal unlocked group. and, our study showed the reduction position might be associated with post-operative complications. we concluded that nailing without distal locking screw might be dangerous and subtype-p should be avoided. introduction: heterotopic ossification (ho) after acetabular fracture surgery has been one of the common complications and often limits function with the range of motion severely. surgical resection is challenging and only effective treatment for established ho. we herein report four cases who underwent surgical resection and mobilization for ho after acetabular fractures surgery. material and methods: four cases with severe ho after acetabular fracture surgery were included in this study. the mean age at operation was 45 years old, and all patients were males. in judet-letournel classification, there were three cases classified as posterior wall fracture, and one case as transverse and posterior wall fracture. two of four cases were combined with posterior dislocation of the hip. in all cases, the first operation was performed using with the kocher-langenbeck (kl) approach. results: surgical resection of ho was performed using with the kl approach at 8.4 months (range 5-12 months) after the first operation. the median operating time and intraoperative bleeding were respectively 4.5 h and 3130 ml. intraoperative 3d navigation was used in one case. as postoperative complications, one case developed sciatic nerve palsy and another case sustained the iatrogenic femoral neck fracture. all cases have no recurrence with a follow-up of 4.9 years after the surgical resection. conclusions: surgical resection is the only treatment for symptomatic ho. but that requires preoperative planning and must be performed carefully because the extent of resection is still controversial and that may develop severe complications such as nerve palsy and iatrogenic fractures. by using navigation, we can determine the extent of resection easily and operated safely. case history: 18-year-old male, previously healthy, turned to the hospital after a motorbike crash, resulting in high energy direct trauma of the right wrist. clinical findings: upon admission, cranial, thoracic, abdominal and other traumatic injuries were excluded. the patient presented with pain, swelling and visible deformity of the right wrist and hand, hypoesthesia of the 5th finger, and no perfusion deficits. investigation/results: x-rays showed volar perilunate carpal dislocation with associated comminuted scaphoid fracture, radial styloid avulsion, and metacarpal phalangeal dislocation of the 5th digit. under sedation, closed reduction of the metacarpal phalangeal joint was accomplished, and reduction of the carpal dislocation was attempted unsuccessfully. the wrist was temporarily immobilized in a cast and taken to the or. diagnosis: transcaphoid-transradial-styloid-perilunate volar dislocation therapy and progressions: surgical treatment comprised loose bodies removal, reduction of the perilunate dislocation, orif of the scaphoid using a herbert screw, and stabilization of the carpal rows using two percutaneous kirschner wires. after surgery, a thumb spica cast was applied. post-operatively, neurovascular status was normal. at 6 weeks, x-rays showed signs of bone healing, the cast and k wires were removed, and physical therapy was initiated. at 6 months, scaphoid fracture consolidation was achieved. the patient remained with a mild deficit in wrist extension but reported no pain nor important limitation in daily living activities. comments: perilunate injuries with displacement or dislocation usually require surgery. persistent instability is a described complication, often progressing to secondary post-traumatic arthritis of the wrist and carpus, termed scapholunate advanced collapse. introduction: this study was conducted to study the patient characteristics, classification, treatment, complications and functional outcome of operatively treated displaced intra-articular calcaneal fractures (diacf) in a level 1 trauma center in the netherlands material and methods: patients with an diacf, classified as sanders c 2 and operatively treated with percutaneous screw fixation (psf) or open reduction and internal fixation (orif) between january 1998 and december 2017 were identified. pre-and postoperative radiological assessment was performed. functional outcome, range of motion and change in footwear were evaluated with the use of the american orthopaedic foot & ankle society (aofas) score and the maryland footscore. general health and patient satisfaction was assessed using the short form-36 (sf-36) and the visual analogue scale results: in total, 116 patients with an operatively treated diacf were identified. 67 patient with 76 diacf completed the questionnaires. there were 52 males and 15 females, mean age at trauma was 45 years. average follow up was 11 years. 17 were classified as sanders type 2, 31 and 19 as respectively type 3 and 4. 36 were joint depression and 38 were tongue-type fractures. there were no differences in sanders classification between the group treated with orif and psf. for orif and psf there were (25-25%), (52-42%) and (22-33%) for respectively sanders type 2, 3 and 4 fractures. mean aofas, mfs, sf-36 and vas was (75-74), (79-78), (59-66) and (7-9) for respectively orif and psf. mean pre-and post-bohler angle was (11-24) and (15-22) for respectively psf and orif. 7 underwent an ankle arthrodesis. surgical site infection and deep infection occurred in (12,5-25%) and (12,5-8%) in respectively psf and orif conclusions: long-term comparison shows no significant differences between orif and psf in treatment of sanders fracture type, bohler angle reduction, on functional outcome or complication rates introduction: the prevalence of hand injury in the pediatric population is attributed to their curiosity, limited fear of pain and diminuted motor coordination. the seymour fracture, which was first reported by seymour in 1966, represents a transverse extra-articular open fracture of the distal phalanges associated with nail bed injuries. the fracture includes salter-harris type i and ii fractures as well as juxta-epiphyseal injuries. material and methods: the aim of this report is to present a case of a seymour fracture in a young boy and describe the injury mechanism associated with misuse of the newly emerging vehicle, the hoverboard. results: our patient was treated promptly and provided with appropriate management following the standard of care in our hospital for such injuries: disimpaction and repair of the nail bed, reduction of the fracture, and k-wire fixation across the distal interphalangeal joint. the patient was discharged with a volar slab and was prescribed an oral antibiotic. the patient recovered well with no major deficits. conclusions: the timely recognition and management of seymour fractures is crucial. the surgical treatment has good results however, conservative management can be an option in some specific cases. antibiotics are always required. we report a case of a fracture pattern resulting from the improper use of an hoverboard. although improper use was a factor, design fault also plays a role in causing the injury. hoverboards are a new transport technology that has been introduced in recent years. because of the number of injuries that have resulted from hoverboards, they should be used in the most controlled way possible to prevent any unnecessary injuries. case history: we report the case of a 32 years old male from bangladesh, with 6 months of progressively increasing pain, limited range of motion and swelling on his left knee, with 6 kg of weight loss and inguinal lymph nodes. clinical findings: knee radiography and mri of the knee demonstrated a voluminous soft tissue mass surrounding the distal femur with intraarticular and posterior extension. a toracic-abdominal-pelvic ct showed supra and infradiaphragmatic lymph nodes. c-reactive protein level was 5,72 mg/dl. investigation/results: the clinical picture suggested a lymphoproliferative syndrome. a biopsy was performed, revealing 100 cm 3 of purulent material. synovial fluid had 548 leucocytes/ul, 70% of polymorphonuclear cells, 30% of mononuclear cells and undetectable glucose. acid-alcohol resistant bacilli test and pcr test for mycobacterium tuberculosis were positive. diagnosis: mycobacterium tuberculosis knee arthritis therapy and progressions: the patient was treated with polytherapy consisting on rifampin, isoniazid, pyrazinamide and ethambutol. 6 months later, the patient reports no pain, and tumor size has decreased. comments: mycobacterium tuberculosis infection is not a common disease in developed countries. however, the incidence in europe is increasing due to immigration. even though the lung is the most affected organ, osteoarticular tuberculosis represents around 10% of extra-pulmonary cases. tuberculosis simulates several diseases. because of non-specific symptoms and radiological signs, it can be difficult to diagnose. in a patient with chronic knee pain and limited range of motion, tuberculosis infection should be kept in mind, among other differential diagnoses, such as fibromatosis, pigmented villonodular synovitis or soft tissue sarcomas. clinical findings: the patient presented with a valgus deformity of the knee, the medial femoral condyle protuding on the medial side of the knee. neurovascular status was intact. investigation/results: xray revealed lateral dislocation of the knee. mri revealed mcl, pcl and acl rupture. diagnosis: knee dislocation (kd) grade iii (schenck). therapy and progressions: the patient underwent emergent closed reduction. neurovascular status was intact after resuction. due to important oedema and blisters, the lower limb was immobilized with a brace to allow for skin surveillance. after 3 weeks, the brace was replaced by a long leg cast for 2 more weeks. after 6 months, the patient maintained residual pain, rom -5/855 and minor instability. comments: kd are unusual injuries, associated with high energy trauma, therefore they often result in disruption of at least 3 major ligaments and associated injuries, from soft tissue to vascular structures. emergent reduction is mandatory, and definitive treatment can be conservative, or early/late surgical repair/reconstruction of the ruptured ligaments. there is a lack of large prospective clinical studies comparing the different types of treatment. even so, data tend to associate early surgical treatment with better functional outcomes, though there is no statistic evidence supporting its improvement of the range of motion or stability. long term complications most frequently include residual pain, instability or rigidity. rarely the knee returns to its pre-injured state, independently of the treatment used. references: dwyer, t., et al. (2012) . outcomes of treatment of multiple ligament knee injuries. the journal of knee surgery, 25(04), 317-326. advising a reduction after a fracture of the distal radius, reliability with and without use of expert based criteria introduction: distal radius fractures (drf) are common, however many aspects of its management remain subject of debate 1 . this study assessed the interobserver reliability of surgeons concerning the recommendation for a reduction and the improvement of expert based criteria for reduction. material and methods: we sent out 2 surveys to members of the science of variation group. the first survey divided participants in 4 groups, each rated 23-24 radiographs of drf. resulting in 95 rated fractures by 80 participants. each observer indicated whether they would advise a reduction or not. the second survey randomized participants (68 surgeons) to either receive or not receive criteria for reduction and participants indicated if they would recommend reduction. results: the reliability for advising a reduction was poor, kappa 0.31 (95% ci 0.23-0.39). multivariable linear regression analyses indicated that each additional degree of dorsal angulation increased the change of recommending a reduction by 3% (beta 0.03, 95% ci 0.02-0.03 p \ 0.001). criteria for reduction did not increase interobserver reliability for recommending reduction (no criteria kappa 0.43 95% ci 0.26-0.59 vs. criteria 0.47 95% ci 0.33-0.61). the likelihood of recommending a reduction was higher in the group using the criteria (0.61 vs 0.68, p = 0.009). conclusions: poor interobserver reliability is associated with greater practice variation. dorsal angulation is the main drive for recommending a reduction. the liberal use of the criteria in combination with a specific focus on dorsal angulation leads in our opinion to less variation in treatment recommendation for distal radius fractures. this is something future study could assess for distal radius fractures in actual practice introduction: the number of pertrochanteric hip fractures increases proportionally to the increase in life expectancy. currently, the most used treatment in these fractures is the antegrade nailing. suffering a second fracture in the same femur around an antegrade nail is an uncommon complication, but it has a great impact on the patient. the aim of this study is to describe the type of perinail femoral fractures observed in our center, the treatment performed and the medium-term results. material and methods: between 2013 and 2018, 14 patients presented a perinail femoral fracture. 13 were women and one was male, with an average age of 83. initial fractures were classified according to the ao classification: 6 were 31a1, 5 were 31a2 and 3 were 31a3. 8 of them were synthesized by short pfn-a (synthes), 3 with short pfn (synthes) and 3 with gamma3 (stryker). the average time since osteosynthesis of the proximal femur fracture and the perinail fracture was 3.5 years (1 month-12 years). results: 11 of the peri-implant fractures occurred at the level of the nail tip or the distal locking screw. the remaining 3 fractures occurred in the distal femur. these 3 supracondylar fractures and 2 of the fractures at the level of the nail tip were synthesized with a va condylar plate (synthes), overlapped with the nail. in the rest of the fractures around the tip of the nail, the short nail was removed and replaced by a long pfn-a nail. one of the patients died in the immediate postoperative period. two patients died during the first year. in the rest of the patients, a complete consolidation of the fracture was observed, and their previous baseline situation was recovered. conclusions: peri-implant femur fracture is a rare but very severe condition, which requires good surgical planning, and is not without complications. gamagori city hospital, department of orthopedics, gamagori, japan, 3 nagoya daini redcross hospital, department of orthopedics, nagoya, japan introduction: hip fracture is a leading worldwide health problem for the elderly. a missed diagnosis of hip fracture on radiography leads to a dismal prognosis. the application of a computer-aided diagnosis (cad) system using artificial intelligence (ai) to detect hip fracture can potentially improve the accuracy and efficiency of hip fracture diagnosis. material and methods: cad system using ai was trained using 4851 cases, 5242 plain frontal pelvic radiographs (pxrs) between 2009 and 2019 from each institution. the accuracy, sensitivity, falsenegative rate, and area under the receiver operating characteristic curve (auc) were evaluated on 500 independent pxrs. the authors mixed resnext as classification algorithm and ssd as object detection algorithm to train cad system. results: the algorithm achieved an accuracy of 94.1%, a sensitivity of 96.2%, a false-negative rate of 1%, and an auc of 0.94 for identifying hip fractures. the visualization algorithm showed an accuracy of 97.9% for lesion identification. conclusions: our cad system using ai not only detected hip fractures on pxrs with a low false-negative rate but also had high accuracy for localizing fracture lesions. the cad system using ai might be an efficient and economical model to help clinicians make a diagnosis without interrupting the current clinical pathway. medical faculty university of nis, orthopaedic surgery, nis, serbia, 2 clinical center nis, orthopaedic and traumatology clinic, nis, serbia, 3 orthopaedic word of medical center, cuprija, serbia introduction: bone reconstruction and limb lengthening usually refers to application of ilizarov or other ring external fixation devi-ces1. we present here series of posttraumatic reconstruction and limb lengthening, by the use of new concept of 3d unilateral external fixation device. material and methods: as a clinical material, we present series of 59 patients with different posttraumatic deformities (28) and limbs discrepancy (31) as a result of severe traffic accidents and wars. all patients have been treated by specially designed unilateral 3d external fixation system. that system is not bulky and it is more comfortable in comparison to ring fixators. procedure is relatively simple, so patients handle the device by themselves. during biomechanical testing, it was found that stability of this device is similar to ring systems. the last version of the device includes computer program and two sensors. results: all deformity corrections have been achieved successfully. sliding graft procedure has successfully been performed in all 9 patients with bone defect reconstruction from 5 to 11 cm. in one patient with complex deformity and shortening, correction couldn''t be achieved during one procedure, so additional operations, by the use of the same system have been performed and correction completed. superficial pin tract infection rate was 11.1% and we didn''t have deep infection. there were no other complications including dvt, joint stiffness, neurovascular injuries. conclusion: unilateral external fixation device with balanced 3d stability provides the same success of bone reconstruction and limb lengthening as ring fixators, but it is more comfortable and more easy for handling. references: treatment principles in bone reconstruction and limb lengthening of the lower extremity. olesen uk, nygaard t, kold sv, hede a. ugeskr laeger. 2017 nov 20; 179(47) at this moment author has licence agreement with the producer of external fixation devices. all patients were classified into the isolated hip fracture and the concomitant fracture. we analyzed these patients'' characteristics such as age, gender, bone mineral density (bmd), body mass index (bmi), korean version of mini-mental state examination (mmse-k), injury mechanism, and length of hospital stay. results: the most common site of upper extremity fracture was distal radius fracture of 15 patients (42.8%), followed by proximal humeral fracture of 8 (22.8%). concomitant fractures occurred on the same side in 30 patients (85.7%). the mean age of patients with a concomitant fracture was younger than that of patients with an isolated hip fracture (p \ 0.05). mean preinjury mmse-k was 22.7 in isolated hip fracture and 25.6 in concomitant fracture patients (p \ 0.05). mean length of hospital stay was statistically significant different between two groups (p \ 0.05). according to fracture site of hip, there was no statistically different prevalence of upper extremity fracture in femoral intertrochanteric fracture compared to the neck fracture. conclusions: we found a 3.4% prevalence of concomitant hip and upper extremity fractures. it was found that the younger the age with preserved cognitive ability in elderly patients with a hip fracture, the higher the prevalence of upper extremity fracture. in addition, it is important to keep in mind that patients with a concomitant fracture have a longer hospital stay and difficulty in rehabilitation. on the other hand, the amount of bleeding was 658 ml in group e and 792 ml in group l, and there was no significant difference between the two groups. poor cases on postoperative images were 30% in group e and 11% in group l, and the joa hip score was 68.4 (groupe) and 91.2(group l). in clinical results is significantly improved in group l. conclusions: the treatment results improved significantly in group l. as the number of experienced cases increased from these results, the reduction accuracy and treatment results improved, so experience was considered important for improving the treatment results of acetabular fractures. the additional value of the weight-bearing and gravity stress radiograph in determining stability of isolated type b ankle fractures introduction: the goal of the current study is to investigate whether the weight-bearing and gravity stress radiographs have additional value in determining stability in isolated type b fibular fractures. this in order to make the important distinction between fractures that need surgical treatment and fractures that can be safely treated conservatively. material and methods: 90 patients with an isolated type b ankle fracture, without medial or posterior fracture, and a medial clear space (mcs) \ 6 mm on the regular mortise radiograph were included. in the emergency room, a gravity radiograph was performed (in accordance with out protocol). within 1 week, an additional mri scan was made. at this moment, in 51 patients a weight-bearing radiograph was performed too. the mcs measurements of these regular mortise, gravity and weight-bearing radiograph were compared with the mri findings. the mri scan was set as reference standard to detect injury of the deltoid ligament in order to determine (in)stability. results: mean mcs on mortise radiograph was 3.3 mm (range 1.7-5.9); in 12 (13.3%) patients the mcs was [ 4 mm and in 15 patients (18.3%) the superior clear space (scs) was [ mcs ? 1 mm. in 2 (2.4%) patients, the scs [ mcs ? 2 mm. on the gravity stress radiograph, 14.4% of the patients had a mcs [ 6 mm. the weight-bearing radiograph showed a mcs [ 4 mm in 3 (5.9%) patients. in 4 (4.4%) patients, the mri showed a complete rupture of the deltoid ligament. in 21 (23.3%) patients a partial rupture was seen. 10 patients (11.1%) received surgical treatment. in all conservatively treated patients, no secondary dislocation occurred and there was no need for postponed surgical treatment. conclusions: the gravity stress view has a tendency to overestimate the mcs. thus, potentially too many stable fractures are incorrectly diagnosed instable and receive unnecessarily surgical treatment (with additional costs and risks). the weight-bearing radiograph, on the contrary, does not overrate the medial injury and can safely be used in the decision making process of treating conservatively and weightbearing (for example by using a brace) introduction: the purpose of this study was to identify the effect of the intravenous iron supplementation on demand of perioperative blood transfusion and post-operative hemoglobin recovery in geriatric hip fractures. material and methods: a retrospective cohort study was performed on patients who underwent surgery with proximal femoral nail for hip fracture and age 60 years old or older between jan 2018 and may 2019 in a single center. the participants were divided into 2 groups according to preoperative intravenous iron supplementation (iron isomaltoside, monofer ò , pharmacosmos, holbaek, denmark); group 1 (n = 25) with monofer 400 mg before surgery and group 2 (n = 33) without monofer. transfusion was preformed when the hgb was less than 8 mg/dl). primary endpoint was incidence of perioperative transfusion. secondary endpoints were various hemoglobin (hgb) levels. results: the average age of the participants were 77.4 years old, and average body mass index (bmi) was 22.8. demographic data including age, sex, bmi, comorbidity (charlson comorbidity index) of each group showed no difference. the complications from intravenous iron administration were not occurred. the preoperative hgb was 11.4 mg/dl (group 1 11.9 ± 2.1 vs, group 2 10.9 ± 1.9, p = 0.591). the hgb at the postoperative day 2 was 10.2 mg/dl (group 1 10.5 ± 2.1 vs group 2 9.9 ± 1.8, p = 0.273). the average hgb at the postoperative 1 month was 11.6 mg/dl (group 1 11.7 ± 1.7 vs group 2 11.5 ± 1.5, p = 0.431). transfusion rate was 51.7% (30/58) and the rate showed no difference between 2 groups (40.0% vs 60.6%, p = 0.120. the recovery of hgb between postoperative 1 month and preoperative state showed statistically difference (group 1 0.166 vs group 2 -.0579, p = 0.049), and iron supplementation group had more recovery. conclusions: intravenous iron supplement before the hip fracture surgery in elderly helped to recover hgb at postoperative 1 month. comminuted subtrochanteric femur fractures-our experiences introduction: subtrochanteric femoral fractures account for approximately 25% of all the hip fractures and their treatment represents a challenge because of the short proximal fragment and highenergy forces. material and methods: a total of 17 patients with subtrochanteric, highly comminuted fractures, were included in this study, with age range from 30 to 60 years. the mechanism of injury in all patients was high-energy trauma. in each case we applied a long gamma nail (limma lto) without focus opening. results: in all patients, good clinical and radiologic results were accomplished, in addition to early weight-bearing, without shortening of the legs, or consequences on the state of the hip and morbidity in general. conclusions: although the comminuted subtrochanteric femur fractures represent a challenge for the orthopedic surgeons, osteosynthesis using long gamma nail without the focus opening provides outstanding results. introduction: this study analyzed the association between the postoperative reduced position obtained on using short femoral nails (sfns) and the amount of sliding after fixation in unstable trochanteric fractures. material and methods: this retrospective study included 12 patients with unstable trochanteric fractures with posterolateral support deficiency who underwent osteosynthesis with sfns and were followedup for 3 months or longer. the study included 6 men and 6 women with a mean age of 76.3 years at the time of fracture. closed or open reduction was performed to achieve anatomical to medial type position on frontal view and anatomical to extramedullary type position on lateral view, followed by fixation with sfns. immediately and extramedullary type in 4 patients immediately after surgery. three months after surgery, the reduced position worsened from the anatomical to intramedullary type in 2 patients. according to the reduced positions at 3 months after surgery, the mean amount of sliding was 8.7 mm in patients with intramedullary type, 3.3 mm in those with anatomical type, and 3.7 mm in those with extramedullary type. the amount was larger in those with intramedullary type than in those with anatomical and extramedullary types. moreover, excessive sliding was observed in 1 patient with intramedullary type. conclusions:to prevent excessive sliding by ensuring anteromedial bony support in unstable trochanteric fractures with posterolateral support deficiency, open reduction should be aggressively performed to overcorrect to the extramedullary type when reduction performed on a traction table results in either anatomical or intramedullary type positioning. in this paper, we report 31 patient previously studied for osteomyelitis caused by high-energy missile trauma, in 1996. that study involved a total of 120 patients with osteomyelits, divided into two groups, according to the treatment protocol applied. the group 1 included patients treated using classic surgical methods, including debridement, curretage, forage, perfusion drainage and sequestration. the group 2 included patients treated using recommended surgical methods and used pmma antibiotic beads. 25 years after, we tried to contact all of the 120 patients, for the purpose of follow-up. however, only 31 patient was available for analysis. among 31 patients we followed-up, 11 were treated using recommended surgical protocol, while the remaining 20 patients were treated using classic surgical methods. we present the patients' general status, as well as the local surgical status and radiographic analysis, 25 years after. we obtained long-term results of both treatment protocols applied. from the group 1, 9 patients developed chronic recurrent osteomyelitis, while only one patient from the group 2 developed such condition. introduction: the aim of this study was to evaluate the treatment results using anterior subcutaneous internal fixation(infix) for the pelvic fractures and to consider an improvement strategy for the complications. material and methods: from 2013 to 2019, 31 pelvic fractures were enrolled. there were two males and 29 females. the average age was 80 years. there were 26 fragility fractures and five high energy fractures. our operative procedure was as below: the connection between screws and rod was just above the fascia of the sartorius muscle. the connection bar was pre-bended before the operation using the initial axial ct scan. we assessed bone union, additional fixation, the distance between the femoral artery and connection rod (dar), the distance of protruded bar lateral to the connection (dpb), and complications. results: bone union achieved in 27 out of 31 cases. there was one nonunion and three early deaths because of medical complications. seventeen out of 31 cases required additional posterior fixations. the average dar was 17.1 (3.2-49.2 mm) , and the dpb was 10.1 (0-24) mm. thirteen out of 31 cases (41.9%) had complications. there were seven lateral femoral cutaneous nerve (lfcn) symptoms (3 required implant removal (ir)), two infections (1 required ir), one hematoma (ir), one irritation (ir), one heterotopic ossification, one loosening (re-operation). there were no femoral vessels and nerve-related symptoms. to release lfcn and surrounding soft tissues decreased the nerve symptoms. conclusions: to connect the screws, and the rod just above the sartorius fascia could avoid major vessels and nerve complications, and also irritations. although this study found a high complication rate of infix, to release the lfcn and around soft tissue could decrease the complications. introduction: several studies have reported that posterior or anterior tilt increases the risk of reoperation in undisplaced femoral neck fractures (garden i/ii) after internal fixation performed using nonangular stable devices such as pins and multiple screws. however, to the best of our knowledge, there is limited research involving angular stable devices. the present study aimed to investigate the clinical outcomes in undisplaced femoral neck fractures after internal fixation using angular stable devices. material and methods: this retrospective study included 35 patients (mean age, 79.2 [range, 65-95] years) who underwent internal fixation using angular stable devices between january 2011 and january 2019. undisplaced femoral neck fractures with garden alignment index (gai) b 170°(posterior tilt angle c 10°) or gai b 190°( anterior tilt angle c 10°) were included (posterior: 34, anterior: 1) in this study. patients were followed up for at least 3 months (mean, 16.3 months). we analyzed the preoperative and last-followed gai on lateral radiographs, non-union, and late segmental collapse (lsc). results: among the 35 patients, non-union was identified in 2 (5.7%) and lsc was observed in 4 (11.4%). the mean preoperative gai was 159.8°(range, 125°-203°), and the mean last-followed gai was 164.5°(158°-182°). the overall complication (non-union and lsc) rate was 17.1% (6/35 patients). among 16 patients with gai c 20°, lsc occurred in 3 (18.8%). conclusions: in undisplaced femoral neck fractures, preoperative posterior c 10°is a risk factor for postoperative complications even when internal fixation is performed using angular stable devices; thus, primary arthroplasty may be considered. case history: the patient is a 77-year-old female who had undergone lumpectomy at the age of 53 when she was diagnosed with breast cancer. she had antiresorptive drug therapy for bone metastasis, since 10 years after the lumpectomy. she fell down from standing height and was diagnosed as right femoral subtrochanteric fracture. her femur was fixed with short femoral nail. she complained left hip pain at age 77.she complained left hip pain from july 2018. clinical findings: she could walk with crutch.rom of left hip was normal. investigation/results: breast surgeon took mri and there was metastasis in the proximal part of femur. he thought the cause of pain was this metastasis. however, there was fracture line at the height of lesser trochanter when she visited our department. diagnosis: atypical fracture was strongly suspected, however, fracture line was little higher as normal atypical fracture. therapy and progressions: osteosynthesis with long femoral nail was performed 4 months after first visit to our department because of increasing pain. pathological findings were metastasis and fracture. after surgery, radiation to femur was performed. she can walk without pain by crutch and fracture line is almost disappeared on 11 months after surgery. comments: atypical femoral fractures (affs) are recently observed as a complication of antiresorptive drugs for bone metastasis. however, there were metastasis and atypical fracture in this case. introduction: in the present study we aim to evaluate the articular surface reduction quality by means of postoperative computer tomography (ct), in complex tibial plateau fractures, treated with an illizarov frame. materials and methods: this retrospective case series covers the period from 03-2010 to 10-2018. forty-four patients with a mean age of 39 years (range 19-65 years), with a complex intrarticular proximal tibia fracture were included. fracture types iii to vi according to schatzker's classification were included. the majority were closed injuries, apart from 2 cases (a gustilo anderson type 3a and a type 2). all patients were placed on a fracture table. a mini-open reduction of the articular surface was followed by application of a knee spanning illizarov frame. post-operatively all patients were subject to ct of the injured knee. outcomes were measured using the american knee society score. results: mean outpatient follow up was of at least 12 months (range of 12-21 months). mean time for fracture consolidation 15.5 weeks (ranging from 13 to 19 weeks). according to the degree of postoperative articular surface depression patients were grouped as follows: 8 had under 2 mm, 19 had 2-4 mm and 17 over 4 mm of depression. those with less than 3.5 mm of collapse had 95% chances of an excellent result according to akss. on the contrary, those with more than 4.5 mm of articular surface collapse had 100% chances for low scores and functional results. the achievement of a mechanical axis within 5°of the contralateral limb was positively correlated with good functional results but did not have a correlation with the akss. conclusions: complex tibial plateau fractures may be treated successfully with mini open reduction and the application of an illizarov frame. post-operative ct denotes the exact degree of displacement of the articular surface, which is prognostic regarding outcome. postoperative x-rays may be misleading, since they can underestimate articular surface collapse. introduction: a new trauma center building was constructed in march 2016, and the process from the trauma bay to the operation room is faster. we hypothesized that this process improved the survival rate of trauma patients in need of trauma laparotomy. material and methods: the new trauma center separates the trauma bay from the emergency room, and the trauma team exam patients initially. it also has a separate operation room that is always available for emergency surgery. therefore, the decision to perform laparotomy and time to operation has been shortened. from january 2011 to december 2018, trauma patients who underwent emergency laparotomy were included. those younger than 18 years, who had delayed operation, underwent surgical observation, delayed admission by patient, or underwent angiography first were excluded. patients were dichotomized to the before-trauma-center (bc) and after-traumacenter (ac) groups, and their characteristics and clinical outcomes were compared. results: of 644 patients, 349 were included in the bc group and 295 were included in the ac group. the times from admission to operation introduction: acute care is a growing worldwide burden with increasing visits to the emergency department (ed). the acute care system in the netherlands is almost overloaded and costs are increasing. almost 50% of ed visits have surgical disease. there is no nationwide acute care surgery (acs) model implemented yet, and resources and infrastructure are organized differently in almost every hospital. this study provides an overview of the existing systems nationwide, and basis for a national uniform model. material and methods: an online survey was distributed through the dutch surgical society and sent to all dutch hospitals. after sending a reminder, the survey was closed and results were analyzed. results: thirty-two hospitals (41%) participated in the survey. in 78% a surgeon (trauma, vascular or gastro-intestinal) was assigned as consultant and responsible for ed admissions, emergencies in-house, and in some cases also emergency surgeries. 59% of hospitals have an ed observation unit (edou). a dedicated emergency surgery operating room (esor) is available in 69% (24/7 available in 73%), and used efficiently in 55% primarily due to the following challenges: elective surgery scheduled at esor (59%), necessary stop of esor when elective programs are delayed (64%). in hospitals without an esor, the emergency surgeries are scheduled in between elective surgeries resulting in extending programs into the evening. finally, 90% of respondents was familiar with acs, with 62% being positive about exploring options of implementing such a model in our country, and 77% of the respondents opts for more focus on acs in surgical residency. conclusions: in the netherlands the organization of acute care varies. the main common bottleneck is the logistics around the or. implementation of a dedicated esor and unconditional availability 24/7 of this or seem to be the most important factors for optimal efficiency. although there needs to be more focus on acs in general, implementing a uniform model nationwide seems challenging at this moment. trauma team activations (tta) at an european trauma center: 1029 cases analyzed s. saar 1,2 , e. lipping 1 , h. vospert 1 , r. volmer 2 , h. k. laas 2 , j. lepp 1 , k. g. isand 1 , p. talving 2,3 1 north estonia medical centre, division of acute care surgery, tallinn, estonia, 2 university of tartu, tartu, estonia, 3 north estonia medical centre, tallinn, estonia introduction: the north estonia medical centre (nemc) is the largest trauma center in estonia with evolving capabilities. however, studies scrutinizing trauma team activations (tta) are currently lacking. thus, we initiated an investigation to document tta profile and outcomes. material and methods: all tta patients admitted to the nemc between 1/2016 and 12/2018 were retrospectively identified. data collected included demographics, injury severity score (iss), management, hospital length of stay (hlos), and in-hospital outcomes. primary outcome was 30-day mortality. results: overall, 1029 patients were included. mean age was 39.3 ± 20.4 years and 74.2% were male. penetrating and blunt trauma accounted for 11.5% and 88.5% of the cases, respectively. non-ground level falls were the predominant mechanism of injury constituting 32.1% of the admissions. mean iss was 10.3 ± 11.5 and 24.7% of the patients were severely injured (iss [ 15). blood alcohol level (bal) was positive at 31.1%. a total of 21.1% of the patients had an emergent operation. mean hlos was 8.0 ± 15.2 days.overall 30-day mortality and mortality of severely injured patients was 5.1% and 19.3%, respectively. conclusions: the current investigation documents comparable outcomes with established european trauma facilities [1, 2] . blunt injury patterns predominate, however, high penetrating trauma incidence for european settings was noted. high rate of positive bal in tta patients warrants national preventive measures. introduction: the acute care surgery (acs) model was initially developed as a dedicated service for the provision of high quality 24/7 non-trauma emergency surgical care. after implementation in the united states (us), the model has been adopted in several variations around the world.in this systemic review we investigated which components are essential for a potential uniform acs model, by giving an overview of the current available acs models worldwide and their state of implementation. material and methods: a literature search (2000-2018) was conducted using pubmed, medline, embase, cochrane library and web of science databases following the prisma guidelines. all relevant data of acs models were extracted from included articles. results: sixty-five articles describing acs models in 12 different countries were included in this review. the majority consist of a dedicated surgical service, providing non-trauma emergency surgical coverage, with daytime on-site attending coverage by an attending surgeon who is cleared from elective duties, and 24/7 in-house resident coverage. emergency department coverage and access to an acute care operating room varied widely across countries. critical care is fully embedded in the original us model as part of the acute care chain (acc), while in most other countries it is still a separate unit. while in most european countries acs is not a recognised specialty yet, there is a tendency towards more structured acute care, with training and separation from elective practice. conclusions: acs is gradually implemented worldwide. however, large national and international heterogeneity exists in the structure and components of the model. critical care is still a separate unit and specialty in most systems while it is essential to be part of the acc in order to provide the best peri-operative care of the physiologically deranged patient. universal acceptance of one global acs model seems challenging, however a global consensus on essential components would benefit any healthcare system. introduction: the recent financial crisis in greece is coped mainly with reformations towards cost effectiveness and rationality in the management of public expenses. the goal of the study is to evaluate the cost and time effectiveness in the management of the surgical patients admitted in emergency department (ed). methods: for a period of 8 h/day in 8 consecutive days, surgical cases presented in the ed of a tertiary university hospital of athens were followed. inclusion criteria were need for laboratory tests or imaging examinations or an immediate resuscitative intervention. data recorded regarding demographics, vitals, critical time points, disease and management. physician related data and cost of examinations were also collected. case severity was calculated by early warning score [1] . results: she average waiting time for each patient was 51 min and the average total time until final decision was 3:02 h. blood tests costs reached an average of 17,59€ per case and imaging an average of 77,88€. the striking finding was that only one out of 60 patients was of medium clinical risk, while all the others were of low. thus, substantial symptoms and clinical findings were lacking and as the ''tertiary care'' character of the hospital was mandating conclusive diagnosis, exams were ordered. this approach absorbs time and funds putting at risk the very few severe cases which are the target population for the magnitude of the facility. the current study indicates that the use of a tertiary hospital as a primary health care center by the public, is disorganizing the system, and increase the cost in time, funds, and preventable morbidity and mortality. a pre-hospital triage and management of the low severity cases system is pending to be established in our environment and becomes top priority in an era of prolonged financial crash. for years, surgical emergencies in ecuador have been managed without significant standardization. scarce numbers of specialists, lack of a constant presence of full-time teaching faculty versed in emergency surgery and lack of continuity with surgical trainees led to variability in clinical and surgical decision-making. to address these issues, the regional hospital vicente corral moscoso (hvcm) adapted and implemented a model of ''trauma and acute care surgery'' (tacs) to the reality of cuenca, ecuador. a cohort study was carried out, comparing trauma and acute care surgery patients exposed to the ''traditional care model'' before the implementation of the tacs model. variables assessed included: surgical wait times, number of hospital visits, number of surgical interventions, number of surgeries performed per surgeon and inhospital mortality. higher mortality was found in the traditional care model (rr of 1.29, p b 0.05) compared to the tacs model. we observed a statistically significant decrease in surgical wait time (10.6-3.2 h for emergency general surgery, 6.3-1.6 h for trauma, p b 0.05). lengthof-stay decreased in trauma patients (9-6 days p b 0.05). the total number of surgical interventions increased (3,919.6-57,445.8, p b 0.05) ; by extension, the total number of surgeries performed per surgeon also increased (5.37-223.68, p b 0.05) . the implementation of tacs model in a typical resource-restrained, tertiary care hospital in latin america had a positive impact by decreasing surgical waiting time in trauma and emergency surgery patients, and length-of-stay in trauma patients. we also noted a statistically significant decrease in mortality. while cost could not be objectively evaluated with the available data, savings to the overall system and patients can be inferred by decreased mortality, length-ofstay and surgical wait times. to our knowledge, this is the first implementation of an tacs model that has been described in latin america. introduction: traumatic injuries constitute one of our major public health challenges. the most effective means to reduce the impact trauma has on individuals and society is primary injury prevention, reducing the incidence of traumatic events, which relies on detailed knowledge of risk factors. the aim of this study is to facilitate targeted injury prevention through improved data collection and analysis on impairing substances as risk factors for traumatic injuries. material and methods: idart is a national prospective observational study including analyses of the toxicological profile of all patients c 16 year of age admitted via trauma team activation to any norwegian trauma hospital (n38) during a 12 month study period. residual blood from routinely drawn blood samples at trauma admission is analyzed for alcohol, illegal and psychoactive drugs. toxicological data will be linked to clinical data from the national trauma registry. results: the study period started march 1st, 2019, and during the first 6 months 2689 patients were included from 34 trauma hospitals. more than 30% of the included patients tested positive for psychoactive substances according to preliminary data. data on the prevalence of different psychoactive substances disaggregated by mechanism of injury, demography and geography from the 12 month study period will be presented. conclusions: the idart study will provide a detailed descriptive analysis on the prevalence of alcohol, illicit and medicinal drug use among all patients admitted to a norwegian hospital with suspected severe injury. subgroup analyses will include prevalence of alcohol and other substances in subgroups analyses on patient and injury characteristics and geographical variations. analyses will aim to identify high risk groups according age, gender, circumstances of the injury, geographical location and type of psychoactive substance. the dutch nationwide trauma registry: the value of capturing all acute trauma admissions m. driessen 1 , l. sturms 1 , l. leenen 1 1 lnaz/umcu, trauma surgery, nijmegen, netherlands introduction: twenty years ago the dutch government decided to reform the trauma care system and designated 11 level 1 regional trauma centers (rtcs). these centers, in collaboration with ambulance services and regional hospitals, have managed to set up regionalized inclusive trauma systems. moreover, they set up the dutch national trauma registry (dntr) as a quality evaluation and epidemiology resource. in this resource all acute hospital admissions were included, in order to measure the hospital and prehospital processes and outcomes. in the current study we demonstrate its current status and compare it with national trauma registries from the uk and germany. material and methods: the dntr includes all injured patients treated at the ed of 98% of all hospitals in the netherlands within 48 h after the trauma followed by direct admission, transfer to another hospital or death at the ed. a representative descriptive analysis of extracted data from 2018 is demonstrated. results: between 2007 and 2018 a total of 865,460 trauma cases have been registered in the dntr. hospital participation has increased from 64% up to 98%. in 2018 alone, a total of 77.529 patient were included, 50% concerned males, the median age was 64 years. 6% of all admissions had an iss c 16, of which 70% was treated at a rtc. from this cohort, in comparison, only 5% and 32% of the dntr patients met tr-dgu or tarn inclusion criteria. particularly children, elderly and patients admitted at non rtcs are not captured in the tr-dgu or tarn. also, part of iss c 16 and fatal cases do not meet tr-dgu or tarn inclusion criteria. conclusions: the dntr has evolved into a comprehensive wellstructured nationwide population-based trauma register, with an annual number of 80,000 cases being entered in the database the dtr has grown to be one of the largest trauma databases in europe. the registry enables studies on the injury burden and quality and efficiency of the entire trauma care system encompassing all traumareceiving hospitals. introduction: trauma mortality is not distributed evenly. rural areas have higher incidence rates of trauma mortality than urban areas. the rural northern part of the nordic countries have common challenges with sparsely populated areas, long distances, and an arctic climate. the aim of this study was to compare the cause and rate of fatal injuries in the northernmost area of the nordic countries over a fiveyear period. material and methods: in this retrospective cohort we used the cause of death registries and collated all deaths from 2007 to 2011 with an external cause of death (icd-10, v01-y98, except y40-84 and t80-88). the study area was the three northernmost counties in norway, the four northernmost counties in finland and sweden and the whole of iceland. we used 95% confidence intervals (ci 95) to test for differences between the countries. results: there were 4308 deaths in the study area during the 5-year period. low energy (le) trauma constituted 24% and high energy (he) trauma 76% of deaths. northern finland had the highest incidence for both high energy trauma and low energy trauma. iceland had the lowest incidence for high-, and low energy trauma. iceland had the lowest prehospital share of deaths at 74% and the lowest incidence of injuries occurring in a rural location. the incidence rates for he trauma death was 36,1/100.000/year in northern finland, 15,6/100.000/year in iceland, 27,0/100.000/year in northern norway and 23,0/100.000/year in northern sweden. conclusions: there were significant and unexpected differences in the epidemiology of trauma death between the countries. the differences suggest that a comparison of the trauma care systems and preventive strategies in the countries is required. the diurnal and seasonal relationships of pedestrian injuries secondary to motor vehicles in young people introduction: there remains a significant morbidity and mortality in young pedestrians that are hit by motor vehicles, even in the era of pedestrian crossings and speed limits. the aim of this study was to compare incidence and injury severity of motor vehicle-related pedestrian trauma according to time of day and season in a young population. we hypothesised that injuries in young people would be more prevalent during dusk and dawn and during autumn and winter. material and methods: data was reviewed from patients in the 10-25 year old age group in the trauma audit and research network (tarn) national database, who had been involved as a pedestrian in a motor vehicle accident between 2015 and 2018. the incidence of injuries, their severity (using the injury severity score [iss]), hospital transfer time and mortality were analysed according to the hours of daylight, darkness and seasons. results: 64.5% of injuries occurred during time of darkness post sunset, while 35.5% occurred during daylight. the incidence of injuries in motor vehicle accidents, in absolute terms, was highest during 1630-2400, with a second peak at 1500-1630. the greatest injury rate (number of injuries/hour) occurred during 0730-0900 and 1500-1630 with respective rates of 5.3 and 8. injuries scoring an iss over 15 occurred 21.7% at 1500-16300 and a further 42.9% until 2400. mortality was greatest during 1500-1630 involving 4 out of the total 7 deaths. autumn was the predominant season and lead to 40.3% of injuries, with a further 22.6% in winter. this demonstrated a clear difference to 19.4% and 17.7% in spring and summer. conclusions: we have identified a relationship between reduced daylight and the frequency and severity of pedestrian trauma in young people suggesting that reduced visibility may play a significant role which could be addressed through a targeted public health approach to implement change. enhancing cost effectiveness in a system in crisis: a 7,581 patient study a. tsolakidis 1 , c. christou 1 , p. smyrnis 1 , a. prionas 1 , a. tooulias 1 , g. tsoulfas 1 , v. n. papadopoulos 1 1 aristotle university of thessaloniki, 1st department of surgery, papageorgiou general hospital, thessaloniki, thessaloniki, greece introduction: to date, there is no national trauma database in greece. the goal of our study is to record and evaluate trauma management at our university hospital as well as to measure the associated healthcare cost, while laying out the foundations for a national database. material and methods: retrospective study of trauma patients (n = 7,581) between 2014 and 2019. demographic information, injury patterns and severity, outcomes and cost were recorded. results: the proportion of patients that were transferred to the hospital by the national emergency medical services was 28,6%, whereas 3873 (51%) of our trauma patients did not meet the us trauma field triage algorithm criteria. over-triage of trauma patients to our facility ranged from 90.7 to 96.7%, depending on the criteria used. 299 (3.9%) of our patients received operative management and 22% (65) of them had postoperative complications. an iss [ 15 was seen in 228(3%) of our patients and their mortality was 19,3%. the overall non-salary cost for trauma management was 3.118.625 euros. the cost resulting from the observed over-triage ranged from 419.501 to 1.742.748 euros. furthermore 1108 (14.6%) of our patients underwent at least one ct scan that did not show any significant traumatic lesion. the cost of hospitalization of these patients was 592.508 euros. conclusions: the prehospital triage of trauma patients in the greek national health system is ineffective, with significant over triaging, leading to excessive costs. appropriate use of criteria for diagnostic procedures and algorithms may lead to a, much-needed, reduction of these costs. introduction: in japan, there are 290 emergency and critical care centers nationwide (one center for approximately every 500,000 people), and a system is in place to accept local critically ill patients 24 h a day, irrespective of whether their conditions are intrinsic or extrinsic. however, manpower and medical care systems differ depending on the emergency and critical care center, and the establishment of a system for consolidating severe trauma patients has been particularly problematic. material and methods: this study examined 518 cases where the patient had some sign of life when encountered by ambulance teams of the 1278 cases of traffic accident deaths that occurred in chiba prefecture between 2009 and 2015. thirteen emergency and critical care center representatives in chiba prefecture met to verify each case based on data from the police, fire department, and medical institutions. the cases were classified into (1) preventable trauma death (ptd) cases, (2) suspected ptd cases, and (3) non-life-saving cases; the problems (causes of ptd) in each case were examined. result: there were 115 cases (22%) of ptd and suspected ptd. sixty-eight of these cases were transported to emergency and critical care centers. the most common cause of death was bleeding, accounting for 78 cases and the locations where the problems that caused ptd occurred were outside of the hospital (n = 11) and in the hospital (n = 67). the problems that occurred in the hospital (including duplications) include circulatory management (n = 42, 54%), the treatment plan (n = 32, 41%), delay of lifesaving surgery (n = 28, 36%), and delay of diagnosis (n = 20, 26%). most of these occurred in the initial emergency care room. conclusion: this study clarified that ptd still occurs in relation to bleeding control in the current trauma care system in chiba prefecture. it is vital to establish a national ''trauma center'' and to thoroughly consolidate trauma cases to eradicate ptd. analysis of the impact of the implementation of a trauma team in a trauma center from an upper-middle-income country introduction: trauma teams (tt) improve the care process and the outcomes. a multidisciplinary tt was conformed in september 2015 to achieve a rapid response by specialists in emergency medicine, trauma surgery, diagnostic imaging services, and blood bank in a level i trauma university hospital in southwestern colombia. objective: to evaluate the impact of a tt implementation in terms of times of attention and mortality. material and methods: retrospective study. all the patients with the highest level of tt activation treated in the 15 months after the tt implementation were included. the subjects triaged to the trauma center in the 15 months pre tt were taken as controls. four hundred sixty-four patients were included, 220 before the implementation of the tt (btt) and 244 after (att). demographic data, trauma characteristics, times to tomography, and trauma surgery and mortality were recorded. the analysis was made on stata 15,1 ò . categorical variables were described as quantities and proportionscontinuous variables as mean and standard deviation or median and interquartile range (iqr). categorical variables were compared by chi2 or fisher's test. continuous variables with student's t or wilcoxon-mann-withney. a multiple logistic regression model was created to evaluate the impact on mortality if being treated att, adjusted by age, trauma severity, and physiologic response on admission. results: the time from admission to the ct scan was 56 min (iqr 39-100) in the btt group and 40 min (iqr 24-76) in the att group, p &lt; 0.001. the time to trauma surgery was 116 min (iqr 63-214) in the btt group and 52 min iqr 24-76) in the att group, p &lt; 0.001. mortality in the btt group was 18.1% and 13.1% in the att group. adjusted or was 0.406 (0.215-0.789) p = 0.006 conclusions: the implementation of a multidisciplinary trauma team associated with a reduction of the times to tomography and surgery and with a decrease in mortality risk. no prediction of an unfavourable outcome after surgical treatment of chronic subdural hematoma patients using machine-learning l. riemann 1 , a. younsi 1 , c. habel 1 , j. fischer 1 , a. unterberg 1 , k. zweckberger 1 1 university hospital heidelberg, neurosurgery, heidelberg, germany introduction: chronic subdural hematomas (csdh) are expected to become the most frequent neurosurgical disease by the year 2030.1 although often perceived as a ''benign'' condition, considerable rates of mortality and poor outcome have been reported. we therefore evaluated factors associated with an unfavorable outcome after surgical treatment of csdh patients by developing a predictive model using machine-learning. material and methods: consecutive patients treated for csdh with surgical evacuation between 2006 and 2018 at a single institution were retrospectively analyzed. potential demographical, clinical, imaging and laboratory predictors were assessed and a decision-tree predicting unfavorable outcome (gos 1-3) was subsequently developed using the classification and regression tree (cart) algorithm. out-of-sample model performance was evaluated using repeated cross-validation (fivefold with 200 repetitions). results: 755 eligible patients were analyzed. median age was 75 (iqr 68-81) years and 69% were males. mortality rate was 1.6% and rate of unfavorable outcome was 14.3%. the developed decision-tree to predict unfavorable outcome had 5 splits and included the following 4 clinical variables (in descending order of calculated importance): gcs, comorbidities, hb, and age. after cross-validation, the following model performance metrics were obtained: a model accuracy of 0.88 (0.85-0.90), sensitivity of 0.35 (0.19-0.51), and specificity of 0.96 (0.94-0.99). conclusions: gcs, comorbidities, hb, and age were identified as the most important clinical predictors for an unfavorable outcome in csdh patients after surgery. the developed model was simple and still displayed a high accuracy and very high specificity, the sensitivity was however rather low. our results might help clinicians to better assess the prognosis in patients with csdh. introduction: in most developing countries access to tertiary care neurosurgical setup is uncommon. majority trauma including neurotrauma & medical conditions requiring emergency neurosurgical interventions present to a general surgeon. this study is an attempt to highlight the importance of emergency neurosurgery as a skill amongst general surgeons & also focus on the challenges in managing such cases in austere environments material and methods: this study was a retrospective analysis of progressively collected data of trauma patients with a specific focus on head injuries & emergency neurosurgical interventions for both traumatic & non traumatic indications in a level 2 trauma centre in a semi urban area over a period of 2 years from august 2016 to september 2018 results: a total of 720 patients of trauma were analysed out of which 392 were head injuries. road traffic accidents accounted for nearly 77% of head injuries. atypical trauma especially in rural setup e.g. train collision, animal related causes were also seen. males accounted for majority (m:f = 2.6:1). mean age was 37 yrs. 104 patients had imaging findings suggestive of severe head injury. acute sdh was the commonest post traumatic finding and mca territory infarct in non traumatic group. 22 patients underwent emergency neurosurgical intervention with a survival of 61%. factors associated with poor outcome were delayed presentation (p \ 0.05), sdh with diffuse axonal injury. alcohol consumption was a significant factor. conclusions: emergency neurosurgery is an essential skill for general surgeons. performing such cases in a low resource environment in absence of modern day facilities for imaging, icp monitoring & powered equipment presents a significant challenge. general surgeons should be able to perform operative interventions with basic handheld instruments. operative management whenever indicated should be done & helps improve outcomes. head trauma in polytraumatized patient. analysis of risk factors and neurological prognosis b. castro 1,2,3 , m. morote gonzález 1,2,4 , l. cebolla 1,2,4 , a. sada 1,2,4 , l. seisdedos 1, 2, 4, 5, 6 , j. gil 6 , c. rey valcárcel 6,7 , f. j. turégano fuentes 6,7 , c. tristan 1 , c. ruiz moreno 1 1 hgugm, surgery, madrid, spain, 2 hospital, madrid, spain, 3 hospital, madrid, spain, 4 hospitall, madrid, spain, 5 hospital, madrid, spain, 6 hospital, madrid, spain, 7 hospital, madrid, sri lanka introduction: severe trauma is one of the most frequent causes of death and disability and traumatic brain injury (tbi) in polytrauma is the main cause of death and disability in survivors. the aim of this study is to analyze mortality associated to tbi in the last 25 years, prognostic factors associated with it and neurological outcomes in survivors with tbi. methods: retrospective observational study that includes risk factors and functional neurologic evaluation in polytrauma patients attended in gregorio marañon hospital between 1993-2018. inclusion criteria were severe trauma patients (iss c 15) with a tbi and abnormal ct of the head. we analyzed mortality trend in two periods : 1993-2005 and 2005-2018 , and neurological evolution and outcome at discharge with functional scores (ramkin scale and gos) in the second one. results: from 1993 to 2018, 2818 severe trauma patients were admitted, 788 (27,9%) with brain or central nervous system injuries visible on head ct. median age was 37'5; 71.4% were men. the global mortality of the cohort has been 34,1%, 27.6% of them for neurological causes. ischemic heart disease, anticoagulation, abnormal pupils or eye opening, the need for surgery, shock, gos, iss, niss, cranial ais are significant associated with higher mortality (p \ 0,05).the mortality rate due to neurological causes decreases in the second period from 19,5 to 14,8%, this descent being statistically significant (p = 0,017). between 2005 and 2018 27,9% patients died from cnsi, and 4,2% of tbi survivors had a vegetative status at discharge, 16,7% had major disability, and 33,9% had a good neurological recovery. conclusions: mortality due to tbi decreased in the last 12 years, but this improvement after tbi was at the expense of a high rate of vegetative status and great disability, showing the need for continuous research in this area. introduction: severe traumatic brain injury (tbi) constitutes one of the most frequent causes of intensive care unit admissions and is a major cause of death and disability among young people. decompressive craniectomy (dc) is a life-saving measure used to relieve intracranial pressure (icp). this procedure is related with low mortality rates and poor functional outcomes. the aim of this study is to analyze the survival rates and prognostic factors related with functional outcomes after dc for severe tbi. material and methods: retrospective, single center study of 60 patients with severe tbi in whom a dc was performed between the years 2006 and 2016. demographic features, clinical parameters, radiological findings and clinical outcomes were included in the study. for the statistical analysis we used anova, chi-square, kaplan meyer, cox regression and logistic regression. a p value of less than 0.05 was considered to indicate statistical significance. results: the mean initial glasgow coma scale was 5,65 ± 1,69 and the mean initial motor response (imr) was 3,20 ± 1,48. the mean icp after dc was 9,75 ± 3,35. the 30-day survival after dc was 65%. twenty percent of the patients improve ate least 1 point in the glasgow outcome scale (gos) between 6 and 24 months after surgery. twelve patients improve from unfavorable gos to favorable gos. at 24-month follow-up, 30% of the patients has gos [ 3. younger age, high irm a post-operative icp were the factors significantly associated with a higher chance of outcome improvement. conclusions: dc is useful for the management of refractory intracranial hypertension related to severe tbi, and in selected patients is associated with good functional outcomes. introduction: antiplatelets and anticoagulation, commonly referred to as antithrombotic therapy, are frequently used in patients c 65 years. the use of antiplatelets and anticoagulation are associated with increased incidence of intracranial bleeding (1, 2) . there are two research questions addressed in this study: (1) does preinjury antithrombotic therapy affect survival in elderly patients with tbi? (2) are direct oral anticoagulants (doacs) associated with better survival than vitamin k antagonists (vka) in tbi patients on anticoagulation? materials andmethods: retrospective cohort study based on data extracted from the oslo tbi registry. included in the study are tbi patients c 65 years admitted to ouh with cerebral-ct showing signs of acute trauma (hemorrhage, fracture, vascular injury) in the time period 2014-2019. the impact of age, comorbidity, antithrombotic medication and antithrombotic reversal protocol for survival will be explored. results: the patient inclusion is ongoing. preliminary data will be presented at the 21 st ectes in april 2020. the estimated number of tbi patients c 65 years with cerebral-ct showing signs of acute trauma in the study period is * 850. in this patients group, the expected preinjury use of antiplatelet and anticoagulation medication is * 33% and * 23%, respectively. conclusions: the knowledge regarding impact of preinjury antithrombotic therapy on survival in elderly tbi patients is clinically relevant, and may improve patient management in the acute phase of injury. references: introduction: traumatic acute subdural hematoma (asdh), especially the large ones in need of surgical evacuation, is associated with high mortality. contemporary population-based series of surgically treated asdh are sparse. the two main aims of this single-center study from oslo university hospital (ous) were to estimate incidence of surgery for asdh in the population of helse sør-øst, and estimate in-hospital and 1-month survival of these patients. treatment of tbi at ous adheres to the brain trauma foundation guidelines, with icp controlled therapy and evacuation of asdh when gcs \ 14 and hematoma volume c 30 cm 3 or midline shift c 5 mm or hematoma width [ 10 mm. the goals of tbi treatment for adults have been to maintain icp \ 22 mmhg and cerebral perfusion pressure (cpp) c 60 mmhg. methods: from 01.01.2015 all patients with traumatic brain injury (tbi) with positive head ct, admitted to ous, living in helse sør-øst (3.0 million inhabitants) and having a norwegian social security number, have been included in our approved tbi-quality register. included in the present study are all patients with asdh undergoing evacuation of the hematoma within 7 days of trauma. the following data were extracted from the register; demographic variables, date of injury and trauma mechanism, severity of head injury according to hiss grade, rotterdam ct score, surgical procedures, multitrauma, glasgow outcome scale at discharge and date of death. results: 116 asdh patients were operated in the 4-year period 2015-2018, 72% males, mean age was 58 years (10-92), the most frequent trauma mechanism was falls (60%), 29% were under influence of ethanol, 58% had severe tbi and 28% had multitrauma. the incidence of surgically treated asdh in helse sør-øst was 1/100.000/year. in-hospital and 1-month mortality was 9.5% and 15%, respectively. conclusion: the presented data for incidence and mortality will be compared with earlier reports. age-related difference in impacts of coagulopathy in patients with isolated traumatic brain injury: an observational cohort study w. takayama 1 , a. endo 1 , y. otomo 1 1 tokyo medical and dental university hospital of medicine, trauma and acute critical care, tokyo, japan background: age and trauma-induced coagulopathy (tic) have been reported to be the predictors of poor outcome following traumatic brain injury (tbi). whether the impact of brain injury induced coagulopathy on outcomes have age related differently is unknown. objectives: we evaluated the age-related difference in the impact of tic on outcomes in patients with isolated tbi. methods: a retrospective observational study was conducted in two tertiary emergency critical care medical centers in japan from 2013 to 2018. the patients with isolated tbi [head abbreviated injury scale (ais) c 3, and other ais \ 3] were included. we evaluated the impact of coagulopathy (international normalized ratio c 1.2, and/or platelet count \ 120 9 109/l, and/or fibrinogen b 150 mg/dl) on the outcomes [glasgow outcome scale-extended (gos-e) scores, inhospital mortality and ventilation free days (vfd)] in both group using univariate and multivariate models. furthermore, we visualized the impact of coagulopathy on gos-e according to age, by using a generalized additive model. results: of the 1036 patients studied, they were divided based on their age: non-elderly group (n = 501, 16-64 years) and elderly group (n = 535, age c 65 years). although, in the multivariate model, age and coagulopathy were significantly associated with lower gos-e, in-hospital mortality and shorter vfd in the non-elderly group, significant impact of coagulopathy was not observed for all the outcomes in the elderly group. the correlation between coagulopathy and lower gos-e decreased with age after round 70 years old. conclusions: in patients with isolated tbi, impact of coagulopathy on functional and survival outcomes was lower in geriatric patients. no difference in mortality between isolated tbi and polytrauma with tbi: it is all about the brain introduction: despite improvements in trauma and critical care mortality caused by traumatic brain injury (tbi) remains high. [1] as polytrauma is naturally associated with increased mortality, this study compared mortality rates in isolated tbi (itbi) patients and polytrauma patients with tbi admitted to icu. material and methods: a 3-year retrospective cohort study included both consecutive trauma patients with itbi with ais head c 3 (ais of other body regions b 2) and polytrauma patients with ais head c 3 admitted to a level-i trauma center icu. patients \ 15 years of age, injury caused by asphyxiation, drowning, burns and transfers from and to other hospitals were excluded. patient demographics, shock and resuscitation parameters, denver multiple organ failure scores and acute respiratory distress syndrome (ards) data were collected. [2] data is shown as medians with interquartile ranges. p-values \ 0.05 were statistically significant. results: a total of 259 patients were included. the median age was 54 (33-67) years, 177 (68%) patients were male, median iss was 26 (20-33). seventy-nine (31%) of all patients died. polytrauma patients developed more often ards (7% vs 1% p = 0.041) but had similar mods rates (18% vs 10% p = 0.066). polytrauma patients stayed longer on the ventilator (7 vs. 3 days p b 0.001), longer in icu (9 vs. 4 days p b 0.001) and longer in hospital (24 vs. 11 days p b 0.001). there was no distinction in in-hospital mortality of itbi and polytrauma patients (35% vs. 24% p = 0.06). tbi contributed to all deaths in itbi patients and all but three deaths (89%) in polytrauma patients. conclusions: tbi was the main cause of death in both groups. there was no difference in mortality rates between polytrauma patients with tbi and itbi patients, even though polytrauma patients were more severely injured. references: [1] dewan mc et al. estimating the global incidence of traumatic brain injury. j neurosurg. 2018;130(4):1080-97. no significant relationships or conflict of interests. how modeling the brain ventricles could help brain trauma understanding (1). in pathological cases as in hydrocephalus, or in brain trauma, it is likely that each patient's ventricle structure has an impact on the way they behave. for instance, a shock wave may turn out differently according to the ventricle's shape. this can explain why for a same shock, the clinical translation is not the same. the aim of the study is to implement a finite element model of the cranio-cerebral system and to analyse the impact of a trauma simulation. material and methods: this is amonocentricretrospective study from 2018. the database contains 33 ct scans of healthy patients. we used itk-snap software to segment the ventricles and matlab to implement the model. results: the mean volume of the 33 total ventricles is 43 ml (sd = 31). the median is 31 ml (table 1) .to identify the correlation between the parameters acquired we performed a pearson test. we found multiple significant correlations and one of the most relevant one is between the ventricular volume and the width of the third ventricle ( table 2 ). showing that the total ventricular volume is statistically correlated to the width of the third ventricle is clinically interesting. we could potentially simplify our analysis of the ventricular system in head trauma by measuring less coordinates and yet come up to an accurate prognosis. the ventricle volumes are used as neuroimaging marker of brain changes in health and brain trauma. to our knowledge, it is the first time they are studied in vivo on ct-scan. this study and the existing correlations are relevant for the configuration of the finite element model on going. it can surely help the comprehension of the interaction between the structural parts of the cranio-cerebral system during brain trauma. (excitatory-glutamate, and inhibitory-c-aminobutyric acid, gaba), is crucial for the normal cerebral functioning. gaba concentrations vary in different cerebral zones [1] responsible for different cerebral tasks. in this study, [gaba] is measured in the posterior cingulate cortex (pcc) of children with acute mtbi. material and methods: 8 acute mtbi patients (\ 70 h since injury, 15.7 ± 1.9 y.o) and 12 healthy controls (19.3 ± 0.7 y.o). mri scanner philips achieva 3t was used. standard mri protocol for tbi revealed no pathological lesions in brain of any subject. magnetic resonance spectroscopy (mega-press [2] ) was applied to obtain gaba signal without macromolecules. spectroscopy voxel is demonstrated on fig. 1 . intensities of gaba, glutamate ? glutamine, creatine and water signals were calculated in gannet program [3] . absolute concentrations were calculated. mann-whitney was used to reveal the statistical significance of between-group differences. results: typical gaba spectrum processing in gannet is demonstrated on fig. 2 . no changes in glx were found. the values of [gaba] in pcc are demonstrated on fig. 3 : the increase in gaba is not statistically significant. conclusions: this is the first study of [gaba] in pcc of children with acute mtbi. the result of current work disagrees with our previous study, where gaba was increased (p \ 0.005) in the anterior cingulate cortex of children with mtbi [4] . this indicates to a necessity of further data collecting in order to reveal any [gaba] alterations in various cerebral loci. this would help to identify the causes of an inhibition/excitation imbalance and to predict possible dysfunctions of cns following mtbi. results: tnaa and naag concentrations along with stable naa concentration were found to be reduced in patient group. reduced asp and elevated mi concentrations were also found. the main finding of the study is that tnaa signal reduction in wm after mild traumatic brain injury is associated with the drop of the naag concentration rather than of naa one, as it was thought previously. this highlights the importance of separation of these signals at least for wm studies to avoid misinterpretations of the results. naag plays an important role in its selective activation of the mglur3 receptors, thus providing neuroprotective and neuroreparative function immediately after mtbi. it might have potential for the development of new therapy strategy for patients with injuries of various severity. introduction: traumatic brain injury (tbi) is globally recognized as a major health and socioeconomic issue. however, reported numbers vary and often represent subgroups. the number of hospital-admitted tbi has an important impact on hospital resources. thus, the monitoring of hospitalized tbi patients is needed. in 2015, oslo neurosurgical tbi registry was established and includes patients admitted to oslo university hospital (ouh) with traumatic intracranial injury identified by neuroimaging. the aim is to introduce the registry; describe the patient group and volume. material and methods: descriptive study from oslo neurosurgical tbi registry. results: 1701 patients from south-east region were included in 2015-2018 (population 3 million). mean age was 52 years (sd 24), 69% were males. most frequent cause of injury was falls (55%), increasing with age. 27% was influenced by alcohol at time of injury. preinjury antithrombotic therapy was common (25%). most of the patients had multiple pathologies on ct caput, e.g. simultaneous cranial fracture, sdh, tsah and brain contusion (four most frequent). accompanying injuries were found in 48%. 37% was transported to ouh directly form accident scene. 27% was classified as severe tbi upon arrival ouh, 35% was intubated, and trauma team was activated in 77%. median annual and monthly numbers of cases were 419 (range 384-480) and 36 (range 17-49), respectively. no clear change in case load between years and months, except a slight decline in march. admission rate peaked during the weekend. patients were continuously admitted throughout day and night, [ 50% between 18:00 and 06:00. conclusions: patients included in the registry were older than those included in previous tbi studies. the numbers of cases admitted were stable across the months and years. however, the majority of patients were admitted during weekends and nights; thus handled by duty staff. relationship between brain-body temperature difference and neurologic outcomes in patients with severe head trauma introduction: brain is one of the most vulnerable organ to temperature. the association between core body temperature(ct) and neurologic outcomes in patients with post-cardiac arrest, severe head trauma and stroke has been reported. there were few reports comparing brain temperature(bt) with ct and peripheral temperature(pt). we investigated the association of differences among bt, ct and pt with neurologic outcomes in patients with severe head trauma. material and methods: we retrospectively reviewed data for patients with severe head trauma who underwent monitoring intracranial cerebral pressure(icp), bt, ct and pt simultaneously between january 2012 and december 2018. results: we evaluated 6 patients with a median age of 32 years (range 20-71 years). glasgow outcome scale(gos) at discharge were as follows: good recovery(gr) 2, severely disabled(sd) 1, vegetative state(vs) 2, death(d) 1. table 1 showed the average values of icp, cerebral perfusion pressure(cpp), bt, ct, pt, differences between each temperature (bt-ct, ct-pt, bt-pt) and gos in each patients. there was remarkable difference between bt and ct in the dead patient, whereas less differences were found in the other alive patients. we found greater difference between bt/ct and pt in the vs patients than gr patients. conclusions: greater differences between bt/ct and pt can be related to poorer neurologic outcomes introduction: minor head traumas are difficult to assess even with guidelines, hence head cts are often requested. as head cts are increasingly accessible, the demand on the radiology department often exceeds its capacity. there has been an increase in head cts at the oslo emergency department (oed), norway. the scandinavian guidelines for initial management of head injuries in adults (sg) is standard practice in the oed when assessing patients with head trauma.the aim of this study is to assess the number of patients with traumatic brain injury, evaluate guideline compliance and false negative initial reports by junior radiologists. material and methods: a consecutive cohort of 2000 patients from jan-june 2016 who received a head ct at oed due to minor head trauma was assessed. data was gathered from the ct request form, radiology report and ct images. the data points analyzed were: type of trauma, gcs, anticoagulants, loss of consciousness, nausea and vomiting, positive traumatic ct findings, and number of head cts within a 5 year period. results: intracranial bleeds were reported in 100 (5%) patients, 5 (0.25%) required neurosurgical intervention. skull fractures were reported in 10 (0.5%) patients, however no intracranial bleeds were present. it was impossible to assess guideline compliance because 40% of the referrals lacked adequate clinical information. ten bleeds were missed, however no further action was needed. 20% received more than 2 head cts in 5 years conclusions: head injury guidelines can improve clinical practice and reduce unnecessary ct scans; thus minimizing radiation exposure. based on the low number of positive findings, we hypothesize that sg compliance can be improved at oed. compliance was not assessable for nearly half of the patients, due to vital clinical factors missing. implementation of a standardized ct referral form based on the sg and educating junior ed doctors may decrease the number of unnecessary head cts. introduction: to date, there is no ideal allograft that provides local antibiotic release. along with this, existing fillers are expensive material, which complicates their application in practice. all this leads to the need to look for new ways to solve this problem. material and methods: gentamicin was used as an antibacterial drug because of its wide spectrum of action and thermal stability. for the study, staphylococcus aureus attc 1518 was used as a microbial strain. the antibiotic release from the studied materials was determined by equilibrium dialysis over the entire observation period. gentamicin antibiotic concentration was determined by hplc. results: an allograft impregnated with an antibiotic, prepared according to the marburg system in the area of the subcortical part of the bone, suppresses the staphylococcus aureus attc 1518 strain twice as much as perossal. when comparing bone allografts impregnated in various ways, the longest release time showed a perforated allograft.a bone graft impregnated with an antibiotic by incubation showed a 9% longer release time compared to perossal granules (p \ 0.05).when in vitro incubation of the antibiotic gentamicin with the drug ''perossal'', the dissociation rate is more than 97% in the first two days. when the antibiotic gentamicin with a bone allograft is incubated in vitro on the second day, dissociation into the extracellular space makes up more than 56% of the drug from the previously bound (p \ 0.05), which also indicates a longer release time from the bone allograft. conclusions: in vitro, a bone allograft impregnated with an antibiotic is able to reversibly bind the antibiotic gentamicin and gradually release it over a period of 7 days. the use of a bone allograft impregnated with an antibiotic suppresses the growth zones of staphylococcus aureus strains. references: rudenko a., impregnation of the bone allograft: comparison of heads coloring. european journal of trauma and emergency surgery 2019 (suppl) p.70 acute appendicitis and pregnancy: from incidence to modern management: literature review and proposal for consensus estes experts guidelines a. l. bubuianu 1 , a. mihailescu 1 , g. pokusevski 1 1 tameside general hospital, general/emergency surgery, ashtonunder-lyne, united kingdom introduction: acute abdominal pathology during pregnancy has historically been a challenging decision for the emergency surgeon, that had to deal with 2 patients at same time. acute appendicitis has probably the highest prevalence of all. early involvement of the gynaecological team was considered paramount and the ongoing debate laparoscopic versus open intervention, has been more recently challenged by case reports where antibiotics alone have been a successful strategy. material and methods: literature review has been conducted by the investigating team, using the following search algorithm: 2 reviewers screened pubmed portal to conduct a thorough search of the 3 most important medical databases, cochrane's library, medline and embase. case reports and low quality case series have been excluded from the literature review. results: there is currently no general consensus in regards to operative strategy in acute appendicitis during pregnancy, but most authors described safety of laparoscopic intervention in the first 2 trimesters and favoured open approach in a mother closer to term. the antibiotic treatment alone can only be considered in presumed early appendicitis, where there are no features of pending perforation, presence of phlebolith or established peritonitis and should be done under the close monitoring of experienced general surgeons. conclusions: an expert consensus is required in first instance, (set of questions submitted to audience at end of presentation for their expert opinion) regarding optimal treatment strategy in acute appendicitis during pregnancy, followed by a multicenter prospective randomised control trial, which we are hopeful to engage with help of numerous european hospitals where estes members activate. introduction: deep tissue pressure injuries (dtpi) are complex and difficult to treat. the higher prevalence is observed in paraplegic and elderly populations. primary closure of large, stage-4 dtpis is rarely feasible and flap closure is customarily applied. presented is a technique using tension relief system (trs; topclosureò tension relief system) and regulated oxygen and irrigation negative pressure wound therapy (roi-npt; vcareaò) to facilitate simple primary wound closure of dtpis. methods: large, stage-4 dtpis were closed by a limited surgical procedure entailing conservative debridement, en-bloc primary wound closure based on the application of trs and roi-npt. results: details of the closure of consecutive 10 large dtpis in 9 patients is presented. immediate primary closure was achieved in 7 cases, while three others were closed over 6-45 days. surgery time ranged between 1.5 and 3 h and hospitalization between 8 and 37 days. following a median follow-up of 19 months (range 1-42 months), all wounds healed with one late recurrence. post-operative wound infection observed in one patient was successfully treated with systemic antibiotics. minor skin damage inflicted by the tension sutures at the anchoring sites healed spontaneously. gradual return to partial loading of the operated area was enabled within 1-4 weeks and full weight-bearing was achieved within 4-6 weeks. introduction: chronic pain is a disabling condition affecting 50-85% of trauma patients. 1 considering the burden of chronic pain, interest in interventions to prevent this disorder after trauma has grown. a descriptive review of literature was undertaken to assess the evidence on these interventions. 1 material and methods: medline, cinahl and cochrane library databases were searched to identify interventional studies published up to august 2019. websites of injury, critical care and pain organizations were also consulted to retrieve relevant guidelines. the literature search used combinations of medical subject headings and keyword under the themes of pain, trauma, surgery and preventive interventions. results: many knowledge syntheses relevant to the population of trauma published between 2016 and 2019 were found. 1 low to moderate level of evidence was reported for pharmacological interventions such as the administration of ketamine, neuropathic pain medication and multimodal analgesia. local or regional nerve block in the presence of factures was associated with a high level of evidence. very low to low evidence was described for nonpharmacological interventions including cryotherapy and early mobilization. finally, psychological interventions were associated with a low to moderate level of evidence and multimodal pain management interventions (pharmacological and non-pharmacological) with a high level of evidence. conclusions: research is still needed to define the role of interventions to prevent chronic pain in trauma patients. thus far, multimodal pain management interventions involving multidisciplinary team management appear to be the most promising. implementing such interventions could reduce the negative consequences associated with chronic pain. introduction: chronic use of opioids has been documented 60% of trauma patients. 1 accordingly, the tapering opioids prescription program in trauma (topp-trauma) was developed. 2 the aim of this study was to assess the feasibility of topp-trauma and explore the efficacy of topp-trauma in reducing opioid use. material and methods: a 2-arm pilot rct was conducted in patients presenting a high risk for chronic opioid use. we aimed to recruit 50 participants to receive either topp-trauma or an educational pamphlet. topp-trauma comprised educational and counseling sessions. the feasibility assessment of topp-trauma was based on the ability to provide its components. the morphine equivalent dose (med) per day as well as pain intensity and pain interference with activities were measured at 6 and 12 weeks following discharge. results: preliminary findings based on data collected in 30 participants showed that 4 counseling sessions were most frequently needed to completely taper opioids. sessions attendance reached 70%. nearly 70% of eligible patients accepted to participate and an attrition rate of 23% was found. even though the experimental group consumed a higher med 24 h prior to hospital discharge compared to the control group (77.1 vs 54.8), its med/day intake was lower at 6 weeks (1.0 vs 9.20) and 12 weeks (0 vs 3.8). these self-reported data were validated by the total med delivered by participants'' pharmacy at both time points (500.6 vs 561.3 at 6 weeks; 500.6 vs 949.3 at 12 weeks). minimal mean score differences were observed in both groups with regard to pain intensity and interference with activities. conclusions: data collected until now provided evidence on the feasibility of topp-trauma and on the program potential efficacy. challenges that will require to be addressed in future rct include the acceptance to take part in the study and participants' drop out. introduction: head preserving surgical treatment for ao-type 31b fractures with little to no dislocation consists of three canullated screws or a dynamic hip screw (dhs). there is a new alternative: the femoral neck system (fns). the fns has some advantages over dhs. the anti-rotation screw provides extra rotational stability because of the diverging design. furthermore, the incision is smaller in fns and only one locking screw is necessary for plate fixation. we present the first results of this new surgical fixation of femoral neck fractures with fns. material and methods: during the period of november 2018 until october 2019, all patients with femoral neck fractures treated with fns, were included in this prospective single center cohort study. patient characteristics, fracture classification (ao, garden, pauwel), perioperative parameters and postoperative complications were registered. patients were allowed to mobilize based on the principle of permissive weightbearing. follow up was planned after 6 weeks and 12 weeks. primary outcome measure was cut-out rate within 3 months. results: twenty-four patients with a femoral neck fracture (ao-type 31b) were surgically treated with fns. median age was 58, (range 47-75). median operation time was 33 mins (range 16-49). mean duration of in hospital stay was 4 days (range 1-12 days). twentytwo (91,67%) patients completed the regular follow up of 12 weeks. one patient (4%) had a reoperation due to a cut-out. during follow up one patient developed a wound-infection (4%) which was treated with intravenous antibiotics conclusions: femoral neck system as surgical treatment for femoral neck fractures shows promising first results. low cut-out rate, limited operation time, low mortality and short duration of in-hospital stay make this device a possible alternative for dhs of canullated screws. definitive conclusions should be made after studying long term results in larger cohorts. references: none. new personalized approach to enteroatmospheric fistulas using 3d bioprinting device introduction: enteroatmospheric fistula is a challenge for surgeons. it presents a great clinical variability. this diversity means that, despite having tried multiple devices and techniques to achieve local control of the intestinal effluvium over the rest of the wound, there is currently no technique that can solve this problem in all patients. 3d printing is a novel therapy that allows the customization of the devices according to the needs of each patient. the aim of this study is to describe the technique of manufacturing a custom device designed by bioscanner imaging and manufactured using a 3d printer for use in the management of enteroatmospheric fistula. we describe our initial results. materials and methods: we present four patients with enteroatmospheric fistula. the intestinal segment involved, the dimensions of the wound, the intestinal debit and the size of the exposed intestinal surface are substantially. all require an average of 4-5 daily cures by the nurse. after obtaining images of each fistula with a bioscanner, a personalized device was designed and made by a 3d printer. the polycaprolactone device was placed including inside the fistulous orifices and surrounding it with npwt in order to accelerate the healing of the wound to ostomize the fistula or achieve its definitive closure. results: four devices with different designs have been manufactured. the wound remained isolated from the intestinal contents after placement, favouring the granulation of the surrounding tissue with npwt and thus avoiding contamination of the wound. the system remained without leaks for an average of 48 h, reducing the need for daily cures, improving patient comfort and avoiding complications. conclusions: the use of a manufacturing model using 3d bioprosthesis printing in order to create a personalized device that fits the characteristics of the patient's wound is feasible and offers promising results in the management of enteroatmospheric fistulas. new approaches in bone tissue engineering: innovative scaffold design for principle unlimited size bone substitutes introduction: in bone tissue engineering (bte), autologous boneregenerative cells are combined with a scaffold for large bone defect treatment. microporous, polylactic acid scaffolds showed good healing results in bone defects in small animals. transfer to large animal models, however, is challenging and not easily achieved simply by upscaling the design. increasing diffusion distances has a negative impact on cell survival and nutrition supply. this can lead to cell death and ultimately implant failure.this approach focuses on scaffold architectures, that meet all the requirements for a modern bone substitute. biological-functional, porous subunits in a loadbearing, compression-resistant frame structure characterise the innovative design. an open, macro-and microporous internal architecture provides optimal conditions for oxygen and nutrient supply in the inner areas of the implant by diffusion. material and methods: during the design process, 3 prototypes (temple (figure a) , grid (figure b) , onion (figure c)) were 3dprinted (fused filament fabrication) using polylactic acid (pla). -after incubation with saos-2 (sarcoma osteogenic) cells for 14 days (measurements on days 1, 7, 14 and 21), cell morphology, distribution and survival (fluorescence microscopy, ldh-based cytotoxicity assay), metabolic activity (mtt test) and osteogenic gene expression were determined. results: all designs not only showed cell colonization, but cells also sustained their ability to differentiate (already after 14 days) and to divide. the open, hierarchical-structured design, with its innovative porous structure, provides a good basis for cell settlement and proliferation. the modular design allows easy upscaling and offers potential solutions to previous limitations scaffold developement in bone tissue engineering. references: the value of 3d reconstructions in determining post-operative reduction in acetabular fractures: a pilot study introduction: in patients with acetabular fractures, the reconstructed three-dimensional (3d) model of the contralateral acetabulum could be used as a mirrored template for the anatomic configuration of the affected joint. this has not been validated. material and methods: computer tomography (ct)-scans of twenty patients with unaffected acetabula were used. the symmetry of the generated 3d models was evaluated through; (1) mirroring of the acetabulum; (2) initial rough matching; (3) automatic optimisation of the matching via surface-based matching; (4) calculation of distances between surfaces by evaluating the euclidean (straight-line) error distance between the closest points between left and right. the percentages of surface-points of the left and right acetabulum with a distance smaller than 0.5, 1.0, 1.5 and 2.0 mm were calculated and evaluated, in relation to matta's criteria, for acetabular fracture reductions. the analysis was performed using the mirrored left acetabulum matched onto the right original structure (left mirrored to right original; ''lm2ro'') and the right mirrored to left original (rm2lo). to determine the inter-observer agreement the procedure was repeated by a second assessor for the first ten patients. results: patients had a mean ± sd age of 39.6 ± 15.6 years, 56% was male. the mean distance deviation was less than 0.75 mm in all 40 comparisons. the calculated distances in 90.7% of the surface points of the left and right acetabulum were below the tolerance threshold of 1.0 mm, based on matta's anatomical reduction critera (table 2). absolute differences between assessors were\ 0.5 mm per patient with an overall moderate agreement of 70%. conclusions: 3d reconstructed models of healthy left and right acetabula are highly similar and could potentially be used as mirrored duplicates. the next step will be to investigate these results in patients with reduced acetabular fractures. : matta, j. (1996 ).j bone joint sur am. 1996 78:1632-45 pr 202 minimally invasive plate osteosynthesis technique for distal humeral fracture: a cadaveric study v. hofmann 1 , c. deininger 1 , t. freude 1 , f. wichlas 1 1 university hospital salzburg, orthopedics and traumatology, salzburg, austria introduction: in our study we want to evaluate the feasibility of minimally invasive plate osteosynthesis (mipo) technique for distal humeral fracture using anatomically precontoured double plate osteosynthesis. material and methods: eight elbows from four thiel fixed cadavers were included. on unfractued cadavers we tested the minimally invasive approach with two separate incisions, one at the lateral and one at the medial epicondylus. the preformed plates were inserted directly into the bone on sides and fixed with percutaneous screws. then we created an ao type a3 and c3 fracture. the reduction was performed under x-ray control and stabilized with k-wires. then we also inserted the plates in mipo technique. in the case of an intraarticular fracture, an olecranon osteotomy was additional performed in a minimal invasive way to control the distal humeral joint surface. after finishing reduction and fixation the approach were extended to control the fracture alignement, position of the plates and to expose the ulnar nerve. results: the plate position was satisfactory and we could not detect any major soft tissue damage or ulnar nerve injury by using the minimally invasive plate osteosynthesis technique. in the extraarticular fractures, reduction was achieved with k-wires and was acceptable in all cases. the intra-articular fractures were controlled by an additional olecranon osteotomy using the mipo technique with a good view on the joint surface of the distal humerus. conclusions: the findings of the present study show that mipo technique in distal humerus fracture is feasible and save especially for ao type a fractures. in ao type c fractures the olecranon osteotomy provided enough visibility to evaluate the distal humeral joint surface. the surgical technique is demanding, and care must be taken not to injure the ulnar nerve. never the less it is an effective surgical treatment method and an alternative option to open techniques. correlation between pelvic incidence and acetabular orientation in anteversion and inclination-an analysis based on a 3d statistical model of the pelvic ring introduction: the pelvic ring is a complex bony structure with a central role for the human''s mobility building the connecting part between the upper body and the lower extremities. pelvic incidence and acetabular orientation are two important parameters used in the description of pelvic anatomy and are of central importance for understanding the biomechanical interaction of spine, pelvis and hip joints. the objective of the study was the analysis of a potential correlation between pelvic incidence and acetabular orientation. material and methods: a 3d statistical model of the pelvic ring consisting of 100 individual ct scans of european adults without bony pathologies was used to analyse pelvic incidence and acetabular orientation in anteversion and inclination. an additional analysis on the correlation between those parameters was performed using the software spss. results: a slight positive correlation between pelvic incidence and acetabular anteversion could be shown (r = 0.223; p = 0.019) as well as a strong positive correlation between anteversion and inclination (r = 0.570; p \ 0.001). pelvic incidence and acetabular inclination showed none statistically significant correlation (r = 0.102; p = 0.311). conclusions: the results of the study might contribute to a better understanding of the biomechanical interaction between the axial skeleton and the lower extremities and deliver valuable information concerning preoperative planning in orthopaedic and trauma surgery of the lumbar spine, the pelvis and the hip joints like for example reconstructive surgery after trauma, operative treatment of congenital or acquired deformities or total joint arthroplasty. references: boulay et al., ''pelvic incidence: a predictive factor for three-dimensional acetabular orientation-a preliminarystudy. '' anat res int. 2014; :594650. doi: 10.1155 /594650. epub 2014 . introduction: the majority of distal clavicle fractures (dcfs) are displaced fractures and are prone to delayed-or non-union. 1 there are several options for surgical reconstruction, open reduction and fixation or hook plate, but in patients with a comminuted or small fracture they are known to have a high complication and failure rate, and secondary surgery for removal is often necessary. we hypothesize that resection of the distal fracture fragment and subsequent stabilization with the lockdown device, is an alternative for selected patients with dcfs. methods: eleven patients with a comminuted dcf were treated with a lockdown device. data on pain and range of motion were documented and the constant shoulder score (css), oxford shoulder score (oss) and nottingham clavicle score (ncs) were assessed at one year follow-up. results: eight patients underwent surgery within 2 weeks, compared to 3 patients where the surgery was delayed ([ 2 weeks) due to persisting pain and delayed-union. none of the patients had postoperative complications. in 3 months after treatment, 10 patients were complaint-free. one patient had hardware removal due to pain at the site of the screw head. four patients were assessed after one year follow-up. the mean pain score was 3.2. the mean flexion 142,5°, abduction 120,5°, exorotation 56°and extension 54°. the css had a mean of 21.75, oss 43.75 and the ncs a mean of 70. conclusions: all 11 patients had a good short-term clinical outcome and hardware complications did not occur. we are the first to describe the use of the lockdown device in dcfs. this device is not dependent on fracture healing and secondary surgery is not necessary, therefore it can be an alternative in the treatment of dcfs. a larger series and longer follow-up is necessary to confirm this conclusion. in this ongoing study, the remainder seven patients will be included and presented at the estes. moore type i tibial head fractures are one of the most challenging fractures to treat. material and methods: we performed the following approaches on eight thiel fixed cadavers: the anterolateral (with an osteotomy of the tuberculum gerdyi, a subcapital fibula-osteotomy and an osteotomy of the tuberositas tibia), the medial approach (with submeniscal arthrotomy and a dissection of the medial collateral ligament) and the posterior approach with a submeniscal athrotomy. the reachable borders of the articular joint surface have been marked by a k-wire. the visual joint surface has also been radiographically documented by inserting k-wires into the tibia head. finally the results have been photo documented on the exarticulated joints. results: the reachable areas of the articular surface have been defined and documented. the combination of the subcapital fibulaosteotomy and the submeniscal arthrotomy showed the most increase in accessibility to the articular surface in the dorsal part. an additional osteotomy of the tuberculum gerdyi increased the vision on the entire lateral and anterior articular surface. the submeniscal arthrotomy, at the medial approach, has not a good view on the surface. the posterior approach showed only a limited view on the lateral and medial articular surface at the dorsal part. none of the surgical approaches sufficiently visualizes the intercondylar region. conclusions: a fracture-specific approach strategy is critical for the preoperative planning of complex tibia-head fractures. subcapital fibula osteotomy is the most efficient surgical approach to reach the posterior and lateral articular surface. for the anterior articular surface, the best overview was achieved by an osteotomy of the tuberculum gerdyi. it was not possible to see and control the intercondylar region with any approach. introduction: osteosarcoma (os) is the most common bone carcinoma in humans. at the time of the first diagnosis are already in about 20% metastases present. the current treatment strategies include above all radical surgical resection and chemotherapy. in the search for alternative therapy methods. treatment with cold atmospheric plasma (cap) shows promising prospects. at the cellular level, this leads to various cellular mechanisms and finally to induction of anticancerogenic effects such as growth inhibition, apoptosis, and changes in the cell-cell interactions. the impact of cap on the integrity of the cell membrane of os cells, however, is unknown. material and methods: suspended cells from two human osteosarcoma cell lines (u2-os, mnng) were treated for 10 s, 30 s, and 60 s with cap. cell proliferation was determined after 4 h, 24, 48, 72, 96 and 120 h using casy cell counter. dye loss assay was performed by using fluorescein diacetate (fda). this was followed by indirect treatment with cap for 60 s. in the cell-free supernatant was determined by tecan multireader the dye emission. flow cytometry assay was used after cap treatments and incubation with fda. the mean fda fluorescence intensity of individual cells in the flow cytometer was measured. results: cell kinetics showed significant inhibition of cell proliferation in both cell lines after cap treatment. the assays for determination of the dye level showed a significantly increased membrane permeability of both cell lines after cap treatment. the significant effect on the membrane integrity correlated with treatment duration. conclusions: this confirms a modulating influence of cap on the functionality of the cell membrane and may support the anti-proliferative effect of the cap treatment. thus, cap is a promising therapy option, especially for chemotherapy-resistant entities introduction: osteosarcoma (os) is the most common bone cancer in humans. standard therapy includes radical surgical resection and chemotherapy, but due to strong toxic effects, new treatment options are urgently needed. currently, there is a discussion about expanding the oncological therapy spectrum and treat with cold atmospheric plasma (cap). it is a reactive ionized gas rich in radicals, photons, and electromagnetic rays. its biological effects are primarily mediated by reactive oxygen and nitrogen species (rons). due to its low temperature, cap is suited for medical applications. in vitro studies have shown the antitumoral effect of cap also for pancreatic cancer, melanoma, ovarian, breast, and colon cancer. material and methods: human os cell lines u2-os and mnng/ hos were used. proliferation assay. the growth of cap-treated cells was examined using a casy cell counter. caspase 3/7 assay. following cap treatment, the activities of caspase-3 and caspase-7 were measured using a specific substrate peptide coupled with a fluorescent dye (cellevent tm ). single-cell gel electrophoresis comet assay. dna damage after cap treatment was identified using alkaline microgel electrophoresis. dna migration was measured using comet score software. the percentage of tail dna was used to indicate the relative fluorescence intensity of the head and tail. tunel assay. after cap treatment tunel analysis was performed. results: the results revealed that the cap treatment of os cell lines leads to significant inhibition of cell growth. subsequently, the activation of caspases and the induction of apoptotic dna fragmentation was demonstrated. the treatment of os cells with cap leads to an induction of apoptosis and a reduction of cell growth. introduction: extra peritoneal packing (epp) is a quick and highly effective method to control pelvic hemorrhage. we hypothesized that this procedure may be as safely and efficiently performed in the emergency room (er) as in the operating room (or). methods: retrospective study of 29 patients who underwent epp in the er or or in two trauma centers in israel between 2008-2018. material and methods: retrospective study of 29 patients who underwent epp in the er or or in two trauma centers in israel between 2008-2018. results: 29 patients were included in our study, 13 in the er-epp group and 16 in the or-epp group. the mean injury severity score (iss) was 34.9 ± 11.8. following epp, hemodynamic stability was successfully achieved in 25 of 29 patients (86.2%). a raise in the mean arterial pressure (map) with a median of 25 mmhg (mean 30.0 ± 27.5, p = 0.000009) was documented. all patients who did not achieve hemodynamic stability after epp had multiple sources of bleeding or fatal head injury and eventually succumbed. the overall mortality rate was 27.5% (8/29) with no difference between the or and er-epp groups. patients who underwent epp in the er showed higher change in map (p = 0.0458). no differences were found between er and or epp in the amount of transfused blood products, surgical site infections and length of stay in the hospital. however, patients who underwent er epp were more prone to develop deep vein thrombosis (dvt): 50% (5/10) vs 9% (1/11) in er and or-epp groups respectively (p = 0.038). conclusions: epp is equally effective when performed in the er or or with similar surgical site infection rates but higher incidence of dvt. level of evidence: retrospective cohort study, level iv. introduction: application of supraacetabular schanz screws is usually performed under image intensifier guidance. the aim of this study was to perform it without imaging, with the hypothesis that, respecting anatomical landmarks, pre-and intraoperative fluoroscopy can be avoided. material and methods: insertion of the supra-acetabular schanz screws was performed in 14 human adult cadavers. with cadavers placed in supine position, the anterior superior iliac spine (asis) was palpated. starting from this landmark, 2 cm were measured in a distal and 2 cm in the medial direction. at this point, a 2 cm long oblique skin incision was performed. through this approach, 150 mm schanz screws were drilled bilaterally into the supra-acetabular corridor with an angulation of 20°to distal as well as 20°to medial. combined obturator oblique-outlet views (cooo) were taken bilaterally to prove the screw position. six of the specimens underwent a 3d-ctscan. images were evaluated concerning correct screw positioning. skin and subcutaneous tissues were removed in the ilioinguinal region and possible lesions to the lateral femoral cutaneous nerve (lfcn) or to the joint capsule were evaluated. results: during radiographic evaluation of the cooo-scans (14 specimens) and the 3d-scans (6 specimens), the schanz screws were placed inside the supra-acetabular corridor in all specimens (14/14). during dissections, no intracapsular screw placements or lfcn lesions were found. conclusions: using our technique, all schanz screws could be sufficiently inserted without intraprocedural x-ray imaging. references: 1. karaharju, e. and p. slätis, external fixation of double vertical pelvic fractures with a trapezoid compression frame. inhury, 1978. 10: p. 142-145. 2. mears, d. and f. fu, external fixation in pelvic fractures. orthop clin north am, 1980. 11: p. 465-479. 3. mears, d. and f. fu, modern concepts of external skeletal fixation of the pelvis. clin orthop, 1980. 151: p. 65-72. pr 210 epidemiology of self-inflicted major trauma r. stoner 1 , n. misra 1 , l. mason 1 1 aintree university hospital, liverpool, united kingdom introduction: in the united kingdom, severely injured patients are taken directly to a major trauma centre (mtc). whilst deliberate self harm (dsh) is a known mechanism for this, there is limited prior research. 1-9% of major trauma is thought to be self inflicted 1,2 . our aim was to describe the epidemiology of presentation to our mtc resulting from dsh. material and methods: retrospective review of patient records in our mtc for adult trauma team activations between 01/07/2016 and 30/06/2018. data was collected on patient demographics, location type, injury severity score (iss), mechanism of injury and mortality. results: 194 episodes of dsh made up 6.4% of all trauma cases, involving 180 patients; 2.6% re-attended. z-scores show no change in incidence over time, but significant variability month by month, with 6/24 months [ 1sd from mean. mean patient age 37 years (range 16-78). 67.8% were male. 64.9% came from residential location and 8.2% from prison. most common mechanism was penetrating trauma (51.5%). in-hospital mortality was 10% (13.4% in males vs 3.4% in females, chi 2 p = 0.04). conclusions: this is the largest review of self inflicted trauma cases in a uk mtc, with a similar incidence to prior studies. there was no observed correlation with season or trend over time. mortality was higher in male patients, in keeping with national statistics on suicide, whilst dsh in females was linked to less severe injury; severity is related to mechanism of injury. injury from self stabbing/cutting was most common in patients from residential locations, whilst hanging was more common in prisoners. this study identifies preventable risk factors for major self inflicted injury. introduction: the distribution of trauma deaths was classically described following a trimodal pattern. during the last decade improvements in trauma care as damage control resuscitation (dcr) have minimized resuscitation injury. we hypothesized that the implementation of dcr in severely injured trauma patients is associated with less mortality and modifies mortality pattern. material and methods: we performed a 25-year (1993-2018) retrospective cohort analysis of all severely injured trauma patients (niss c 35) who underwent surgery at our level 1 trauma center. since 2005, dcr was implemented including damage control surgery, minimizing crystalloids and increasing the use of blood products. our patients were stratified into two phases: pre-dcr ( -2004 ( ) and post-dcr (2005 . results: a total of 308 patients were identified. there were 172 patients (55.84%) in the pre-dcr group and 136 patients (44.16%) in the post-dcr group. mean age (35.17 vs 39.49, non significant (ns)), mechanism of injury (blunt trauma: 89.53% vs 86.76%, ns) and shock on admission (35.46% vs 36.02%, ns) were similar between groups. there is a significant reduction in the rate of overall mortality (44.18% vs 33.82%, p \ 0.05). while early deaths from traumatic brain injury (47.36% vs 47.82%, ns) and hemorrhage (39.47% vs 41.62%, ns) are alike, mortality secondary to multisystem organ failure (msof) is lessened (13.15 vs 6.52%, p \ 0.05). conclusions: dcr has helped in reducing overall mortality and mortality due to msof in our severely injured trauma patients. introduction: the mangled extremity severity score (mess) was constructed as an objective quantification criterion for limb trauma. a mess of or greater than 7 was proposed as a cut-off point for primary limb amputation. opinions concerning the predictive value of the mess vary broadly in the literature. the aim of this study was to evaluate the applicability of the mess in a contemporary civilian central european cohort. material and methods: all patients treated for extremity injuries with arterial reconstruction at two centres between january 2005 and december 2014 were assessed. the mangled extremity severity score (mess) and the amputation rate were determined. results: seventy-one patients met the inclusion criteria and could be evaluated for trauma mechanism and injury patterns. the mean mess was ). seventy-three percent of all patients (52/71) had a mess b 7 and 27% (19/71) of c 7. eight patients (11%) underwent secondary amputation. patients with a mess c 7 showed a higher, but statistically not significant secondary amputation rate (21.1%; 4/19) than those with a mess b 7 (7.7%; 4/52; p = 0.20). the area under the roc curve was 0.57 (ci 0.41; 0.73). conclusions: based on these results, the mess seems to be an inappropriate predictor for amputation in civilian settings in central europe possibly due to therapeutic advances in the treatment of orthopaedic, vascular, neurologic and soft tissue traumas. introduction: in polytrauma victims the acute respiratory distress syndrome (ards) is a major cause of morbidity and mortality. it presents a complex pathophysiology that is characterized by pulmonary activated coagulation and reduced fibrinolysis. due to the fact that the pulmonary endothelium is considered a key modulator of ards and that tpa in plasma is predominantly synthesized and secreted by vascular endothelial cells, we hypothesized that the time courses of serum tissue-type plasminogen activator (tpa) and its main inhibitor, the plasminogen activator inhibitor type-1 (pai-1), might indicate a clinical approach to preventing ards in polytrauma victims. material and methods: twenty-eight consecutive polytraumatized patients with concomitant thoracic trauma, age c 18 years, iss c 16, who were directly admitted to our level i trauma center, were evaluated. blood samples were taken initially and on day 1, 3, 5, 7, 10, 14 , and 21 during hospitalization. luminex multi-analyte-technology was used for analysis of tpa and pai-1 antigen levels. results: both levels were particularly high at admission. although they significantly declined within three and seven days, respectively, they remained elevated throughout three weeks. throughout this observation period mean tpa antigen levels were higher in polytrauma victims suffering ards than in those without ards, whereas mean pai-1 levels were higher in polytrauma victims sustaining pneumonia than in those without pneumonia. noteworthy, in each patient, who developed ards, the tpa antigen level raised up to the onset of the syndrome and declined afterwards. conclusions: the development of ards has to be expected in a polytrauma victims if the tpa antigen level continues to rise after admission. potentially, in patients with a low risk of excessive bleeding the onset of the syndrome might be prevented by the timely administration of recombinant profibrinolytic proteins. motocross is a dangerous business: small bowell perforation case report case history: a 19 year-old male, previously healthy, was admitted to the ed after being involved in a motorcross accident. he suffered blunt abdominal trauma. clinical findings: at admission, patient presented pale but haemodinamically stable. physical examination was unremarkable except for an evident abdominal wall hematoma and abdominal guarding over the left quadrants. investigation/results: abdominal ultrasound showed an intestinal loop with decreased peristalsis with a small amount of liquid adjacent (fig 1) . due to the patient's haemodynamic stability, ct scan was performed (fig 2. ) which showed liquid in the left flank and iliac fossa, but without an identifiable intrabdominal lesion. diagnosis: the patient was admitted to the operating theatre with acute abdomen. therapy and progressions: intraoperatively fecal peritonitis was evident from a 3 cm-hole on the antimesenteric border of the jejunum, the enterotomy was closed and profuse lavage was done; the abdominal wall closed without drainage. the patient went through an empirical antibiotic cycle. liquids per os were started on the first postoperative day and the patient progressed without issues. he was discharged at the 5th postoperative day. the remaining follow-up was uneventful. comments: small bowel perforation after blunt abdominal trauma is rare. sbmi has a high morbidity and mortality that increase with delayed diagnosis; however, clinical and radiographic signs of perforation are often absent, like in the case presented. ct is considered the gold-standard. in our specific situation, the small bowel perforation did not produce any pneumoperitoneum in a young patient with very good physiologic status that kept him hemodynamically stable. the prognosis of pelvic injury is closely related to the severity of vascular injury rather than the complexity of bony fracture y. wu 1 , c. hsieh 1 , c. fu 1 1 chang gung memorial hospital, trauma and emergency surgery department, taoyuan city, taiwan introduction: pelvic injuries are among the most dangerous and deadly trauma. although complex pelvic fractures are often associated with vascular injuries, it is still unclear regarding the impact of the severity of vascular injury to the outcome of patients. we hypothesized that, in addition to the complexity of bony fracture, the severity of pelvic vascular injury plays a more decisive role to the patients'' outcome. material and methods:medical records of patients with pelvic fracture in a single trauma center between jan 2016 and dec 2017 were retrospectively reviewed. those who had an abbreviated injury scale (ais) c 3 other than pelvis were excluded. based on ct results, the type of pelvic fracture was classified according to young-burgess classification, and the severity of vascular injury were recorded as minor (fracture with or without hematoma) or severe (hematoma with contrast pooling or extravasation). the patient demographics, clinical parameters, and outcome measures were compared between the groups. results: among the 156 patients, severe vascular injury were noted in 26 patients. patients with severe vascular injuries had significantly increased amount of red blood cell transfusion (rbct) (11.8 vs. 3.8 units, p = 0.002), longer icu stay (is) (3.1 vs. 1.0 days, p = 0.011) and total hospital stay (hs) (15.8 vs. 11.0 days, p = 0.023) compared to minor vascular injuries. on the other hand, those with complicated pelvic fracture (lc type ii/iii, apc type ii/iii, vs and combined type) had similar amount of rbct and is compared to that of simple pelvic fracture (lc type i, apc type i) except a longer hs (13.4 vs. 10.1 days, p = 0.036). conclusions: our results indicated that the severity of vascular injury is more closely correlated to the outcome of patients with pelvic fractures than the type of bony fracture does. in addition to the type of bony fracture, the grade of vascular injury should be considered as an important part of pelvic injury classification. associated abdominal injuries do not influence reduction quality in operatively treated pelvic fractures-a multicenter cohort study from the german pelvic registry results: 16.359 patients with pelvic injuries were treated during this period. 21.6% had a concomitant abdominal trauma. the mean age was 61.5 ± 23.4 years. comparing the two groups, patients with a combination of pelvic and abdominal trauma were significantly younger (47.3 ± 22.0 vs. 70.3 ± 20.5 years; p \ 0.001). both, complication rates (21.9% vs. 10.0%; p \ 0.001) and mortality (8.1% vs. 1.9%;p \ 0.001) were significantly higher. in the subgroup of acetabular fractures, the time until definitive surgery of the pelvis was significantly longer in the group with the combined injury (5.7 ± 4.8 vs. 4.7 ± 4.0 days; p \ 0.001) . the grade of successful anatomic reduction did not differ between the two groups. conclusions: patients with a pelvic injury have a concomitant abdominal trauma in about 20% of the cases. the clinical course is significantly prolonged in patients with a combined injury, with increased rates of morbidity and mortality. however, the quality of the postoperative results is not influenced by a concomitant abdominal injury. a. martins rangel 1 , r. pozzi 1 , j. alfredo cavalcante padilha 1 , s. sardinha 1 , f. eduardo silva 1 , d. teixeira rangel 1 1 heat, trauma center, são gonçalo, brazil f.f.c., male, 27 years old, was admitted to the trauma center about 12 h after a stabbing wound in the neck. upon examination the patient was mechanically ventilated and hemodynamically stable, with an exposed sectioned trachea, which had a tracheostomy tube applied. the penetrating injury itself was mostly allocated in zone ii. he had a ct angiography and was referred to the or for surgical treatment. the cervicotomy found that both the external and internal right jugular veins had been injured alongside the sternocleidomastoid, sternohyoid and homohyoid muscles, the thyroid cartilage, just above the vocal cords, which had exposed the anterior larynx and the epiglottis the right anterior jugular vein and smaller tributaries of the right internal jugular vein, were ligated; a tracheostomy was performed and the thyroid cartilage and anterior laryngopharyngeal wall were reconstructed with the epiglottis implantation, sternoid, homohyoid and sternocleidomastoid muscle sutures, after which the platysma was closed but not the skin, left to secondary healing. patient was extubated within 48 h, discharged from icu on the fifth postoperative day. thickened oral diet was introduced on the 16th day, and by the 21th day he was discharged without the tracheostomy tube, with a normal diet. comments: the cervical region is an area susceptible to serious injury due to the presence of vital structures, with massive hemorrhage, airway obstruction, cervical spine injuries and cerebral ischemia as the leading causes of death. initial management of penetrating injuries follows the principles of trauma care with airway control initially. references: bhatt nr-penetrating neck injury from a screwdriver: can the no zone approach be applied to zone i injuries? bmj yan wang-penetrating neck trauma caused by a rebar-a case report. medicine (2018) introduction: annually, approximately 3,600 people decease as a result of a fall in the netherlands, according to the statistics netherlands. the aim of this study is to evaluate the demographic parameters, fall characteristics and resulting injury patterns of this group in the region of amsterdam. methods: all patients deceased as a result of injury due to a fall in the period july 1st 2013 until july 1st 2018 in the region of amsterdam were included. data were collected from the database (formatus) of the department of forensic medicine (public health service amsterdam). results: during the study period 1,258 patients deceased after a fall. the mean age was 83 years (0-103 years) and 41% was male. a psychiatric disease was diagnosed or suspected in 44% of the population of which cognitive impairment, including dementia, was encountered in most of the cases (82%). the majority of the falls happened at home (47%) or at nursing facilities. a minority (1.3%) was work related. over 81% of the falls was from standing position, 17.6% was not from standing position of which 80.1% regarded falls from stairs, the majority was male. multitrauma patients accounted for 17.1% of the population. from the remaining 1,040 patients, 61.7% sustained one or more injuries to the pelvis or extremities. central nervous system (cns) injuries were described in 31.3% of the patients. mortality was in 26.8% of the cases due to primary cns injury, 62.3% was due to complications of which clinical deterioration (58.7%) and infection (17.1%) were the most common. conclusions: in the region of amsterdam the majority of deaths due to a fall regards the geriatric population. fall from standing position and mortality due to complications, mainly clinical deterioration, accounted for the majority of deaths. intervention to prevent falls and thereby complications need more awareness to reduce mortality. results from a multidisciplinary blunt splenic injury protocol introduction: the majority of splenic injuries are currently managed non-operatively. failure of non-operative management includes grade iv or v splenic injury or vascular abnormalities that are suitable for embolization. the primary indication for operative management of blunt splenic injury is hemodynamic instability. in our center, the last twenty splenic injuries, admitted during two years, were not managed according to published guidelines. ten patients (50%) underwent splenectomy, being unstable only 2 of them (10% of the whole sample). material and methods: staff from anesthesiology, interventional radiology and trauma surgery came up with a joint protocol. grade iii splenic injury non-operatively management, including fluid responsiveness (achieving shock index (ht/bp) below 0.9 after a bolus of colloids) and, focus placed only on hemodynamic stability instead of on vascular abnormalities are our principal modifications regarding already published protocols. results: seventeen patients with blunt spleen trauma were admitted after starting up our protocol. six (2 grade iii, 2 grade ii and 2 grade i) splenic injuries were successfully managed non-operatively. prophylatic embolization was performed in five patients: 3 were grade iv spleen trauma and 2 were grade iii spleen trauma with vascular abnormalities. one grade iii splenic trauma was embolized due to a pseudoaneurysm detected in ct scan performed 72 h post injury. five grade v spleen trauma required urgent surgery. 4 of them presented with shock index [ 0.9. conclusions: our multidisciplinary protocol has helped in improving outcomes in blunt splenic injuries. we have achieved an almost full compliance to our protocol. case history: 82-year old male experienced severe blunt trauma after a bus accident. clinical findings: he is found alert (gcs = 15), hemodynamically stable and with a patent airway. he presented catastrophic lower left limb where tourniquet was applied. 1 gram of tranexamic acid (txa) and 500 ml of crystalloids were administered. he was intubated in the site of injury and transfered to our center, being always hemodynamically stable. on hospital admission he was normotensive (bp = 140/70 mmhg, sinus rithm 85 ppm), shock index \ 0.9. he suffered uneventfully amputation of the limb with no need for blood products transfusion. his past medical history was only pertinent for hypertension. investigation/results: following urgent damage control surgery, ct scan was performed where acute bilateral pulmonary embolism was diagnosed. diagnosis: asymptomatic acute bilateral pulmonary embolism therapy and progressions: during icu stay, the patient kept hemodynamically stable. endotracheal tube is removed one day later and he is successfully transfered to the ward three days later. comments: hypercoagulability can occur after severe tissue injury, that is likely related to tissue factor exposure and impaired endothelial release of tissue plasminogen activator (tpa). in contrast, when shock and hypoperfusion occur, activation of the protein c pathway and endothelial tpa release induce a shift from a procoagulant to a hypocoagulable and hyperfibrinolytic state with a high risk of bleeding. it can be inferred that a patient presenting with severe tissue injury without shock is at high risk of perioperative thrombosis and txa might not be administered. (1) . it signifies high energy force, representative of severe overall trauma. study reported mortality of blunt pelvic trauma to reach 4.8-50% (2) . injury severity score (iss), hypotension, head injury, posterior fracture & haemorrhage have been implicated (3) . however, there is a paucity of data in developing countries. this study identifies the problem burden, management outcomes and factors predicting mortality. material and methods: 568 patients had pelvic trauma, retrospectively from jan 2014 to dec 2017 and prospectively from may 2018 to april 2019. 501 patients was included after excluding less than 18 years and coagulation disorder results: majority were males (78.2%),with a mean age of 34.8. mechanism was rti (72.3%) followed by fall from height (18%), railway accidents (4.8%). mean iss & rts was 17.37 and 7.41 respectively. associated injury were long bone fractures (34.3%), chest injuries (33.53%).head injury (10.4%). lateral compression (63.9%), was the most common followed by anteroposterior compression (17%) & combined (11.17%).majority underwent operative intervention (56.5%) for pelvis or associated injury. the mortality rate was 15.7% secondary to haemorrhagic shock (49.4%) and sepsis (34.2%). the factors were male gender, age, iss, rts, head injury, unstable pelvis. however, no association with haemoglobin, long bone fracture, and massive transfusion protocol was found conclusions: our study showed a mortality of 15.7% which is comparing with previous study introduction: the number of patients admitted to oslo university hospital (ouh) due to bicycle trauma is increasing. we aimed to identify possible predictors of serious and fatal bicycle injury. material and methods: the ouh trauma registry was searched for patients treated for bicycle trauma between 2005 and 2016. data extraction included putative predictors of serious and fatal injuries, defined as iss c 9 and death within 30 days, respectively. univariate analyses were performed and reported as odds ratios (or). p \ 0.05 was regarded as statistically significant. results: 1543 bicyclists were admitted, 72% were males, median age was 40 years (range 3-91). injury mechanisms were single bicycle crash in 68%, collision with a motorized vehicle in 27%, bicycle vs. bicycle in 4% and others in 1%. serious injuries were seen in 63% and 2.3% died. predictors for serious and fatal bicycle trauma are presented in figure 1 . conclusions: we identified age c 50, high comorbidity and loss of consciousness (gcs b 12) as predictors for both serious and fatal injury after bicycle trauma. single bicycle crash was the most common cause of serious bicycle injury in our trauma center. diagnosis, investigation and results: all case reports represent polytrauma patients with clinical worsening and admission to the icu, with subsequent development of acute respiratory distress syndrome (ards) refractory to primary measures. therapy and progressions: different mechanisms led to the development of ards in the different cases. on a primary approach, standard measures such as curarization, recruitment maneuvers, prone positioning and peep increase were applied whenever possible. an absence of improvement led to an almost inevitable need of extracorporeal membrane oxygenation (ecmo) rescue therapy. all patients responded positively to this treatment without major complications and were eventually discharged from the icu. comments: ards is a major cause of respiratory failure in polytrauma patients. among the many therapeutic options, ecmo emerges as a powerful tool as rescue therapy in respiratory failure refractory to all other measures, being the present case reports corroborative examples of its efficiency. introduction: nowadays when cities are improving fast and significantly, including transportation system, even more we encounter with high energy trauma . still the most vulnerable on the roads are pedestrians. material and methods: the analysis of the data collected prospectively from january 2017 to october 2019 was performed including the mechanism and diagnosis of polytrauma, patient demographics and the main outcomes. results: in total, 903 patients were assessed according to the polytrauma protocol. the median age of the cohort was 43 years (iqr 30-55), male patients, 68.2% vs. 31.8% females, p = 0.045. the most frequent mechanism was a pedestrian struck by a vehicle in 33.9% cases, and falling from a height of over 2 m in 29.7%. of those patients who had musculoskeletal injuries, in 31.1% the trauma mechanism was a fall from a height and in 28.2% pedestrians were struck by a vehicle, 36.1% of patients who fell from a height and 29.5% of those struck by a vehicle suffered visceral injuries. the most common cause of neurotrauma was a fall from a height in 33.7%, and pedestrians involved in car accidents in 29.8%. from the whole cohort, 27 patients were not saved, resulting in a 2.9% mortality rate. most patients (25) who died had iss [ 50. the mortality reached 2.3% among pedestrians struck by a vehicle and 5.1% among patients who fell from a height of over 2 m. conclusions: the most common mechanism in the cohort was a pedestrian struck by a vehicle, followed by falling from a height, with a predominant involvement of male patients. similarly, the most frequent cause of musculoskeletal injuries and visceral injuries was falling from a height and pedestrians struck by a vehicle, demonstrating an important direction for polytrauma prevention. introduction: recent reviews of uk trauma data show altering demographics. patients are increasingly older and sustain lower energy injuries, with falls \ 2 m being the most common (1) . material and methods: data collected over 5 years in a major trauma centre was used to calculate injury specific admission rates, case fatality rates and injury specific mortality attribution. data on patient age, footwear, lighting, alcohol intoxication and previous admissions were collected in falls \ 2 m resulting in mortality. results: patients sustaining falls \ 2 m represented 36% of admissions and 37% of mortalities. all falls represented 58% of admissions and 69% of mortalities. case fatality of falls of \ 2 m and [ 2 m was 6.59% and 9.35%. all fall case fatality was 7.62%. this was significantly higher than the case fatality of stabbings (1.0%) and rtas (4.7%). in falls \ 2 m causing fatality, mean patient age was 71.7 years. 50% of patients aged 40-59 were under the influence of alcohol when falling, with 56% aged 60-79, but only 13% patients aged 80-99. 12% aged 40-59 who died when falling were wearing slippers. this increased to 31% in those aged 60-79, and 50% aged 80-99. 69% of falls occurred under daylight/full light. 13% of patients aged 40-59 who died after falling had been admitted to hospital within the last year, although this increased to 19% in those aged 60-79, and 27% aged 80-99. conclusions: falls were the most common cause for hospital admission, had the highest case fatality of injury mechanisms and caused the most patient mortality. alcohol intoxication was associated with falls in younger patients who died after falling, but this was less common in older patients. wearing slippers was less common in the young but significantly associated with fatal falls in older patients. these results offer a range of therapeutic targets when developing fall prevention strategies. introduction: the treatment of splenic lesions is determined by the hemodynamic situation, the degree of injury and the presence of bleeding. arterial embolization has expanded the indications of the conservative treatment. retrospective observational study on splenic traumatism and its therapeutic options. material and methods: a total of 60 patients with splenic injury have been treated at our centre between 2014 and 2018. 43 patients were hemodynamically stable: 11 were embolized and 32 received a conservative treatment. 17 patients were hemodynamically unstable: 6 had a good response to the resuscitation treatment so they were embolized, but there was one patient who deceased because of other causes. from these 17 patients, 10 patients received splenectomy. results: the main objective of this study is to review the management of the trauma patient with splenic injury. of the total of 60 patients with splenic trauma, average iss of 27, 17 underwent splenic embolization, 17 underwent urgent splenectomy and 26 were treated with conservative treatment. the 17 embolized, 6 were hemodynamic unstable at arrival but responded to the fluid therapy, 3 had a splenic lesion grade iv, 1 a grade iii, 1 grade ii and another a grade i. the success rate of embolization was 100% in the 17 embolized patients. 7 patient died, only one of them in the embolization group and was not related to the splenic trauma nor embolization, 4 were in the urgent splenectomy group due to severity of trauma, 1 died before receiving any treatment and 1 in the conservative treatment group due to other complications. conclusions: patients who respond to volume or are hemodinamically with high-grade lesions, arterial embolization would be less aggressive treatment options with excellent results. haukeland university hospital, surgical unit/ regional traumacenter, bergen, norway, 2 norwegian university of science and technology, trondheim, norway, 3 haukeland university hospital, physical and rehabilitation medicine, bergen, norway, 4 university of bergen, bergen, norway, 5 st olavs hospital, physical and rehabilitation medicine, trondheim, norway introduction: during the past decades acute trauma care has improved through the development of highly specialized trauma centres and teams. since patients are considerable young when being affected, trauma may lead to life-long physical, cognitive and emotional constraints interfering with an independent self-determined life (1, 2) . in 2016, a revised national plan for the treatment of trauma patients in norway was published (3) . the plan emphasizes the importance of rehabilitation and the need for early interdisciplinary rehabilitation. this study will examine in which extent patients receive rehabilitation in early phase after trauma as recommended in the norwegian national plan. in addition we will examine what follow-up patients receive after trauma, quality of life, functional level and use of health care and next-of kin resources. material and methods: patients admitted to regional trauma center in mid-or western norway in 2017 with niss c 12 are recruited to participate. data will be collected from national trauma register, the norwegian patient register, the municipal patient and user register, data from statistics norway, the electronic patient record (epj) and the patient/relatives questionnaire. discussion: the results will be useful in the preparation of patient courses that comply with strong recommendations in the national trauma plan, ensuring equal treatment and raising awarness about rehabilitation for trauma patients. introduction: diaphragmatic lesions involve wounds and rupture of the diaphragm, through penetrating wounds or thoraco-abdominal trauma. their incidence is 1-15%. the diagnosis may be late, despite the technical advances made by medical imaging. the choice of surgical approach and technique is still controversial. mortality is usually related to the associated injuries. the present paper analyzes the incidence of diaphragmatic lesions that occur in thoraco-abdominal trauma, their epidemiology, diagnosis and treatment. material and methods: we performed a retrospective study over a 5-year period (2014-2018) , in the surgical units of the emergency county hospital of braila, including all patients diagnosed with diaphragmatic lesions. results: during the study period, 73 patients had thoracic-abdominal trauma. there were 41 cases of blunt trauma and 32 thoracic-abdominal trauma. our study involved 9 cases of diaphragmatic injuries (12.3%), 7 by road accident and 2 by white weapon. the sex ratio was 4:1. the average age was 38 years. chest radiography was a contributory preoperative diagnosis in 4 cases. the diaphragmatic wound was on the left side in 8 cases, and its average size was 5 cm. the surgical procedure involved the reduction in the abdomen of the herniated viscera and the monoplane suture of the diaphragm by nonabsorbable ''x'' points in all cases. chest aspiration was the rule. there was only one death in a complex polytrauma case. case history: we report the one case which performed tae, angioplasty, thoracotomy, laparotomy and preperitoneal pelvic packing (ppp) in the hybrid emergency room (h-er). the patient was male in the 60 s, who was riding on his motorcycle and fell from a 5 m height. clinical findings: he was in shock state. diagnosis: we scanned cect and diagnosed subdural hematoma, traumatic subarachnoid hematoma, lt hemopneumothorax, lung contusion, multiple costal bone fracture, intercostal artery injury, splenic injury (gradeiii), pelvic bone fracture. therapy: we inserted the drainage tube to the hemopneumothorax and did the tae for the pelvic bone fracture and splenic injury. after tae, he was in still shock state. the bleeding volume from the lt drainage tube increased, so trauma surgeons did the emergency thoracotomy and thoracic endovascular aortic repair (tevar) for intercostal artery injury. we suspected he also had abdominal compartment syndrome due to recanalization of tae, and they performed the emergency laparotomy and did ppp for the pelvic bone fracture. comments: we install an ivr-ct system in our trauma resuscitation room in october 2017. we named it h-er, as it enables us to do all examinations (sonography, ct and fluoroscopy) and treatments (ir, operation) required for trauma in a single room. we have to perform prompt diagnosis and treatment, especially in cases of severe polytrauma cases. a retrospective study proved that the h-er had shortened the time of ct initiation and emergency procedure and that lead to improve mortality 1). h-er is a novel trauma resuscitation room to do all treatments required in the only one room for severe traumatic patients introduction: according to the previous advanced trauma life support (atls) guidance, the early assessment of trauma patients with haemorrhage were classified upon the vital signs. recently, national trauma registry analyses suggested to extend the assessment criteria with the base deficit (bd), referring to the metabolic status. our objective was to investigate the relevance of bd and to explore new prognostic factors in the early assessment of the severely injured. material and methods: our study included 162 patients registered between 01.01. 2016 and 11.09 .2019 on our emergency ward for whom the trauma team was activated. they were grouped into severity groups (i-iv) according to either the vital signs (classical) or the extended criteria with bd. the data were extracted from medical documentations of the early phase of treatment. as primary outcome, we compared the 24-h mortality rate of the patient groups. we studied the need for massive transfusion and intensive care unit care as secondary outcomes. results: according to the classical assessment, 50% of the patients were assigned to group i (lowest risk for haemorrhagic shock) and 23% to group ii. the remaining 27% were grouped into groups iii and iv (higher risk). with taking bd into consideration, 58% were reassigned to a higher risk group; however, this change affected only groups i and ii. the 24-h mortality changed only in group i (0.7% vs 7.7%; p = 0.002). bd did not affect the need for massive transfusion. in groups i and ii, 3.5% of the patients, in groups iii-iv 23% needed intensive care unit treatment. conclusions: bd is an effective prognostic factor in the early assessment of trauma patients. however, compared to the vital signbased evaluation, it provides extra informaton only in less severe cases. according to our findings, it may help to assess the need for the administration of blood products. grants: nkfi k120232; ginop-2.3.2-15-2016-00015; efop-3.6.2-16-2017-00006 . complejo hospitalario de jaén, servicio de cirugía general y del aparato digestivo, jaén, spain, 2 complejo hospitalario de jaén, servicio de anestesiología y reanimación, jaén, spain case history: 56 years old male, with history of hypertension and dyslipidemia, suffered a backhoe accident and was admitted in a regional hospital. on initial assesment he presented contusion and two laceration wounds in left chest and in lumbar region. body ct informed subcutaneous emphysema and left rib fractures from 6th to 11th, left hemidiaphragm edema, laminar left pneumothorax and contusive lung. posterior lumbar hematoma and no intra-abdominal free fluid. laceration wounds were partially sutured, with drainages through the wounds clinical findings: he was transferred to our emergency department, presenting dyspnea, tachycardia, sweating, painful luq and left hemithorax worsening with breathing investigation/results: reviewed by our radiologist, tc images showed herniation of abdominal organs into the chest diagnosis: traumatic hernia in left costophrenic recess. multiple rib fractures therapy and progressions: the hernia contents (left colonic flexure and omentum) were reduced and defect closed with primary repair in emergency surgery. rib fractures treated by osteosynthesis.on 4th pod left renal artery dissection and renal infarction were evidence in a new ct. comments: diaphragmatic injuries are caused by blunt or penetrating thoraco-abdominal trauma. potentially life-threatening due to the herniation of abdominal organs and severe associated lesions. clinical suspicion is important as prompt diagnosis and treatment are necessary for good outcomes. in our case, the initial clinical assessment was incorrect and the transfer put the patient in danger as an emergency surgery should have been performed before transfer. this enhances the importance of a correct initial management of polytrauma patients. introduction: the fractures of the calcaneus account for about 1-2% of all fractures of the human skeleton. the majority of these fractures (70%) are intra-articular and surgical intervention is a widely accepted way of treatment material and methods: the aim of this study was to evaluate the results of open reduction and internal fixation for di-afc.in a period of 24 years (1995-2019) 70 patients (9 patients with bilateral fractures) with age range from 19 to 79 years old, were treated surgically using the lateral extensile approach. follow-up was 1-24 years. the results were evaluated based on x-ray parameters (calcaneal morphology, bohler''s and gissane''s angles), active range of motion, footwear problems and time needed to return to work. the sf-36 health survey was used for outcome assessment. results: fracture mean healing time was 15,6 weeks. the outcome was excellent in 32 cases, good in 28 cases and poor in 12 cases. the complications were malposition of fixation in 11 patients, superficial wound slough in 8 patients, reflex sympathetic dystrophy in 6 patients, deep infection in 2 patients who were treated with antibiotics and metalwork removal following union of the fracture. one patient resulted in metal breakage with consequent pseudarthrosis. finally one patient developed chronic osteomyelitis and is under treatment. the treatment with open reduction and internal fixation for di-afc is indicated, provided that the restoration of calcaneal shape, alignment and height is achieved. long term functional results with mild pain, few alterations in activities of daily living or work, and essentially no footwear problems, can be expected from a properly performed open reduction and internal fixation. extraperitoneal rectal injury in emodinamically unstable patient treated after dcs with external traction applied in an endorectal balloon r. somigli 1 1 hospital, general and emergency surgery, pistoia, italy case history: a 46-year-old man was crushed between two vehicles while he was working. he arrived in er hemodynamically unstable, so he underwent to emergency surgery. clinical findings: at rectal examination there was evidence of almost complete antero-lateral anorectal laceration. at abdominal examination there was evidence of anorectal full-thickness laceration and urethra full laceration. investigation/results: no diagnostic was required in preop because of patient instabilty. diagnosis: pelvic fracture with hemodynamic instability, severe rectal injury and complete prostatic urethra transection. therapy and progressions: el, lateral colostomy, pelvic paking, cistostomy and hip external binder. damage control surgery was performed. on 3 pod second look was carried out and an almost complete extraperitoneal rectal injury was found during pelvic depaking. properitoneum was drained and a baloon probe was introduced in the rectum to allow the proximal rectal flap to advance to the distal rectum. stomal washes were performed with no rectal leak and rectal baloon traction mantained for 10 days. radiological and endoscopic check haven't shown any leak and a good mucosal reconstruction. mri no sphincteral anatonical defects. waiting for emg before stoma reversal. comments: the optimal managment for extraperitoneal rectal injuries remains controversial. an approach with lateral colostomy and conservative treatment of rectal lacerations with rectal trac-tion baloon, could represent a safe treatment alternative in those cases with sphincter preservation, with a lower risk of complication. exploring differences between iss and niss scores for 30-day mortality in adult and elderly trauma patients in a norwegian national trauma cohort m. introduction: injury severity score (iss) and new injury severity score (niss) with a threshold over 15 is commonly used to define severe injury and to define the study population in trauma registrybased studies for both adult and elderly trauma patients (1) . for elderly patients (c 65 years) this might be unreasonably high and might lead to exclusion of significantly injured elderly with increased risk of mortality. the aim of this study was to assess whether there were significant differences in 30-days mortality between adults and elderly trauma patients for different frequently used iss and niss thresholds material and methods: the norwegian trauma registry was interrogated to identify all adult (c 16 years) trauma patients included in the registry from january 2015 through december 2018. data were dichotomized to age groups ''adult'' and ''elderly'' (16-64 and c 65 respectively) with 30-days mortality as primary endpoint. mortality rates were assessed for iss and niss thresholds of [ 9, [ 12 and [ 15. we applied descriptive statistics and chi-squared test for comparisons. results: 23768 patients with available information about age, 30-days mortality and iss and niss scores were included in the analysis, of which 16224 patients were 16-64 years old and 4706 patients were c 65 years. 238 adult and 500 elderly patients died, giving overall mortality rates of 1.5% and 10.6% respectively. for iss and niss [ 9 there was a significantly higher 30-days mortality in elderly trauma patients (17.3% and 15.2% respectively) than adult patients (4.7 and 3.8% respectively) (p \ 0,001), as for all other iss and niss thresholds tested. conclusions: this study demonstrates that elderly trauma patients has a significantly higher mortality risk than adult trauma patients at all iss or niss-thresholds analysed. this group has a significant mortality even at iss and niss above 9. introduction: the trauma tertiary survey (tts) is a widely accepted tool in the prevention of missed injury. existing literature on its effectiveness focusses on multitrauma patients. this study investigates the yield of the tertiary survey in trauma who are admitted for tts, without having any significant injury. material and methods: a single center retrospective cohort study was performed in a level ii trauma center. trauma patients without any clinically significant injury at the primary and secondary survey were included. the primary outcome was missed injury found during tts (type 1). secondary outcomes were missed injury found after tts but during admission (type 2), mortality and hospital length of stay [ 2 days. results: from 355 included patients, 11 patients (3.1%) had a type 1 missed injury. alcohol consumption was associated with an increased risk for type 1 missed injuries (odds ratio = 5.49, 95% ci: 1.36-22.16) . a type 2 missed injury was only found once, it concerned the only case of trauma related mortility. out of 335 nonoperated patients, 65 (19.4%) were admitted for more than two days. these patients were significantly older (71 vs. 39 years, p \ 0.001) and had a higher asa classification, 3-4 vs. 1-2 (47.5% vs. 12.7%, p \ 0.001). conclusions: tts showed missed injuries in only 3.1% of trauma patients who had no clinical significant injury found during primary and secondary survey. high costs of admission, together with a low yield found for this study's population the cost benefit of hospitalizing these patients is for discussion. future research should therefore focus on the identification of predictors of a positive tertiary survey. references: 1. advanced trauma life supportò student course manual. 2. keijzers, et al., the effect of tertiary surveys on missed injuries in trauma: a systematic review. 3. enderson et al., the tertiary trauma survey: a prospective study of missed injury. the 4-h rule in the emergency department and its association with surgical mortality in one public hospital in israel: retrospective study i. ashkenazi 1 1 hillel yaffe medical center, hadera, israel introduction: in order to improve patient treatment the 4-h rule in the emergency department (ed) was introduced in many countries as well as in israel. within four h, patients attending the ed must be seen, treated, and a decision must be reached whether these patients are to be admitted or discharged. though a popular performancebased measure, whether the 4-h rule in ed is associated with a decrease in mortality is controversial. the primary objective of this study was to evaluate the association between time in the ed and surgical mortality in one public hospital in israel. material and methods: included in this retrospective study were patients admitted to the ed of hymc during 2017. patients dying on the first day were excluded. . results: included in this study were 106,766 patients. of these, 28,108 (26.3%) patients were hospitalized and the rest were discharged. overall, 825 patients died. general surgery accounted for 18,391 patients of which 73 died (8.8% of hospital deaths; 0.4% of all surgical patients; 1.9% of patients hospitalized in general surgery). internal medicine together with general surgery and orthopedic surgery accounted for 98.5%, 98.6% and 98.5% of the mortalities observed in patients with decisions made within 0-4 h, in patients with decisions made beyond 4 h and in all the patients respectively. forty-five patients with decisions made within 4 h died compared to 28 with decisions made beyond 4 h. these represent 0.3% and 0.6% of all surgical patients in the ed (whether hospitalized or discharged) and 1.9% and 1.9% of those hospitalized. conclusions: general surgery is the second largest contributor to hospital morality. in both absolute terms and relative terms, mortality was not increased by delays in decisions made beyond 4 h. the adoption of this performance-based measure should be questioned. introduction: trauma is an important cause of mortality [1, 2] . researchers are looking for optimal death/survival predictive models in trauma population. one way is to validate traumatic scores for different medical systems [1] . the aim of our study was to validate the new injury severy score (niss) in severe trauma ( introduction: the international classification of diseases-based injury severity score (iciss) has been proposed as a reliable tool to measure trauma system performance especially in countries where a trauma registry has not been yet established. the purpose of this study is to assess the predictive capability for in-hospital mortality of iciss with international and adjusted survival risk ratios (srrs) in greek trauma population. material and methods: this single center, retrospective cohort study was conducted in a greek tertiary care hospital between january 2015 to december 2018. the trauma population was defined as hospitalized patients with a principal hospital discharge diagnosis in the range icd-10 s00-t79. duplicated injury icd codes, readmissions, transfer to another hospital and missing data were excluded. the primary outcome was in-hospital mortality. adjusted srrs was calculated from patients with multiple injuries and the following two iciss scores were evaluated: multiplicative-injury (iciss) and singleworst-injury (swi). the models were assessed in terms of their discrimination, measured by receiver operating curve (roc) analysis and calibration measured using calibration curves. results: a total of 30195 patients were included in the study. median age was 60 ± 22 years and mortality rate was 2,1%. based on international srrs, the area under the curve was 0,839 (95% ci 0.826-0.852) for iciss-multiplicative and 0,839 (95% ci 0.826-0.852) for iciss-worst injury. both modes had statistically significant better performance with adjusted greek srrs (aur = 0,877 95% ci 0.867-0.887 and aur = 0,880 95% ci 0.870-0.890, respectively). conclusions: this analysis has demonstrated the validity iciss model for in-hospital mortality prediction in greek trauma population. further research is warranted to confirm the performance of iciss using a sufficiently sized sample to define national srrs. introduction: the occurrence of intra-abdominal abscesses is the most serious post-operative infective complication after appendectomy. a significant amount of research has been conducted in an attempt to identify those patients at greatest risk. pct is initially described as an early, sensitive and specific marker for sepsis associated with bacterial infection. we hypothesize that pct could serve as a predictor of the development of intraabdominal abscess and postoperative infective complication material and methods: the present study is a prospective, single centre, observational cohort study involving patients undergoing emergency appendectomy. all patients admitted to the acute care surgery ward for appendicitis were screened for study eligibility. pct poc samples will be obtained preoperatively (t0) and post procedure (t1) at 24 h (t2), 48 h (t3), and 5 days (t3) post procedure. the primary objective of this study was to assess the diagnostic accuracy of point-of-care testing for pct in identifying post appendectomy abscess. the secondary objective was to determine the diagnostic accuracy in identifying any infective complication conclusions: we expect the incidence of abscess and infective complication to be increased in the pct elevated group compared with the control group. previous investigations indicate the overall morbidity related to infective complication is approximately 1-10% of patient undergoing laparoscopic appendectomy. our pilot study revealed that the incidence could be as high as 15% in patients with prolonged elevated pct levels. introduction: hand trauma is a common cause for attendance to the accident and emergency (a&e), accounting for nearly 10-30% of all patients 1 . it is essential that accurate treatment and management is done as the implications of mismanagement are long term, which may lead to disability, loss of work and income, livelihood, and even psychological issues 1 . the presence of a specialised hand surgeon is essential for management of these injuries 2 , but in the a&e setting it is not always possible to have such specialised care and there is a need for an efficient triage system. materials and methods: we did an audit in our department and found a delay in the referral of patients from a&e to our trauma clinic, which was quite expected due to a high patient inflow. we devised a trauma pathway for the a&e, known as the d-system which outlines for them till what day from trauma is a particular hand patient safe to be sent to the hand clinic or who needs an urgent referral to a higher trauma centre, based on urgency of need of intervention. the pathway is in the form of a simple flowchart, which is easy to understand even for junior members of the team. we intend to do another audit after implementation of the pathway to assess change in practice. conclusion: it is essential to have simplified pathways for non-specialist areas in order to streamline treatment and offer the best care, in the limited availability of resources, especially at smaller hospitals. our aim is to develop one such system and assess it's effective in delivering better care. introduction: a quantitative method for measuring trauma severity has many potential applications. the intent of this study was to evaluate the accuracy of the mgap score and its components in prediction of in-hospital mortality versus the accuracy of the revised trauma score rts at a trauma center. material and methods: this study included 825 patients with trauma. data regarding age, mechanism of injury, systolic blood pressure, glasgow coma score and respiratory rate were collected at trauma center of alberto torres hospital. mgap and rts scores were calculated, and their accuracy to predict survival/death outcome. results the study included 825 patients, ranging in age from 2 to 89 years, 69% male. from the total sample, 159 patients who suffered from penetrating trauma and 666 patients who suffered from blunt trauma were observed. in the comparison of the scores, rts and mgap, there was no significant superiority in any of them for predicting the outcome -which in our study was hospital discharge or death -even when compared by trauma mechanism. the gcs proved to be a very sensitive criterion in both scores, especially in patients with traumatic brain injury, totaling 62 patients in our statistical analysis, of which 56,4% had a negative outcome. rts was slightly superior than mgap in patients classified by the score as high chance of mortality, with 75% versus 69% of assertiveness. conclusions: up to the moment, there is no evidence to support the superiority of one of the analyzed scores as a predictor of mortality in the patients evaluated. although the rts score is more widely used in trauma centers, the application of the mgap score is more feasible in pre or in-hospital care of polytrauma patients, since it does not use respiratory rate in its parameters. validation of d-dimer for screening for venous thromboembolism in pelvic and lower extremity trauma patients t. uehara 1,2 , t. noda 3 , t. yumoto 4 , n. kobayashi 5 , a. nakao 4 , t. ozaki 2 1 okayama university, emergency healthcare and disaster medicine, okayama, japan, 2 okayama university, orthopaedic surgery, okayama, japan, 3 okayama university, musculoskeletal traumatology, okayama, japan, 4 okayama university, emergency and critical care medicine, okayama, japan, 5 okayama saidaiji hospital, okayama, japan introduction: venous thromboembolism (vte) is a life-threatening complication after major trauma patients. we previously reported that the patients with higher injury severity score (iss) and lower extremity trauma had high risk for vte. additionally, high d-dimer levels (cut-off d-dimer value, 12.45 lg/ml) on day 10 were useful for screening for vte in major trauma patients. we validated d-dimer levels for vte screening for patients with pelvic and lower extremity trauma. material and methods: a retrospective study was undertaken between april and august 2019 at the okayama university hospital. 19 patients with pelvic or lower extremity trauma were included (median iss, 18). we collected following data; age, sex, iss, the number of operation times, value of d-dimer in screening, incidence of vte and use of anticoagulants. results: eleven patients showed high d-dimer levels in screening, furthermore, six patients were diagnosed vte using contrast-enhanced computed tomography. symptomatic pulmonary embolism was not occurred. patients with vte had undergone orthopaedic surgeries two or more times. fourteen patients received therapeutically or prophylactic anticoagulation therapies. conclusions: measurements of d-dimer levels after pelvic or lower extremity trauma patients were useful for screening of incidence of vte. direct oral anticoagulants were convenient for treatment to vte. trauma patients often needed several times of surgeries, heparin was also useful in perioperative period. introduction: early assessment of the clinical status of severely injured patients is crucial for guiding surgical treatment. several scales are available to differentiate between risk categories. we compared four established scoring systems in regard to their predictive abilities for early versus late in-hospital complications. methods: database from a level i trauma center. the following four scales were tested: the clinical grading scale (cgs; covers acidosis, shock, coagulation, and soft tissue injuries), the modified clinical grading scale (mcgs), the polytrauma grading score (ptgs), and the early appropriate care protocol (eac; covers acid-base changes). admission values were selected from each scale and the following endpoints were compared: mortality, pneumonia, sepsis, death from hemorrhagic shock, and multiple organ failure. results: in total, 3668 severely injured patients were included (mean age, 45.8 ± 20 years; mean iss, 28.2 ± 15.1 points; incidence of pneumonia, 19.0%; incidence of sepsis, 14.9%; death from hem. shock, 4.1%; death from multiple organ failure (mof), 1.9%; mortality rate, 26.8%). istinct differences in the prediction of complications, including mortality, for these scores (or ranging from 0.5 to 9.1). the ptgs demonstrated the highest predictive value for any late complication (or = 2.0), sepsis (or = 2.6, p = 0.05), or pneumonia (or = 2.0, p = 0.2). the eac demonstrated good prediction for hemorrhage-induced early mortality (or = 7.1, p \ 0.0001), but did not predict late complications (sepsis, or = 0.8 and p = 0.52; pneumonia, or = 1.1 and p = 0.7) cgs and mcgs are not comparable and should not be used interchangeably (krippendorff a = 0.045). conclusion: our data show that prediction of complications is more precise after using values that covers different physiological systems (coagulation, hemorrhage, acid-base changes, and soft tissue damage) when compared with using values of only one physiological system (e.g., acidosis). none of the authors have any conflicts of interest to declare. mortality rate related to trauma mechanisms in trauma center at alberto torres hospital from january 2014 to july 2019 r. p. pereira 1 , r. adriana martins 1 , j. a. c. padilha 1 , f. e. silva 1,2 , d. rangel 1 1 alberto torres hospital, trauma center, são gonçalo, brazil, 2 federal university of rio de janeiro, niterói, brazil introduction: to demonstrate the healthcare services of the trauma center of rio de janeiro based on epidemiological data and on the specificity of the type of initial care delivered to multiple trauma patients, comparing the mortality rate at the second peak of death with the worldwide literature. materials/methods: retrospective study extracted from ''ct heat'' database. polytraumatized patients of both sexes were included and the mortality rate was calculated taking into account the second peak of death from trauma, gender, age and primary mechanisms of injury. discussion: the data collected show 3% mortality in the second peak, with firearm projectiles (40%) followed by traffic accident and fall as the primary causes of death. conclusion: because of the structural and health care profile of this trauma center, it was possible to reach the desirable mortality rate according to the worldwide literature (less than 5%). introduction: trauma patients are sometimes in critical condition upon arrival and need aggressive treatments to survive. despite all efforts many end up dying. it seems necessary to try to identify those patients with a very high risk of death to avoid futile treatments. the aim of our study was to develop a simple clinical tool to predict mortality in trauma patients that can be easily calculated in the ed. material and methods: we analyzed data from all trauma patients arriving at a spanish trauma hospital from june 1993 to june 2018. patient demographics, physiologic trauma scores, vital signs, and glasgow coma scale (gcs) were recorded. our primary outcome was mortality. logistic regression analysis (lra) was performed using three variables (age, shock index (si), and gcs) to determine the appropriate weights for predicting mortality. using them, we constructed a simple score to calculate mortality. results: 2678 patients were studied. the mortality rate was 15.9%. our score was constructed using weights derived from lra for age [ 55y (2 points), si [ 1(3 points) , and gcs conclusions: our score is easy and quick to calculate and could be a useful tool to predict mortality using early available parameters upon arrival in the ed. acknowledging the ethics involved in this topic, this score could sort out patients with a very high risk of death and in whom aggressive therapeutic measures could be limited early or withdrawn in agreement with family members references: haider a, et al (2019) (2015) (2016) states the average cost for an a&e attendance and non-elective inpatient stay is £138 and £1,609 respectively highlighting the importance for schemes to reduce hospital admissions. assess impact of ambulatory care, surgical emergency assessment unit (seau) and ''emergency surgeon of the week'' (esw) on hospital admissions for surgical referrals (gp/ a&e). material and methods: retrospective analysis of prospectively collected data of hospital admissions from the patient centre database before and after implementation of seau (in november 2014) and esw (in november 2017), including the units'' activities. emergency general surgeon followed 1:5 (monday-thursday, 0800-1800) rota based at seau. results: since 2014 (50 months), seau has reviewed 12451 (new 7543; follow ups 4908) patients. surgical admissions (sa) pre and post implementation seau were 766* and 629*/month respectively, a drop by 18%. esw helped a further drop by another 14% to 520*/month. 58% of new referrals were admitted and overall 35% of all patients reviewed were admitted. juniors (st3/st4) and seniors (st5-8/staff grades/consultants) admitted 40% and 34% of the referrals respectively. 2950 uss and 1959 ct were performed in dedicated seau slots. 98% attending seau were likely to recommend the unit to friends or relatives. conclusions: in the face of unprecedented demand for hospital beds (more so in the winter), ''emergency surgeon of the week'' based at seau could be the answer to relieving the capacity, financial pressures and providing high quality safe patient care for our already strained nhs. surgical emergencies, an educational and medico-economic challenge introduction: surgical emergencies are a frequent reason for consultation in the emergency department and are responsible for significant morbidity and mortality. our study aims to present the number of patients admitted for a surgical emergency in a french level 1 trauma-center and the volume of patients operated in emergency depending on the different specialties. method: we conducted a retrospective, single-center study of the hospital emergency department (uas) of the university hospital center of nice between january 2017 and december 2018. we studied the volume represented by surgical emergencies according to the different specialties. results: the emergency department welcomed 192,004 patients, of which 38,351 surgical emergencies patients accounted for 20% of the total activity; 14397 patients were operated on urgently, which represents 35% of all surgical procedures in our hospital. conclusion: surgical emergencies are an important part of the activity of our hospitals. an academic definition is difficult to achieve. a regional organization is needed for the management and optimal care of these patients. the creation of regional centers, as for the trauma centers, seems indispensable, especially for the most serious patients, allowing both a better medico-economic and educational management of surgical emergencies. introduction: every new admission to the icu prompts a handover from the referring department to the icu staff. this step in the patient pathway provides an opportunity for information to be lost and for patient care to be compromised. mortality rates in intensive care have fallen over the last 20 years, however, 20% of patients admitted to an icu will die during their admission (1) . communication errors contribute to approximately two-thirds of notable clinical incidents; over half of these are related to a handover (2) . nice have concluded that structured handovers can result in reduced mortality, reduced length of hospital stay and improvements in senior clinical staff and nurse satisfaction (3) . material and methods: a checklist was created to review to score the handover. this was created with doctors and nurses and is relevant for handovers between all staff members. information was gathered prospectively by directly observing 17 handovers on the icu. results: there is a notable discrepancy in the quality of handovers of new patients. this is true of handovers between doctors, nurses and a combination of the two. 41% (n = 7) of patients weren't handed over to a doctor. the most commonly missed pieces of information were details of the patient's weight (96%, n = 16), their height (100%, n = 17), whether the patient has previously been admitted to an icu (78%, n = 15) and whether the patient has any allergies (71%, n = 12). conclusions: the handover of new patients to the icu is often unstructured and important information is missed. this can be said for all staff members and grades, and for handovers from all hospital departments. introduction: bowel resection for acute mesenteric ischaemia (ami) in elderly is associated with significant morbidity and mortality, and increasing age and frailty are associated with increased risk. this study aims to assess the short-term outcomes for elderly patients undergoing surgery for ami, and to assess the accuracy of surgical risk calculators in this population, to determine their utility in preoperative discussions. introduction: intertrochanteric femoral fracture of the super-elderly is often difficult to treat because good surgery does not always lead to good functional prognosis. we investigated the factors affecting the functional prognosis in patients with intertrochanteric fracture over 90 years old. material and methods: 94 cases of intertrochanteric fracture over 90 years old who had undergone surgical treatment at our hospital between december 2010 and september 2018 were examined. nine men and 85 women, age at injury ranged from 90 to 101 years, with a median of 93 years. the average postoperative follow-up period was 3.7 months. for these cases, the mobility was classified into independent walking, assisted walking (cane, walker), wheelchair, bedridden, and the transition of pre-and postoperative mobility was analyzed. the significance test was performed using the mann-whitney u test, and p \ 0.05 was considered significant. results: by fracture type, when jensen classifications i and ii were stable, iii, iv, and v were unstable, mobility of unstable type was significantly reduced (p = 0.024). when the waiting period for surgery is divided by the median of 4 days, there was no difference in mobility reduction between groups of less than 4 days and groups of more than 4 days (p = 0.925). although there was no significant difference in the presence or absence of preoperative rehabilitation intervention (p = 0.08), there was a tendency for less decline in mobility when preoperative rehabilitation intervention was performed. conclusions: in the treatment of this fracture, early surgical treatment after injury is recommended, but in the case of very elderly people, waiting is often required due to existing diseases and poor general condition . this study suggests the importance of preoperative rehabilitation intervention during the waiting period for surgery to prevent disuse disorders. references: 1. kelly-pettersson et al. waiting time to surgery is correlated with an increased risk of serious adverse events during hospital stay in patients with hip-fracture: a cohort study international journal of nursing studies 69 (2017) 91-97. older patients with traumatic shock exhibited lower pulse pressure compared with younger patients; an analysis of nationwide trauma data base in japan introduction: the study purpose was to assess the effect of age on the relationship between pulse pressure (pp) and systolic blood pressure (sbp) in patients with traumatic shock. material and methods: in this retrospective cohort study using nationwide trauma data base in japan from april 2004 to may 2019, trauma patients 18 years of age and older with sbp \ 90 mmhg were selected. patients with severe traumatic brain injury (the abbreviated injury scale on head [ 3) and cardiac arrest (hr = 0 and sbp \ 60 mmhg) were excluded. linear regression analysis assessed association between pp and sbp interacted by age group dichotomized as \ 60 or c 60 years old. results: during the study period, 12444 patients were included. the linear regression analysis indicated the significant association between pp and sbp in overall population (ec, estimated coefficient = 0.37 95%ci [0.33, 0.37], p \ 0.001). association between pp and sbp was significantly interacted by the age group (ec = 0.32 95%ci [0.29, 0.35] introduction: high rates of trauma in south africa (sa) predominantly affect the youth, yet the geriatric population is not exempt. 1 in addition to inherent challenges of age, elderly trauma patients are further compromised by resource constraints. 2 we aimed to assess injuries and outcomes in elderly patients admitted to a tertiary trauma unit in sa. material and methods: a retrospective record review was done of all patients 60 years and older, admitted to the trauma unit over an 8-month period. injury severity score (iss), mechanism of injury (moi), in-hospital complications and length of hospital stay were documented. results: 275 patients (mean age: 72 years; 57% female) were included with mean iss of 8. the most frequent mois included nontraumatic falls (54%), falls from height (10%), motor-vehicle collisions (9%), pedestrian vehicle collisions (7%), and blunt injuries (8%, 87% intentionally inflicted). eighty patients (30%) experienced at least one in-hospital complication. the mortality rate was 7%. the mean length of hospital stay was 7 days. conclusions: despite the known vulnerablities of the elderly, the mortality rate and isss of this cohort were relativley low. however, when compared to first world literature, intentionally inflicted injuries and certain preventable mois (e.g. fall from height and pedestrian vehicle collisions) were common, [3] [4] introduction: the majority of new colorectal cancer is diagnosed in people [ 65 years, yet the elderly are less likely to undergo curative surgery. chronological age is poorly correlated with post-operative outcomes and is not an acceptable measure of risk. conversely, frailty is a strong predictor of poor outcomes following surgery and presents an opportunity for patient optimisation. the aim of this systematic review is to assess the available evidence between frailty and outcomes in patients of all ages undergoing surgical resections for colorectal cancer. material and methods: pubmed was searched for articles reporting outcomes for patients deemed frail undergoing elective or emergency colorectal cancer resection up until august 2019. the primary outcome was mortality (30 and 90 day). secondary outcomes; length of stay, readmission, reoperation & post-operative complications. results: 143 studies identified, 17 studies were deemed eligible for inclusion. study types, frailty assessments & outcomes measured were variable. despite this heterogeneity, categorisation of ''frailty'' was associated with higher rates of post-operative mortality, complications, readmission, and length of stay. conclusions: based on current evidence, frailty is a strong predictor of poor clinical outcomes in patients undergoing surgery for colorectal cancer. standardisation of frailty assessment and measure of outcomes is needed for more robust analysis. accurate risk stratification of patients will allow us to make informed treatment decisions and identify patients who may benefit from prehabilitation and intensive tailored post-operative care. introduction: pneumatosis intestinalis (pi) and hepatic portal venous gas (hpvg) are two radiological findings associated with a broad range of medical conditions. pi can be primary (15% of cases),usually with a benign course, or secondary (85% of cases),which results from obstructive or ischemic gastrointestinal diseases. only a minority of pi is associated to free abdominal air. in literature there is no consensus on radiological and biochemical markers of favourable outcome nor on treatment options-medical or surgical. we tried to identify prognostic markers in a series admitted to a single university hospital. material and methods: the medical records of 36 patients with pi and/or hpvg admitted to ospedale maggiore policlinico (milan, italy) in the period 2012-2019 were collected the ct scan were reviewed by a single radiologist. results: mean age was 76.4 ± 14 years (43-94). pi was primary in 13,9% of the patients (n = 5), and secondary in 86,1% (n = 31). at ct, pi was associated to portal gas in 13 patients (36%) (8 dead, 6 alive) and to free air in 7 patients (20%) (4 dead, 3 alive). linear or rounded gas collections were equally distributed in primary and secondary pi. the colon was involved in 16 patients (44%), followed by the small intestine in 15 (41,6%),and the stomach (n = 2). in 7 patients serum lactate was [ 4, and 6 died. leucocytosis (wbc [ 11,000/mm 3 ) was present in 8 patients (1 alive).four patients had peritonitis and 2 abdominal tenderness. laparotomy was performed in 1 primary (alive) and 16 secondary pi (4 deaths).in two patients it was diagnostic; in 6 and 2 associated to right or left colectomy, in 3 to ileal resection and in 3 to other procedures.surgery was judged futile in 12 patients; all died a few hours after emergency department access. conclusions: we could not found any relationship between clinical, biochemical and radiological findings and outcome of pi. mesenteric and portal gas is a ominous finding, but did not reach significant value. successful transcatheter arterial embolization for a giant pseudoaneurysm of gluteal muscle due to ground level fall in elderly woman with direct oral anticoagulants t. kadoya 1 , r. nakama 1 , k. arakawa 2 , t. ogura 1 , k. kase 1 1 saiseikai utsunomiya hospital, department of emergency medicine and critical care medicine, utsunomiya, japan, 2 saiseikai utsunomiya hospital, department of radiology, utsunomiya, japan case history: a 90's year-old woman using apixaban fell on the ground and was transferred to previous hospital. magnetic resonance imaging was taken and she was diagnosed as gluteal hematoma. she was treated conservatively but hemoglobin (hb) level was gradually decreased. although she was administered red blood cell as needed, anemia progressed. contrast-enhanced ct showed expanding hematoma of gluteal muscle. she transferred our hospital for advanced treatment including surgery on 5th day on hospital. clinical findings: vital signs were stable on arrival at our hospital. extensive subcutaneous hematoma was found in the right thigh and gluteal lesion. investigation/results: laboratory test showed that hb 6.6 g/dl and normal coagulation status. contrast-enhanced ct showed a giant pseudoaneurysm inside the gluteal muscle. therapy and progressions: angiography showed a giant aneurysm of peripheral branch of internal iliac artery. we performed transcatheter arterial embolization (tae) for it by gelatin sponge. after tae, there was no complication and progressive anemia was stopped. she was transferred to another hospital for rehabilitation six days after tae. comments: increase use of direct oral anticoagulants in elderly people could induce severe hemorrhagic trauma by minimal mechanism. tae is minimal invasive and safety procedure for such trauma case. introduction: the number of elderly people will increase during the next few decades. more importantly, the number of people aged 80 or above are projected to increase 100% in developed countries. in spain, people over age 80 were 4.68% of the population in 2009, and this will increase to 6.19% in 2019. that has implications in the health services and in the management of trauma patients. material and methods: we did a retrospective cohort analysis of trauma patients c 80 y.o. admitted to our level i trauma center during the time-period of 2009-2019. demographic data, icu care, and mortality were assessed. results: 109 trauma patients c 80 y.o. were admitted during that period. this is a 200% increase compared with the number of patients admitted during the previous decade (1999) (2000) (2001) (2002) (2003) (2004) (2005) (2006) (2007) (2008) (2009) . mean age was 84.8 ± 2.4 years, and median new injury severity score (niss) was 17 (interquartile range 13 to 27). 46% were male. the mechanism of injury was 50% falls, and 47% pedestrian runovers. 48 patients were admitted to icu, with median niss of 25 and mortality rate of 38%. among severely injured trauma patients (niss c 35) the hospital mortality rate of those c 80 years was 90%, much higher than in the age group of 65-79 years (40%), with a significant difference (p \ 0.05). no differences mortality rates between 65-79 years and youngers with the same niss. conclusions: the geriatric trauma patient population is on the rise worldwide. this should be taken into account in our trauma centres in order to be able to adapt and try to improve trauma care in these patients. introduction: frailty is a geriatric syndrome which has been considered as a risk factor in the elderly, increasing adverse events in terms of global health, as hospitalization, increase of falls, need of institutionalization, and mortality. the aim of this study is to evaluate relationship between frailty, and the presence of major complications in the postoperative course of patients older than 70 years undergoing emergency surgery. material and methods: prospective, longitudinal, cohort study, using four different scales of frailty as a predictor of risk for short-term adverse events, for patients during the postoperative course of emergency surgery (may 2017-september 2018). the sample is categorized according to four frailty scales (clinical frailty scale, frail score, trst and share-fi) . we analyze the variables regarding diagnoses, clinical examination at admission, surgical procedures, and postoperative outcomes during the first 30 days. clavien-dindo classification was used in order to graduate the severity of complications. results: 92 patients were included with a mean age of 78,71 years (sd 6, 26) . 53,3% of the simple are women. frailty prevalence ranges, according to the frailty scales, from 14,13% to 46%. median hospital stay was 6 days ( iqr 3, 65) . all four frailty scales show statistical differences to predict major complication in our simple. trst and frail scales show the strongest measure of association (or 7,69 and 5,92, respectively). the frail phenotype, is also related to an increased of mortality, and frail scale is the frailty scale with largest or (or = 16,071).only frail show association with longer hospital stay ([ 12 days), and reoperation rate. conclusions: frailty represents a predictive marker of major complications and mortality, for patients older than 70 years undergoing emergency surgery. frail score, shows the strongest relationship with mortality and complications. introduction: age has been identified as a predictor of trauma mortality [1] and it is known that even low energy trauma may cause severe injuries in the elderly [2] . the aim of this study was to explore how the elderly trauma patients, and the care thereof, differ from the younger ones in a swedish context. material and methods: the swedish trauma registry (swetrau) was used. consecutive recorded trauma cases that presented at one level ii trauma hospital during december 2019-august 2019 were included (n = 676). patients were stratified into groups; those c 65 and those results: in the c 65 years group, sex distribution was more even (female 49.6 vs 34.9%, p \ 0.05), physical status according to pretrauma asa classification was higher (mean 2.62 vs 1.45, p \ 0.05) and the trauma mechanism was predominantly low-energy (falls from no height) as opposed to the conclusions: the trauma among elderly swedish patients are more often of low energy compared to the younger population. in spite of this, the elderly are more severely injured, require more surgical interventions, and their short term mortality is increased 20-fold. measures aimed at prevention of low energy trauma of the elderly are therefore much needed. introduction: there are intramedullary or extramedullary methods in internal fixation od trochanteric fractures. seldynamisalbe internal fixator with two sliding screws (sif), as an extramedullary method, and gamma nail (gn), as an intramedullary method, are in routine trochanteric fractures treatment at our institution for last two decades. material and methods: health related quality of life and hip function were assesed at least two years after surgery, in the series of 71 patients with a surgically treated ao 31a1 or 31a2 fracture type. there were two groups of patients: group treated by sif and group treated by gn. examination had been performed using sf-12 test, with its physical component score (pcs) and mental component score (mcs), and harris hip score (hhs) tests. results: in sif group, mean pcs was 59,7, mean mcs was 64,9 and mean hhs was 70,7. in gn group mean pcs was 68,2, mean mcs was 70,7 and mean hhs was 76,3. there was no significant difference regarding all these parameters between the groups of patients (p [ 0,05). there was correlation between all evaluated parameters, both in groups of patients particularly and in all patients (p \ 0,05 we identified undertriage in 31,6% (31/98). falls from own height (0-1 m) was found in 54 patients with iss [ 15, 25/54 (46%) of them was found to have been undertiaged (p 0.004). we found an association between gcs \ 15 and undertriage (p = 0.01). 60% (206/341) falls between 0-1 m and 30% (61/ 206) of these without trauma team. falls between 1-5 m 12,5% (15/ 120) without trauma team. all 10 with fall [ 5 m had trauma team. mortality was 12% (41/341), no association between height of fall and mortality (p 0.237). undertriage was not associated with increased mortality (p = 0,104). median age in mortality group was 87 years versus 73 years in surviving group (p \ 0.001). in univariate analysis there was association between prehospital bp \ 90 (p 0.043), gcs \ 15(p \ 0,001), iss 3 16 (p \ 0.001), prehospital rr [ 30, rts \ 12 (p \ 0.001) asa score [ 1 (p \ 0.001) and mortality. conclusions: we found significant undertriage in the geriatric trauma population with fall injuries. gcs \ 15 and low energy falls was associated with undertriage but not with mortality. laparoscopic direct repair of an incarcerated spigelian hernia c. bergamini 1 , v. iacopini 1 , r. de vincenti 1 , a. bottari 1 , g. alemanno 1 , p. prosperi 1 1 aou-careggi, emergency surgery, firenze, italy spigelian hernia occurs through a defect in the anterior abdominal wall adjacent to the semilunar line. it is in itself very rare and more over it is difficult to diagnose clinically. it has been estimated that it constitutes 0.12% of abdominal wall hernias. the majority of patients present with symptomatic incarceration of preperitoneal fat or intraabdominal viscera. radiographic studies are beneficial in confirming the diagnosis. the high rate of incarceration with or without strangulation mandates operative repair once the diagnosis is confirmed. the spigelian hernia has been repaired by both conventional and laparoscopic approach. laparoscopic management of spigelian hernia is well established. most of the authors have managed it by transperitoneal approach either by a direct repair or by placing the mesh in intraperitoneal position or raising the peritoneal flap and placing the mesh in extraperitoneal space. there have also been case reports of management of spigelian hernia by total extraperitoneal approach. we present the case of an obese eighty-four y.o patient. complaining for a sudden onset abdominal pain in the right low quadrant, mimicking an appendicitis. the ct scan demonstrated a typical picture of a spigelian hernia containing an intestinal loop. the loop showed classical signs of parietal wall ischemia. the video describes the surgical laparoscopic approach of this case which was able to confirm the diagnosis e to reduce the loop into the abdomen. the loop initially appeared diffusely ischemic, but after the intra-abdominal reduction some signs of vitality started to be noticed. however, they were incomplete; thus the loop was resected. the hernia defect was successively repaired in a direct way because of the small caliber (\ 4 cm of diameter) and the possible contamination coming from the intestinal resection. post-operative course was particularly benign and the patient was discharged on the seventh post-operative day in good health. introduction: trauma audit & research network (tarn) data shows older persons falling from standing height and sustaining significant injury has become the commonest trauma presentation in england and wales 1 . we aimed to assess whether frailty predicts poor outcomes in the elderly. material and methods: retrospective database review of tarn eligible patients [ 65 years old admitted in a 19 week period with documented rockwood clinical frailty score 2 . age, injury severity score (iss), length of stay (los) and mortality were noted. the inhospital mortality group was sub-analysed. logistic regression was performed (stata v15), odds ratios and 95% ci reported. results: older age was associated with higher cfs in the 263 patients studied. increasing cfs was associated with increased overall mortality (cfs6-9 vs cfs1-5 or 2.14; 95% ci 0.88-5.21), decreased likelihood of pre-hospital trauma alert and increased length of stay (cfs6-9 stayed 4 days more than cfs1-5). all 22 deaths had cfs [ 3 and head or chest injury. adjusting for age and cfs those with chest injury were 1.15 times more likely to die (or 1.15 95%ci 0.44-3.04). mortality in those with rib fracture was 5 times higher in cfs6-9 vs cfs1-5 (or 5.53 95%ci 1.21-25.28). conclusions: increasing age and cfs (especially 6-9) are associated with poor outcomes in elderly trauma, thus cfs is a useful prognostic tool in severely injured elderly patients. chest injuries are a major cause of mortality in this group, especially with increasing frailty. major trauma centres must develop practice management guidelines to appropriately manage these patients. introduction: major trauma causes activation of the complement system, which plays a key role in development of systemic inflammatory response syndrome and multiple organ failure. complement is known to be activated early after trauma 1, but the relationship between outcome and the extent of complement activation during the first critical hours after injury is unknown. we hypothesized that complement activation in the first hours after trauma displays a highly dynamic pattern which is associated with outcome. material and methods: complement activation was assessed by plasma terminal c5b-9 complement complex (tcc) using elisa in a prospective cohort of 136 trauma patients. samples were obtained at admission, after 2, 4, 6 and 8 h, and daily in the intensive care unit. the extent of complement activation was assessed as area under the concentration curves 3-6 h after injury (tcc-auc3-6). the relative contribution of complement activation, base excess (be) and new injury severity score (niss) to outcome was analyzed by multivariable analyses. results: niss and be were associated with tcc-auc3-6 in bivariate analyses (spearmans rho (p) was respectively 0,23 (p = 0.01) and -0.33 (p = 0.0003)). in multivariable analyses, niss and initial tcc alone predicted 50% of the variability in ventilatorfree days (vfds), whereas initial tcc and tcc-auc3-6 predicted 66%. tcc auc3-6 alone contributed with 16% to the model. tcc-auc3-6 was also significantly higher in patients deceased at day 30 (4.9; 2.1-17.9 (median; quartiles) vs. 2.4; 1.8-3.8, p = 0.048 introduction: massive transfusion protocols [mtp] have been widely adopted for the care of bleeding trauma patients but their actual effectiveness is unclear. this study aims to conduct an updated meta-analysis to evaluate the effect of implementing an mtp on the mortality of trauma patients. material and methods: medline, pubmed, google scholar and cochrane library databases were systematically searched for relevant articles published from 1 january 2008, to 31 july 2019, using a combination of key words and additional manual searching of reference lists. three reviewers independently screened the articles for potential inclusion. eligible articles were original articles in english, included trauma patients and compared mortality outcomes before and after institutional implementation of a mtp. primary outcomes were 24 h and overall mortality. results: nineteen studies met inclusion criteria, analyzing outcomes from 2,962 trauma patients. there was a wide range of outcome and process indicators utilized by the different authors. mtps significantly reduced over-all mortality, pre-mtp-40.4% and post-mtp 32.6% [or 0.7 (0.56-0.89)] for trauma patients. 24-h mortality was not significantly reduced [or 0.87 (0.60-1.25)]. conclusions: the institution of an mtp has a significant over-all mortality reduction for trauma patients. we encourage that researchers use standard nomenclature and indicators, provide more details regarding protocols and patient populations and incorporate advances in the management of bleeding trauma patients in all future mtp studies. introduction: when resuscitating patients with hemorrhagic shock following trauma, fluid volume restriction and permissive hypotension prior to bleeding control are emphasized with good outcomes for penetrating trauma patients. however, evidence that these concepts apply well to the management of blunt trauma is lacking. this study aimed to assess the impact of vasopressor use in patients with blunt trauma in severe hemorrhagic shock. material and methods: in this single-center retrospective study, we reviewed records of blunt trauma patients with hemorrhagic shock and included patients with a probability of survival \ 0.6. patient's characteristics, examinations, severity and administrated therapies were compared between survivors and non-survivors. data are described with median (25-75% interquartile range) or number. results: thirty patients were included and median injury severity score in survivors vs non-survivors was 41 (36-51) vs 45 (34-53) (p = 0.49), with no significant difference in probability of survival. despite no significant difference in injury severity, non-survivors were administered vasopressors significantly earlier after admission and at significantly higher doses. total blood transfusion amount administered within 24 h after admission was significantly higher in survivors (8310 [ conclusions: vasopressor administration and high-dose use for hemorrhagic shock following severe blunt trauma are significantly associated with increased mortality. although the transfused volume of blood products tends to be increased, early termination of vasopressor should be considered. all authors have no significant relationships with regard to this study. early amplitudes of citrated functional fibrinogen in thromboelastography to predict massive transfusion introduction: this study aims to evaluate the role of early amplitudes of the thromboelastography measure of citrated functional fibrinogen (cff) to predict massive transfusion (mtx) defined as transfusion of c 4 of any blood products within an hour of arrival to a major trauma centre. material and methods: trauma patients c 16 years requiring activation of the major haemorrhage protocol with teg performed on a tegò 6 s hemostasis analyser were eligible for inclusion. exclusion criteria were arrival [ 3 h after injury, pregnancy, bleeding disorder or anticoagulant use. patient demographics and transfusion requirements were obtained from medical notes. teg manager was accessed to extract amplitudes at 5 min (a5), 10 min (a10) introduction: hyperfibrinolysis, remains a significant characteristic of acute traumatic coagulopathy induced mortality. s100a10, a cell surface protein, when shed creats an occult hyperfibrinolytic subtype. annexin a2 (a2), a multicompartment protein that co-localizes with s100a10 and contains a tissue plasminogen activator (tpa) binding site has been shown to enhance tpa activity 100-fold and thus behaves as marker of hyperfibrinolysis. we hypothesize that increased concentrations of a2 in blood will enhance tpa fibrinolysis. material and methods: blood was collected from (12) healthy volunteers. recombinant a2 in concentrations 1, 25, 50, 75, 100, 125 lg/ ml was added blood and then combined with tpa 75 ng/ml. samples were assessed using thromboelastography (teg). blood samples were collected from trauma activations from 2014-current at a single, urban, level-1 trauma center. samples were assessed using a combination of rapid, citrated native and tpa challenge teg. a2 levels were established via proteomic analysis. results: a2 50-125 (lg/ml) significantly increased tpa mediated ly30% vs tpa alone (a2 ? tpa [50-125] median 21.5% vs tpa 12.0% p \ 0.01). a2 without tpa had no significant effect on ly30% and was similar to the lysis of control (a2 75 lg/ml 0.7% vs control 1.2% p = 0.36). a2 75-125 (lg/ml) significantly increased r time from control and tpa alone (control normalized to 1 vs a2 median 1.77-fold increase in minutes p \ 0.01 and tpa 0.68-fold decrease vs a2 median 1.77-fold increase p \ 0.001). rapid teg for patient 1 vs patient 2 in our ongoing study was 3.4% vs 4.2% and 1.7% and 51.8% respectively on tpa challenge teg. proteomic analysis of a2 relative activity found a 6.6-fold a2 activity in patient 2 compared to patient 1. conclusions: exogenous cell free a2 significantly increases tpa mediated fibrinolysis measured by teg. preliminary data from our ongoing trauma study evaluating a2 levels and hyperfibrinolysis coincide with our in vitro study. introduction: massive transfusion protocol can be activated to mobilize the blood products resource in a timely and effective manner. blood products, however, are still wasted or overused. we aimed to study what proportion of patients who met the abc criteria for massive transfusion received 4 or more units packed rbc (prbc). material and methods: a retrospective study all level i trauma patients admitted with arrival systolic blood pressure of 90 or less (july 2017 to may 2018) was recruited. transfusion was complied with stts. all clinical and laboratory findings, and management procedures were populated from the data registry. results: 214 of 1200 admitted trauma patients met the inclusion criteria. of 214 patients who where admitted with hypotension, 39 of 95 patients (41.05%), who met the abc criteria for receiving 4 or more prbc were stabilized with 2 or 3 units. in other words, stts enabled us to save 69 units of prbc. arrival data, i.e. blood pressure (cut of point: 83 mmhg and p value:0.01), shock index (cut of point: 0.79 and p value:0.0009) and pulse rate (cut of point:112 beat/min and p value:0.01) were significantly different in patients prescribed 4 or more units prbc. after initial resuscitation, blood pressure (cut of point:98 mmhg and p value:0.0001 shock index cut of point: 0.9 and p value:0.001), pulse rate(cut of poinan95 beat/min and p value:0.001) presence of pelvic fracture, positive fast,and base deficit [ 10 were significantly different in the group received 4 or more units prbc. conclusions: massive transfusion protocol with abc criteria may lead to wasted or overused blood products.consideration of dcr continuation strategy complied with stts along with the findings of this study has resulted in a refined protocol characterized by more effective and efficient blood product resource allocation. references: 1-chang r, holcomb jb. optimal fluid therapy for traumatic hemorrhagic shock. critical care clinics. 2017 jan 1;33 (1) case history: we present the clinical case of a female patient of 77 years old who had been taking aspirin. mechanism of injury: a fall from her own height, resulting in head trauma. clinical findings: dysphonia and stridor, having underwent an immediate orotracheal intubation. investigation/results: she had a head ct done that was normal; and a cervical column and neck ct that showed a large retropharyngeal hematoma, without an associated vertebrae fracture. diagnosis: large retropharyngeal hematoma. therapy and progressions: she was admitted to the intensive care unit for mechanical ventilation. on 2nd day, she underwent a surgical tracheostomy. on 4th day, underwent weaning from mechanical ventilation. on 6 h day, was transferred to the ent ward, had the tracheostomy tube removed and was discharged from hospital. comments: a hematoma in this potential space may constitute an immediately life threatening emergency due to airway compromise. in 1991, thomas et al found only 29 cases described in the literature since 1966. the most common cause is the blunt cervical trauma (in 38% of the cases). other causes are the cervical hyperextension injury, cervical vertebrae fracture, cough, sneeze, strain, blunt head trauma, swallow a foreign body, retropharyngeal infection, carotid artery aneurism, internal jugular vein puncture, metastatic disease, coagulopathy, anticoagulants, etc. in the setting of trauma, the mechanism of injury generally permits explaining the presenting injuries. in this case, the clinical severity expressed by the patient seemed to be disproportional to the resultant injury. however, the presence of haemorrhage contributing factors associated with the existence of fascial spaces in the neck, should warn us of the possibility of formation of deep cervical hematomas that may cause an occult airway obstruction. case history: a 27-year-old male with a personal history of consumption of alcohol, cannabis, smoked cocaine and heroin. he was found in decubitus position and in a situation of cardiac arrest. the last time he was seen in his baseline situation was 48 h before. after performing cpr and administration of naloxone and flumacenyl, sinus rhythm was achieved. clinical findings: 24 h after admission, increased tension was observed in left leg, thigh and gluteal region. absence dorsalis pedis, tibialis posterior and popliteal pulse was observed in a doppler examination. investigation/results: intracompartmental pressure measurement revealed a result of 28 mmhg in the deep posterior compartment and 20 mmhg in the superficial (diastolic bp 40 mmhg). at admission k levels were 10.50 meq/l, creatinine 2.24 mg/dl and ck 113438 u/l. diagnosis: opioid-related compartment syndrome. therapy and progressions: urgent fasciotomies of the leg and thigh were performed 3 h after diagnosis with a posteromedial and anterolateral approach in the first case and with a lateral approach in the latter. herniation and signs of poor viability in all the compartments were observed. after the surgery, he persisted with anuria and a ck peak of 288,000 u/ l, which was next normalized. 7 debridements were performedfor the next 25 days. subsequently, after the isolation of p. stutzeri and mucor in the wound and the absence of signs of vitality, a supracondylar amputation was performed. after, hemodynamic status improved. 2 weeks after the amputation it was possible to withdraw hemodialysis, which he had required since admission. comments: opioid misuse is a topic of growing interest. recent works have reported a worse prognosis in the case of opioid-related compartment syndrome. a high level of suspicion is necessary to make a prompt diagnose in these patients. introduction: the pelvic binder is a mechanical device designed to compress instable pelvic ring fractures and minimize dead space in order to limit blood loss. it is generally recommended to apply a pelvic binder if an unstable injury is suspected and the patient presents with a ''c-problem''. the effectiveness remains questionable though. material and methods: a total of 1207 trauma patients between 2014 and 2018 were retrospectively evaluated regarding instable pelvic injury. 108 patients were admitted with a pelvic binder applied. the correct application was evaluated using ct scout. four groups were generated: group 1 with correct pelvic binder application, group 2 with incorrect placement, group 3 with no pelvic binder at time of admission, group 4 with pelvic binder applied in er. total outcome was determined based upon iss, age, preclinical time, time to ct, shock index, hemoglobin at admission, survival rate, administration of blood products as well as total hospital and icu days. results: 43% of all pelvic binders were applied incorrectly. 30 patients (28%) suffered an instable pelvic fracture. patient survival was not influenced by the preclinical application of a pelvic binder (80% group 1 vs. 81,82% group 3, p = 0,719). no significant statistical difference was found for total icu days 9,08 vs. 11,56, p = 0,399; total hospital days 23,42 vs. 24,76, p = 0,630; rbc transfusion 5, 87 vs. 3, 63, p = 0, 791; iss 23, 8 vs. 24, 5, p = 0, 815. conclusions: the correct application of a pelvic binder seems to pose problems preclinically. while the need to minimize blood loss is crucial, our collective did not benefit from this device. additionally, survival rates of the patients that suffered an instable pelvic fracture were unaffected. the iss remains the strongest predictor of total patient survival in pelvic trauma. trauma resuscitation times in a level 1 trauma center in the netherlands: a prospective overview introduction: in trauma, time is considered to be an important factor influencing patient's outcome. in the first hour after injury, appropriate care has the greatest effect on trauma patient's survival. previous research showed that measuring in-hospital trauma resuscitation times, contributes to insights and improvement of the resuscitation process. however, despite developments of atls guidelines, no recent empirical knowledge regarding resuscitation times exists. the aim of this study is to examine in-hospital trauma resuscitation times in a level 1 trauma center in the netherlands. material and methods: a prospective study was performed in level 1 trauma center amsterdam umc location vumc, between may 2019 and august 2019. trauma patients, aged c 16, presented during daytime at the trauma resuscitation room were included. information regarding patient's characteristics, trauma-and injury type, handover duration, duration till start of diagnostics and intervention, total resuscitation time, patient's disposition and survival were compared. results: in total, 50 patients were analyzed. motorized traffic accident (42%) and blunt injury (92%) were the most common mechanism-and injury types. median prehospital to in-hospital handover time was 3.40 min (iqr 1.20) . median duration till start of diagnostics and intervention were 8.01 (iqr 2.42) and 9.59 min (iqr 9.55) respectively. median total resuscitation time showed to be 40.25 min (iqr 23.01 background: terrorist attacks and civilian mass casualty events are frequent, and some countries have implemented tourniquets for uncontrollable extremity bleeding in civilian settings. we summarized current knowledge on the use of pre-hospital tourniquets in civilian settings to assess whether their use increases the survival rate in civilian patients with life-threatening hemorrhages from the extremities. methods: using the preferred reporting items for systematic reviews and meta-analyses (prisma) guidelines, we searched medline (ovid), embase (ovid), cochrane library, and epistemonikos in january 2019. all types of studies that examined the topic in a pre-hospital setting published after january 1, 2000, were included. the protocol was registered in prospero (crd42019123172). results: among 3460 screened records, 55 studies were identified as relevant. due to a lack of relevant civilian studies, military studies were also included. the studies were highly heterogeneous, with low quality of evidence. most studies reported increased survival in the tourniquet group, but few had relevant comparators, and the survival benefit was difficult to estimate. most studies reported a reduced need for blood transfusion, with few and mainly transient adverse effects from tourniquet use. conclusion: the data suggest that the use of commercial tourniquets in a civilian setting to control life-threatening extremity hemorrhage is probably associated with improved survival, reduced need for blood transfusion, and few and transient adverse effects. the effect of venous infusion by emergency medical service personnel on the prognosis of severe traffic accident patients: a nation-wide study in japan y. katayama 1 , t. kitamura 1,2 , t. hirose 1 , y. nakagawa 1 , t. shimazu 1 1 osaka university graduate school of medicine, department of traumatology and acute critical medicine, suita, japan, 2 osaka university graduate school of medicine, environmental and population science, suita, japan introduction: in japan, the law of paramedic was revised in 2014, and it became possible for paramedic in japan to secure an infusion route before cardiac arrest for severe patients. however, the effect of this treatment on the prognosis of severe trauma patients has not been assessed. we assessed this effect on the prognosis of severe traffic accident patients with using population-based ambulance record and nation-wide hospital-based trauma registry in japan. material and methods: this study was a retrospective observational study and the study periods was 2 years between january 2016 to december 2017. we linked the nation-wide hospital based trauma registry (jtdb) and the population-based ambulance record in japan in case. in this study, we included the traffic accident patients with iss score more than 16 and excluded cardiopulmonary arrest patients on the arrival of ems on the scene and missing data cases. the main outcome was cardiopulmonary arrest on hospital arrival. mcnemar's test and conditional logistic regression analysis were used to assess the association between the securing a infusion route by ems personnel and the primary outcome after one-to-one propensity score matching for securing a infusion route or not. results: 3502 traffic accident patients were eligible for analysis and 142 patients were dripped by ems personnel. after one-to-one propensity score matching, the proportion of cardiopulmonary arrest on hospital arrival were 5.6% (8/142) in patients dripped by ems personnel and 7.7% (11/142) in patients not dripped by ems personnel, respectively (p = 0.648). the adjusted odds ratio for securing a infusion route was 0.727 [95% confidence interval; 0.293-1.808, p = 0.493]. conclusions: in this study, there was no association between the securing a infusion route and outcome of traffic accident patients. the association between trauma patient characteristics and adverse laboratory values: which patient characteristics are most predictive? introduction: in more than 60 countries worldwide, laboratory testing is protocol driven since 1978 when it was included in the practice guideline of the advanced trauma life support course (atls). 1 however, it is not clear yet which patient characteristics are associated with unfortunate laboratory values. the aim was to create an overview of the characteristics that were associated with adverse laboratory values. material and methods: this cohort study was performed at amsterdam umc, location amc (level 1 trauma center), including patients during a period of 2 years. data concerning age, gender, asa scores, injury severity scores (iss), glasgow coma scores (gcs), mechanism of injury, type of injury (blunt or penetrating) and the presence of helicopter emergency medical services (hems) were obtained. the hematology panel included hemoglobin, hematocrit, mcv, leucocyte and thrombocyte values. the coagulation panel included inr, pt, aptt, fibrinogen and d-dimer values. other panels include arterial blood gas, kidney and liver panels. the association between trauma patient characteristics and laboratory values were determined by using binary and multinomial logistic regression. results: a total of 1287 patients were included, consisting of predominantly men (66%) with a mean age of 46 years old. an increase in age and iss was correlated with abnormal laboratory values (p = 0.00). additionally, male gender, iss [ 16, blunt trauma and the absence of hems was associated with a deviation in laboratory values (p \ 0.05). other patient characteristics did not show a significant correlation with adverse laboratory values. case history: a 47-year-old man presented with a classic case of pituitary apoplexy with a history of headache, nausea and vomiting. clinical findings: he was found to have a sellar and suprasellar mass with internal cystic and hemorrhagic component consistent with a pituitary macroadenoma. investigation/results: he underwent transsphenoidal sugery for a pituitary macroadenoma. because the tumor was invaded to left cavernous sinus, we left small portion of the tumor. eighth day after surgery, he underwent gamma-knife surgery (gks) for residual tumor. after two weeks, he complained of left ptosis. we considered the 3rd nerve palsy to be a post-radiation reaction at first. after 3 months, the symptoms had been continuous and mri showed increased size of cystic lesion involving left cavernous sinus. diagnosis: ct angiogram demonstrated a saccular aneurysm at left distal ica. endovascular coil embolization was performed. therapy and progressions: after 3 months of the intervention, the 3rd nerve palsy was partly improving. comments: our case report emphasizes the necessity of cerebrovascular imaging before surgery for pa. mr angiography/ct angiography is not currently obligatory in patients with pituitary adenoma, but in cases with the symptoms of displacement of the neuro-vascular structures it can be of great value. even in patients without such presentations, it may be helpful to evaluate the vascular involvement. case history: a 16-year-old boy during the preparation for a fishing session was pierced to the left orbitary region by a high-speed spearfishing steel. clinical findings: upon arrival the patient was conscious and responsive with a gcs of 15, he followed commands appropriately and there were no motor of sensory deficits. investigation/results: plain skull radiographs showed the spear crossing the skull from the left orbit to the posterior part of the parietal bone. diagnosis: the patient was immediately intubated to prevent involuntary movement of the foreign body. ct scan showed the fracture of the left orbitary roof where a 30 centimetres long metallic object crosses the cerebral parenchyma of the left hemisphere and perforates the left parietal skull. therapy and progressions: under direct visualization via transorbital approach the foreign body was removed together with bone fragments, hemostasis was done and orbitary roof repaired. serial cranial ct scan showed progressive reduction of frontal and parietal hematoma. the movement of the eye improved after a few days, normalizing with the regression of periorbital edema. upon discharge at 11 th postoperative day the patient had a gcs score of 15, no motor deficit and minimal visual loss. comments: penetrating injury of the skull and brain are relatively uncommon events, representing about 0,4% of all head injuries. orbital roof is relatively thinner part of the skull that can provide easy access to projectile objects, which can penetrate into cranial cavity and damaging the brain parenchyma. the principles of treatment are removal of bone fragments and foreign body, control of persistent bleeding and intracranial hypertension, prevention of infection though debridement of all contaminated and necrotic tissue and at the same time preservation of as much nervous tissue as possible. multitraumapatients whith severe head injury (ais ‡ 3) are more quickly carried out ct scan on than a patient without severe head injury v. giil-jensen 1 , k. andersen 1 , t. k. helle 2 1 haukeland univercity hospital, sugical department, bergen, norway, 2 haukeland univercity hospital, ambulance service, bergen, norway introduction: trauma patients who are prone to severe head injuries during trauma may profit from obtaining a rapid clarification of the injury magnitude when using ct examination. in the case of a delayed ct examination, the consequence of the head injury could be more extensive. in this study, we wanted to see if those with severe head injury (ais c 3) received a faster ct survey than those who had no severe head injury. material and methods: retrospective registry study of severely injured patients (iss [ 15) which had been hospitalized as a trauma patient at haukeland university hospital in the period 2015-2019. in the study, we have excluded all patients entered as multitrauma but who have iss \ 16 and all patients who have not defined ct time. it turns out that over half of the patients lacked the registration of accurate time for the ct survey in the national trauma register. the number is still considered large enough to find a result. results: 2542 patients were received as multitraumatic at haukeland university hospital during the period. of these, 493 was severely injured. of these, 265 patients had severe head injuries and they again had 52 head injuries as the only serious injury (ais c 3). median time from arrival receipt to start ct, for this group was 27 min. in the control group that was severely injured but without severe head injury is the same time 33 min. there was 102 patients in the control group. conclusions: for the patients in this study who had severe injuries (n:493), the median time from the arrival in the emergency department to the ct starts was 6 min shorter for severe head injuries than for the group without severe head injuries. introduction: the patients with severe traumatic brain injury (stbi) who needs surgical intervention often experience acute traumatic coagulopathy (atc). earlier transfusion with high blood product ratios (plasma, platelets, and red blood cells via 1:1:1 ratio) is recommended for severely injured patients. however, recommended blood product ratio for stbi is still controversial. material and methods: we retrospectively reviewed successive adult stbi who underwent surgical treatment in our hospital between january 2016 and december 2018. we have transfused plasma aggressively to maintain blood fibrinogen above 150-200 mg/dl. we evaluated the total amount of transfusion and mortality. we exclude cases administered fibrinogen concentrate. results: 53 patients were enrolled. the amount of transfusion for 24h is rbc 4.2units, ffp 7.8units, pc 3.8units . stbi with severe other trauma needs higher ratio of plasma. discussion: tissue injury of stbi causes severe coagulopathy and 1:1:1 transfusion was thought to be insufficient for stbi in order to maintain fibrinogen. we agressively transfused plasma but we achieved fibrinogen value above 150 only in 20% of stbi with severe other trauma. agressive plasma transfusion had limitation for hyperfibrinolysis so we expect other product, for example fibrinogen concentrate. introduction: traumatic brain injury (tbi) remains a leading cause of hospital admission and mortality amongst trauma patients. intracranial hemorrhage (ich) can occur with tbi and presents a severe complication. low complication tolerance in developed countries and uncertainty on actual risk cause excessive diagnostics and hospitalization, considered unnecessary and expensive. methods: tbi cases indicated for cranial computer tomography (ct) according to international guidelines, at our level i trauma center between 2008-2018 were retrospectively included. multivariate logistic regression was performed for ich, progression and mortality predictors. results: 2036 tbi patients (m: 57.5; age at trauma: 57.6 ± 22.6), were included. ct was performed in 96.5%, skull fracture diagnosed in 18.6%, ich in 51.9%, ich progression in 28.4%. in patients \ 35a, chronic alcohol consumption (p = 0.004) and neurocranial fracture (p \ 0.001) were significant ich risk factors in a multivariate analysis. in patients between 35-65a, chronic alcohol consumption (p \ 0.001) and skull fracture (p \ 0.001) revealed as significant ich predictors. in patients [ 65a, age (p = 0.009), anticoagulation (p = 0.007) and neurocranial fracture (p \ 0.001) were significant risk factors for ich, age (p = 0.01) was an independent risk factor for mortality. late onset ich only occurred in cases with at least 2 of 3 factors: age [ 65, anticoagulation, neurocranial fracture. overall hospitalization might have been reduced by 15.8% via low risk cases. conclusions: triggered by decreasing error tolerance, international guidelines for mild tbi focus on safety maximization. repeated ct in initially ich negative cases should only be considered in high risk patients. non-ich cases aged \ 65 years do not gain safety from observation or hospitalization. recommendations from our data might, without impact on patient safety, reduce costs by unnecessary hospitalization and diagnostics. references: to be added by the authors. evaluation of low-value clinical practices in acute trauma care: a multi-center retrospective study l. moore 1 , k. soltana 2 , j. clément 2 , a. turgeon 2 , î mercier 3 , r. krouchev 2 , p. a. tardif 2 , s. bouderba 3 , a. belcaid 4 1 université laval, social and preventive medicine, québec, canada, 2 chu de québec-université-laval, québec, canada, 3 université-laval, québec, canada, 4 introduction: low-value clinical practices have been identified as one of the most important areas of excess healthcare spending and are associated with adverse health outcomes. the objectives of this study were to estimate the frequency low-value practices in injury care and assess inter-hospital variations. material and methods: we identified low-value clinical practices from internationally recognized clinical guidelines. we conducted a population-based retrospective cohort study using data from an inclusive canadian trauma system (2010-2017) to calculate frequencies and assessed inter-hospital variations with intra-class correlation coefficients (icc). results: we identified 29 low-value practices of which 9 could be measured and validated using trauma registry data. the three lowvalue clinical practices with the highest absolute and relative frequencies were pelvic x-rays in hemodynamically stable patients with a negative physical exam for pelvic injury (42.9%), head ct in adults with minor head injury who were negative on a validated clinical decision rule (24.3%) and chest x-ray in hemodynamically stable patients with a normal physical exam (6.9%). we observed high inter-hospital variation for surgical management of penetrating zone ii neck injury without hard signs (icc = 27%), and moderate variation for head ct in adults with minor head injury who were negative on a validated clinical decision rule (icc = 6.3%). conclusions: we have developed and validated algorithms to evaluate nine potentially low-value clinical practices using trauma registry data. highest frequencies were observed for imaging in the emergency department and the highest inter-hospital variation was observed for inappropriate surgical management. these data can be used to advance the agenda on low-value care for injury admissions. dysfunction of functional connectivity between default mode network and cerebellar structures in patients with mtbi in acute stage. rsfmri and dti study introduction: mild traumatic brain injury (mtbi) occupies one of the first places in children injuries. among all brain networks at the resting state, the default mode network (dmn) is the most widely studied network. the aim of this study is to examine functional connectivity in normal-appearing cortex in acute period of mtbi using rsfmri. material and methods: 34 mr negative participants were studied in age from 12 to 17 years (mean age-14.5 years). group of patients consisted of 17 children with mild traumatic brain injury in acute stage. 17 age-matched healthy volunteers comprised control group. all studies were performed at phillips achieva 3.0t mri scanner using 32-channel head coil. fmri data were processed using functional connectivity toolbox conn. seed-based analysis was performed in order to reveal disturbances in functional connectivity. statistical processing was performed using statistica 12. results: dti analysis didn't show any changes in values of apparent diffusion coefficient (adc) and fractional anisotropy (fa) between two groups (see fig. 1 ). no statistically significant differences in correlation strength between dmn parts were observed in two groups (see fig. 2 ). intergroup seed-based analysis revealed statistically significant (p \ 0,05) difference in neural correlations between dmn parts and vermis (cerebellum structural part): positive link in control group and negative link in group of patients. conclusions: one of the most common symptoms of mtbi is dizziness as a result of impaired movements coordination. vermis as an essential cerebellum part plays an important role in the vestibuloocular system which is involved in the learning of basic motor skills in the brain. vermis aids in the synchronization of eye and motor functions in order for the visual field and the motor skills to function together.our results show that mtbi appears to be a possible reason of connectivity malfunction in normal-appearing vermis. references: predictors of developing post-traumatic endophthalmitis introduction: 1h magnetic resonance spectroscopy (1h mrs) allows to study structural and metabolic brain disorders in various pathological conditions in vivo. non-invasive method determines its advantage for use in children in serious condition with acute cerebral injuries. this determined the purpose of the study: to identify criteria of irreversible brain damage based on the 1h mr spectra analysis in comatose children with acute traumatic brain injury (tbi) or anoxia. material and methods: 8 patients (6 months-16 years) were examined in the acute period of severe cerebral injury (gcs score 3-4): six were in acute and subacute period of severe tbi, one patient was examined on the seventh day after drowning, and one-a day after acute cerebral blood flow (hemorrhage). all patients died in 10-20 days after the study. control group included 10 healthy children aged from 7 to 13 years. single voxel 1h mrs and 2d 1h mrs was performed on 3t scanner. 1h spectroscopic voxel (te/tr = 35/ 2000 ms, voi = 3 cm 3 , nsa = 32) was oriented on mri intact areas: cortex of frontal, parietal and occipital lobes (fig. 1) , thalamic nuclei (fig. 2) , cerebellum, brainstem (fig. 3) . for 2d 1h mrs a spin-echo point-resolved spectroscopy (press) sequence was used (te/tr = 144/2000 ms) with the spectroscopic voi of 150 cm 3 on frontal lobes. results: in all spectra lactate (lac) signal, dominating all other signals, was detected. n-acetylaspartate (naa) was reduced by 60% and creatine/phosphocreatine (cr)-by 35%. conclusions: 1h mrs is a non-invasive prognostic method in patients with acute cerebral brain damage in coma. the cause of patients' death is the shift of cerebral glucose metabolism to an anaerobic type, as evidenced by the accumulation of lac. disturbance of energy metabolism causes a decrease of cr and a decrease in the neuronal marker naa. the combination of these patterns in acute cerebral injury, regardless of etiology indicates irreversible brain tissue damage. introduction: scalds and contact burns are the most common burn injuries both in children and adults. data are conflicting regarding which type of burns are more severe. we compared scalds, contact, and flame/fire burns at our burn center to determine which type were more likely to result in full thickness injuries and prolonged length of stay (los). material and methods: we conducted a structured retrospective medical record review of all patient admissions to a regional burn unit over a 10-year period between 2000 and 2010. data included demographic, clinical, and specific burn characteristics. the association between patient predictor variables and outcomes (full thickness burns, los) was explored using chi-square and stepwise logistic regression. results: there were 1,038 patients with either scald (n = 537, 52%), fire/flame (n = 434, 42%) or contact burns (n = 67, 6%). burn depth was not available for 216 cases (21%). mean (sd) age was 29 (25), 64% were male. mean (sd) total body surface area (tbsa) was 10 (11)%. 24% of burns contained areas of full thickness injury. patients with scalds were younger than those with contact or fire burns (22 ± 24 vs. 32 ± 28 vs. 38 ± 22 years respectively, p \ 0.001). the percentage of burns that were full thickness by etiology were contacts (45%), fire/flame (34%) and scalds (13%); p \ 0.001. after adjusting for age, location, and tbsa, scalds were less likely to result in full thickness injuries than contact burns (odds ratio 0.23, 9%%ci, 0.11-0.48). adjusting for multiple testing, univariate analysis (as well as the multivariate analysis) showed no difference in % 3rd degree burns between fire and contact burns, but scalds were significantly lower than each of those. los for scalds (8 ± 10) and contact burns (8 ± 11) was significantly shorter than for fire/flame (14 ± 25 days, p \ 0.001). conclusions: while less common, contact and flame burns were more likely to result in full thickness injuries than scalds. references: epidemiology, treatment, costs, and long-term outcomes of patients with fireworks-related injuries (rocket); a multicenter prospective observational case series introduction: the aim of this study is to provide detailed information about the patient and injury characteristics, medical and societal costs, and clinical and functional outcome in patients with injuries resulting from fireworks. material and methods: a multicenter, prospective, observational case series performed in the southwest netherlands trauma region, which reflects 15% of the netherlands and includes a level i trauma center, a burn center, and an eye hospital. all patients with any injury from consumer fireworks, treated at a dutch hospital between december 1, 2017 and january 31, 2018, were eligible for inclusion. exclusion criteria were unknown contact information or insufficient understanding of dutch or english language. the primary outcome measure was injury characteristics. secondary outcome measures included treatment, direct medical and indirect societal costs, and clinical and functional outcome until one year after trauma. results: 54 out of 63 patients agreed to participate in this study. the majority was male (n = 50; 93%), 50% were children \ 16 years, and 46% were bystanders. injuries were located to the upper extremity or eyes and were mostly burns (n = 38; 48%) of partial thickness (n = 32; 84%). fifteen (28%) patients were admitted and 11 (20%) patients needed surgery. the mean total costs per patient were €6,320 (95% ci €3,400 to €9,245). patient-reported quality of life and functional outcome was not significantly different during follow-up compared with pre-trauma. conclusion: the most common injuries afflicted by consumer fireworks were burns, mostly located to the upper extremity, and eye injuries. fireworks can result in severe injuries, for which 15 (28%) patients needed hospital admission and 11 (20%) patients needed surgical treatment. although some injuries resulted in permanent disability, 1 year after trauma it in general did not have major or longlasting impact on patients'' self-reported quality of life or functional abilities. persistent inflammation, immunosuppression and catabolism syndrome after polytrauma: a rare syndrome with major consequences. l. hesselink 1 , r. spijkerman 1 , r. hoepelman 1 , l. koenderman 2 , l. leenen 1 , f. hietbrink 1 1 umc utrecht, trauma surgery, utrecht, netherlands, 2 wilhelmina children's hospital, center for translational immunology, utrecht, netherlands introduction: more severely injured patients survive the critical first phase after trauma nowadays. a substantial portion of these patients require long-term critical care support and suffer from recurrent infections. this clinical condition fits in a syndrome referred to as ''persistent inflammation, immunosuppression and catabolism syndrome'' (pics). the aim of this study was to investigate the incidence of pics and clinical outcomes of trauma patients with pics in a level one trauma center. material and methods: all trauma patients c 16 years admitted to the intensive care unit (icu) for c 14 days between 2007 and 2017, were included. patients with isolated neurological injuries were excluded. pics patients were identified by icu stay c 14 days, c 3 infectious complications and increased catabolism. infectious complications included infections during hospitalization and readmissions due to an infection. increased catabolism was defined as weight loss [ 10%, a body mass index. results: of the 3,859 polytrauma patients, 194 patients had an icu stay c 14 days. after exclusion of patients with isolated neurological injuries, 78 patients were included. of these patients, 18 developed pics. pics patients sustained 5 infectious complications on average (compared to 1 in the non-pics group, p \ 0.001) and 72.2% of the pics patients developed sepsis. also, pics patients had a longer hospital stay (mean of 90 days versus 50 days, p \ 0.001) and sustained more surgical procedures (mean of 13 versus 4 per patient, p \ 0.001). infectious readmissions occurred until 5 years after the initial trauma. conclusions: patients who develop pics experience long-term inflammatory complications that lead to frequent readmissions and surgical procedures. therefore, despite its low incidence, this clinical condition forms a burden on patients and a substantial financial burden on society. hyperbilirubinemia as a risk factor of the trauma icu patient introduction: hyperbilirubinemia is common in the intensive care unit (icu). hyperbilirubinemia has been considered as a risk factor of the icu patient. hyperbilirubinemia can have various causes. the hyperbilirubinemia has never been studied for the trauma icu patient. the aim of this study is to elucidate the incidence and effects of the hyperbilirubinemia for the trauma icu patient. material and methods: retrospective review of the trauma icu patients from 2017.01.01 to 2017.06.30. initial bilirubin serum level, 48 h bilirubin level, 7 day bilirubin level, highest bilirubin level, overall morbidity and mortality and other clinical variables were identified and evaluated. the patients who have highest bilirubin level c 3.0 mg/dl were defined as hyperbilirubinemia group. results: a total 78 patients were enrolled in this study. hyperbilirubinemia above serum bilirubin c 3.0 mg/dl were appeared in 26 patients. the mortality of the hyperbilirubinemia group was higher than the other group (71.4% vs 29.6%, p = 0.03). the icu stay of the hyperbilirubinemia group was longer than the other group (12.4 day vs 7.1 day, p = 0.04). the hyperbilirubinemia group had more incidences of pneumonia, acute kidney injury, and sepsis than the other group (42.9% vs 57%, p = 0.01/ 33.3% vs 66.7%, p = 0.001/0% vs 100%, p \ 0.001). conclusions: the hyperbilirubinemia is a risk factor of the trauma icu. if the hyperbilirubinemia is appeared, the cause of the hyperbilirubinemia should be evaluated and make an effort to correct hyperbilirubinemia for the each cause of the hyperbilirubinemia. case history: we present the clinical case of a male patient of 37 years old. injury mechanism: a firework burst on his right forearm. clinical findings: injury: a large area of carbonization of the muscles of the flexor compartment. signs and symptoms: intense pain in the hand and forearm with local oedema and tension. diagnosis: deep burn of the forearm. therapy and progressions: surgical debridement and fasciotomy of this compartment; followed by deferred and progressive primary closure by means of rubber bands that were tightened as the oedema diminuished-shoelace technique. evolution: discharged from hospital on the 8th pos op day; follow-up at 3rd and 6th month without functional impairment, with a good healing evolution. comments: deep burns that reach the subfascial planes of the limbs, increase the pressure in the muscular compartments, and may progress to a compartment syndrome. there is no specific cutoff value of pressure for this diagnosis; consequently, the final decision to proceed with a fasciotomy relies on the clinical experience. surgical debridement and fasciotomy may result in large wounds, sometimes difficult to close. grafts and flaps result in another wounds and carry a risk of pain, infection, scar shrinking and necrosis. the diagnosis of a limb compartment syndrome is almost always a clinical one and requires a high index of suspicion so as to the fasciotomy is done in time. the shoelace technique is a simple, reproducible and cost-effective method of deferred closure of a large wound, preserving functionality and resulting in a good final cosmesis. references: johnson ls et al, management of extremity fasciotomy sites prospective randomized evaluation of two techniques, am j surg. 2018. the use of propranolol in the management of acute thermal burn injury: evaluation of the effect of fixed dosages in african patients c. jac-okereke 1 , i. onah 1,2 1 esut teaching hospital, surgery, enugu, nigeria, 2 national orthopaedic hospital, enugu, nigeria introduction: propranolol has been shown to improve outcomes in burn patients. its effects are achieved at doses that reduce the heart rate by 10-25%. africans have a different propranolol pharmacogenetic profile as compared to other races. there is paucity of literary works on the use of propranolol in africans with burns. in our study, we explored the effectiveness of fixed dosages of propranolol in nigerian patients. material and methods: this was a prospective comparative study of adult burn patients; two test groups received propranolol 40 mg/day and 240 mg/day respectively. the average daily pulse rate prior to and after the administration of propranolol were compared. results: patients in the control group had no effective reduction in their pulse rate. patients who received propranolol at a dose of 240 mg/day had a reduction c 10%. no adverse events were observed. conclusion: it is important to establish the effective dosage of propranolol in burn patients of african-descent and explore its potential benefits in their treatment. although we cannot draw strong case history: the authors present in their paper three cases of blunt abdominal injury caused by seat belt in car accident. in the first two cases there was no diagnostic problem thanks to clear clinical finding. in the third case there was no clinical correlation and even repeated auxiliary examinations did not indicate the need for surgical intervention of the abdominal cavity. clinical findings: case no. 1-male 37 y. old, haemodynamic stability, thoracic an abdominal pain, fast positivity, on ct free fluid in abdominal cavity, small spleen laceration, positivity of peritoneal symptomatology. case no. 2-male 42 y. old, haemodynamic stability, bilateral hypogastric pain without peritoneal symptomatology, fast with small perihepatic fluid, on ct fluido-pneumoperitoneum. case no. 3-female 42 y. old, haemodynamic stability, thoracic pain, massive oedema on the right side of the neck and supraclavicular area, without abdominal symptomatology. fast with small subhepatal fluid collection-4 mm, ct scan with large neck haematoma and fracture of 1st rib, apical pneumothorax-12 mm. intraabdominal only subhepatal fluid stripe-18 mm, suspected of small hepatic laceration. after 3 days the clinical status rapidly changed, during 2 h peritoneal symptomatology occured. on control ct scan fluido-pneumoperitoneum was detected. investigation/results: all patients underwent surgical procedure diagnosis: bowel mesenteric injury therapy and progressions: the first patient underwent ileo-caecal and hartmann resection, by the second patient was small intestine and col. sigmoideum resection needed, and the last one underwent ileal resection and npwt. comments: despite the current diagnostic methods blunt abdominal injuries, unlike the penetrating ones, can present a certain diagnostic problem especially when they are accompanied by other serious conditions such as manifest chest injuries. introduction: patients with hypertension and peritonitis must undergo a laparotomy. in isolated parenchymal lesions of the liver, the spleen or kidneys interventional or conservative approaches are more frequently used. to miss a hollow viscus organ lesion, that would need an operative procedure, is a constant fear. it is the aim of this study to identify significant predictors of the simultaneous presence of a hollow viscus lesion in patients with parenchymal organ lesions. material and methods: data of over 20'000 inpatients of a levelone-trauma centre between 2008 and 2016 were analysed. only hemodynamically stable patients with a splenic-, liver-, or kidney injury (independent of grade) after blunt abdominal trauma were included. significant predictors were detected in bi-and multivariant analysis. results: of the 341 patients with an average age of 42 ± 20 years 43% (n = 148) had a splenic-, 49% (n = 168) a liver-and 23% (n = 79) a kidney rupture. the total iss was 30 ± 16 points. in 52 patients (15%) a hollow viscus injury could be found (stomach n = 5, small bowl n = 29, colon n = 22, rectum n = 4). injuries of the thorax (76%), the extremities (70%), the head (70%), the vertebra column (43%) and the pelvis (30%) were diagnosed as concomitant injuries. due to multivariant analysis neither age, gender, heart frequency at admission, gcs, base excess, the coagulation parameters, the hemoglobin value nor the separate injury regions could be identified to be predictive factors for the presence of a hollow viscus lesion. conclusions: clinical parameters taken at admission are not useful to predict hollow viscus injuries. the ct-scan is currently seen to be the best possible imaging modality, but it can be false negative, especially within the first 60 min after trauma. repetitive clinical examination is necessary. in doubt a diagnostic laparoscopy or even laparotomy has to be performed. introduction: a heavy abdominal trauma is associated with a high morbidity and mortality. it is the aim of this study to show injury patterns in the abdomen and concomitant injuries in polytraumatized patients as well as to identify risk factors of the decease. material and methods: data of over 20'000 inpatients of a level-one trauma centre between 2008 and 2016 were retrospectively analysed. only patients with a relevant abdominal trauma (ais abdomen c 3) were included. the ais score was determined either with a contrast enhanced computed tomography or intraoperatively. significant risk factors were detected in bi-and multivariate analysis. results: 315 patients with an averaga age of 43 ± 18 years were included. 48% (n = 155) had an ais abdomen of 3, 40% (n = 127) of 4 and 10% (n = 33) of 5. the overall iss was 31 ± 16 points. the mechanism of injury was mainly blunt (87%). a splenic rupture was present in 40% (n = 128), a liver rupture in 35% (n = 112) and a kidney rupture in 26% (n = 68). hollow viscus injuries were present in 13% (small bowl n = 44, colon n = 33, stomach n = 13, rectum n = 7, bladder n = 14). concomitant injuries were determined in 88% of the patients. of these 70% were diagnosed a thoracic injury, 66% injuries at the extremities, 55% head injuries. 47% spinal injuries and 31% pelvic injuries. the mortality was 16% (n = 51). a liver rupture (p = 0.031, or 4.0), pelvic injuries (p = 0.02, or 4.4), age (p = 0.043, or 1.032), hypotension (systolic blood pressure \ 90 mmhg) (p = 0.003, or 8.2) and a low gcs at admission (p \ 0.001, or 0.67) were determined to be significant risk factors. conclusions: in our trauma department life threatening abdominal traumata are treated about every 10 days. lethal abdominal injuries were mostly associated with serious liver ruptures or pelvic injuries. due to our experience we recommend the use of an early ct-scan as thereby the injury severity can be fast and precisely assessed. case history: a 44 yo female was tranferred to our icu on day 2 of a severe acute necrotizing alchoolic pancreatitis with mof. crrt with cytosorb was immediately started. on day 7 after onset (dao7) an acs with a new organ failure (lung) showed up. open abdomen (oa) and tac with mesh-mediated/npwt got a temporary improvement. clinical findings: on dao10 (oa3), reopening of the mesh entailed a sudden fascial retraction of 6 cm. a new larger mesh was positioned. on dao14 (oa7) the fascial defect measured both on ct slices and in or was 26 cm. provision of a longterm oa was done. therapy and progressions: a new fascial traction device (fas-ciotensò, germany)1 was positioned on dao14 (oa7), with a continuous traction weight of 6-8 kg. revision was scheduled any 2-4 days, according to clinical needs, including combined anterior and retroperitoneal necrosectomy. progressive traction allowed to get a 5 cm fascial gap under traction on dao38 (oa31). anterior cst was thus performed and fascia primarily closed. completion of necrosectomy was done through the bilateral lumbar incisions and npwt. comments: early fascial closure is a goal in oa. mesh-mediated traction/npwt is the most effective strategy, but primary fascial closure is sometimes impossible. 2 the duration of oa is a key point. fasciotensò allowed to overcome the failure of mesh-mediated option and avoided fascia retraction in a longterm oa. it was quickly managed by the nurse staff, allowed a easier access to the abdomen and a proper positioning of the protective film. its effectiveness in this demanding case makes it an interesting option for shortening fascial closure in septic oa too. background: small bowel obstruction (sbo) caused by intra-abdominal adhesions is one of the main surgical emergencies. in most of the time, adhesions are created by previous abdominal surgeries. without any severity signs, the medical treatment is first proposed to avoid superfluous surgery. we noticed that the failure of medical treatment is frequently seen in patients previously operated of appendicectomy. the purpose of this study is to determine the eventual relation between a previous appendicectomy and failure of medical treatment in sbo. methods: we conducted a retrospective data collection using a diagnostic code for bowel obstruction in patients who have consulted in emergency from 01.01.2011 to 01.01.2019 at the salengro university hospital in lille. using the administrative database, 1194 patients were identified. we excluded all children, patients with wrong diagnosis and those whose outcome was not known. finally, 324 patients with sbo on intra-abdominal adhesions confirmed on ct-scan were reviewed. the patients were separated in two groups. the group 1 (g1) included patients who required surgical management during hospitalization (107 patients) and group 2 (g2) patients with successful medical treatment (217 patients). we compared the rate of previous appendectomy in these two groups using a pearson's chi-squared test. in a second step, we tried to find out if there were others factor associated with failure of medical management. results: there was significant difference between the two groups with a higher rate of appendectomy in the surgical management group g1 (p = 0.00773). this difference was even more pronounced if appendectomy was the only surgical history. in the subgroup analysis of patients with previous appendicectomy, the laparoscopic approach or laparotomy didn't influence the outcome of the management of the sbo. conclusion: this study shows the difference between the two groups of sbo, with more surgery sanction in the group of patients previously operated of appendicectomy. perhaps because this surgery involves the very distal part of the small bowel and decrease the efficiency of a proximal nasogastric aspiration. these results should not change the initial management of sbo by medical treatment in absence of severity signs. however, knowing this data, we have to consider that a history of appendicectomy is a risk factor of failure of medical treatment in this situation. introduction: diaphragmatic injuries are a rare consequence of closed thoraco-abdominal trauma that could be difficult to detect due to paucity of clinical signs and frequent erroneous interpretation of radiological images. the overall incidence of diaphragmatic injury is 0,8-5,8% in blunt trauma. if the injury is not recognized it could lead to considerable risk of late morbidity and mortality. this study reviews our 10 years experience in the management of this patients. material and methods: a retrospective review of trauma registry of our tertiary referral centre was performed. preoperative, intraoperative and postoperative data were analysed to assess determinants of mortality, morbidity and effect of therapeutic delay by univariate analysis models. penetrating injuries were excluded from the study. results: over 10 years 31 patients with diaphragmatic injury due to blunt trauma were identified: 4 had a simple laceration of the diaphragm without hernia, 21 had acute and 6 chronic diaphragmatic hernia. the mean patient age was 40 years (range 17--78 years). overall mortality was 15%. the site of injury was the left diaphragm in 18 cases, the right diaphragm in 8 cases and bilateral in 1 case.the hernia content was stomach (9), colon (4), spleen (3), liver (3), omentum (2) and multiorgan (6). all acute patients were managed with primary suture repair via laparotomy except for two patients that required additional thoracotomy; chronic patients were treated laparoscopically in 4 cases (66,6%), in which a synthetic or a biosynthetic mesh was used to reinforce the suture. higher morbidity and mortality was seen in multiple associated injuries, head injuries associated, right diaprhagm injury, age [ 65 years and treatment delay [ 24 h. conclusions: delayed treatment of diaphragmatic injuries could be dramatic: it is importnat not to misinterpreter the radiological findings and to reassess the patient mantaining a high level of suspicion of these injuries. trauma opposing vector forces resulting in distal avulsion of internal oblique muscle: a case report p. spada 1 , p. fransvea 1 , g. altieri 1 , m. di grezia 1 , v. cozza 1 , g. pepe 1 , a. la greca 1 , g. sganga 1 1 fondazione policlinico universitario agostino gemelli irccs, catholic university of rome, division of emergency surgery, roma, italy case history: abdominal muscle injuries after blunt trauma are rare but increasingly recognized. here we report a case of blunt trauma resulting in a complete disinsertion of the distal part of the internal oblique muscle. case report: 46 y.o. male, was involved in a roll over motor vehicle accident. primary survey was carried out according to atlsò approach with good response. he had a seatbelt sign. according to the dynamic of the trauma he underwent a ct. diagnosis: a ce-mdct revealed complete disinsertion of the oblique muscles of the left abdomen from their iliac insertion, with herniation of adipose tissue and hematoma of the soft tissues without active blushing. no other traumatic injuries were identified. therapy progressions: a conservative treatment of the hematoma of the left abdominal wall was adopted. the patients was then ischarged from hospital after 4 days. no late complications were observed. comments: the overall incidence in all traumatic admission is 0.2-0.9%. a deep knowledge of vector force involved in trauma and their influence in the specific anatomical changes of the abdominal wall muscle can lead to suspicious of this rare injuries even if no other lesion are detected. in our opinion this trauma case is useful in reminding us to look for it because the radiologist or a no well experienced trauma surgeon may miss it 1 fondazione policlinico universitario agostino gemelli irccs, catholic university of rome, division of emergency surgery, roma, italy introduction: the best and correct management of patients with open abdomen (oa) is nowadays still unclear. our algorithm consists of using an intra abdominal negative pressure wound therapy device plus an early medial mesh mediated fascia traction (''step by step'' procedure). the aim of this study was to asses outcomes of this algorithm technique based on patient conditions and open abdomen technique performed. materials and methods: we performed a retrospective analysis of 50 patients treated with open abdomen technique from 01/06/2016 to the 01/06/2019. variables taken into account were: initial diagnosis, open abdomen technique used, number of surgical interventions, abdominal wall closure technique, length of stay in the icu, inhospital morbidity and mortality rates. we collected also data on the post-operative development of incisional hernias and entero-atmospheric fistula. results: 4/50 of open abdomen were done after trauma. in the remaining cases open abdomen was done for non-traumatic disease. 36 patients have been treated following our algorithm (with negative pressure wound therapy abthera device and step by step approach with medial mesh mediated fascia traction). in this group fascial retraction was significant lower and definitive direct abdominal wall closure rate was statistically higher. conclusion: an early fascia traction mediated with a mesh lead to an earlier fascia closure with a lower need of mesh positioning for definitive closure; the rate of post incisional hernia is similar among the two groups references: case history: a 59 year old male presented in the er with malaise, fatigue and loss of appetite. he was recently hospitalised due to a peritonsillar abscess and during investigations he was first-diagnosed with non-hodgkin lymphoma. his medical and surgical history were otherwise unremarkable. clinical findings: on admission the patient was febrile and tachycardic (hr 120 bpm) but remained hemodynamically stable (bp:157/ 99 mmhg). clinical examination revealed abdominal distention and rebound tenderness in the right abdomen. investigation/results: blood tests were significant for leukocytosis (wbc: 48.300/ll-neut:75%), acute kidney injury (urea: 240 mg/dl, cr: 3.0 mg/dl), elevated crp (313 mg/l) and ldh (520 iu/l), hyponatremia (na:126 mmol/l) and hypoalbuminemia. chest and abdominal x-rays were non-diagnostic, while abdominal ultrasound showed increased air presence along the medial line. investigations concluded with an abdominal ct scan that revealed pneumoperitoneum, small bowel distention and multiple enlarged mesenteric lymph nodes. diagnosis: the patient was transferred to the or for an explorative laparotomy. he was diagnosed with ileo-cecal intussusception causing bowel ischemia and perforation at the ileocecal valve. enlarged lymph nodes were observed along the mesentery. therapy and progressions: the affected ileus and colon were removed and a subtotal colectomy with end ileostomy was performed. the pathology report confirmed infiltration of the dissected bowel and lymph nodes by lymphoma cells. the patient continued treatment in the icu. he was discharged on the 14th postoperative day. comments: intussusception is rare in adults and, contrary to children, is highly associated with malignancies. resection without reduction has been advocated-wherever possible-in order to ensure better oncological outcomes. introduction: emergency surgeries are oftenly related to contaminated/infected fields, where the implantation of non reabsorbable meshes for reconstruction of the abdominal wall may not be recomendable. we aim to evaluate the results of polyvinylidenfluoride (pvdf) meshes used for complicated ventral hernia in the acute setting material and methods: retrospective analysis of patients with vh undergoing emergency surgery on which a pvdf mesh was required, in a third level hospital (november 2013-september 2019). we analyzed early and late postoperative complications and 1-year recurrence rates. association between grade of contamination, mesh placement and infectious complications and recurrences was investigated using binary and multiple regression. results: we collected 123 patients with a mean age of 62''3 years, mean bmi of 31''1 kg/m 2 and mean cedar index of 51''6. 96''4% of patients had a grade 2-3 ventral hernia according to rosen''s index. concomitant procedures included al least one organ resection in 48''7% of surgeries and previous contamined mesh explantation in 11''5%. a pvdf mesh was placed using an intraperitoneal onlay mesh (ipom) technique in 56''3% of cases and an interposition location in 39''9%. readmission rate was 15''7%, one-month recurrence 5''7% and recurrence after a year 19''1%. overall mortality rate was 27.6%. risk of recurrence was related with patients with a rosen score over 2 (p \ 0.001) and also with postoperative ssi (p = 0.045). higher recurrence rates were not found regarding the pdvf meshes placement. postoperative seroma and hematoma rates were 21''1% and 10''6%. enteroatmospheric fistula rate was 7''8%. conclusions: pvdf prosthesis seems to be an useful material for complicated ventral hernia repair, specially in the acute setting, showing similar recurrence and infectious complication (fistula, chronic mesh infection, surgical site infection) rates with regard to different prosthesis used in the literature. operative vs non-operative management in liver trauma patients in a uk major trauma centre conclusions: the airs can predict the histologic severity and the intra operative findings in patients with a high clinical suspicion of aa. airs could be useful to reduce negative appendectomy and predict the postoperative stay to evaluate the deformity progression in spine injuries (dorsal, dorsolumbar, lumbar) managed by internal fixation. introduction: there continues to be controversy surrounding the management of thoracolumbar burst fractures. numerous methods of fixation have been described for this injury, but to our knowledge, spinal fusion has always been part of the stabilising procedure, whether this involves an anterior or a posterior approach. material and methods: 64 patients with spinal injury (dorsal, dorsolumbar, lumbar) were included. all patients had dorsal, dorsolumbar, lumbar spine injuries managed with posterior short segment pedicle screw fixation and were followed up for at least one year after surgery. preoperative, post operative and follow up lateral radiographs were examined for cobb''s angle, anterior wedge compression angle and upper and lower adjacent intervertebral disc heights anteriorly, middle and posteriorly. results: at final follow up, the mean improvement in cobb''s angle post operatively was 10.8°. the mean loss of correction of cobb''s angle was 7.1°with sd of 5.7°compared to post operative. the mean improvement in anterior wedge compression angle was 7.1°post operatively. the mean loss of reduction in anterior wedge compression angle was 2.05°with sd of 2.3°. the increase in cobb''s angle was statically significant (r = 0.684, p = 0.001) with the loss of reduction of anterior wedge compression angle at follow up and loss in intervetebral disc height at upper intervetebral disc anteriorly only(r = 0.545, p = 0.013). the mean period at which sitting and standing was initiated was 1.5 months and 3.12 months respectively and mean periods for which brace was used was 8.6 months. conclusions: pedicle screw fixation is good but related to loss in reduction of anterior wedge compression angle and decrease in upper intervertebral disc height anteriorly. references: p. l. sanderson:short segment fixation of thoracolumbar burst fractures without fusion. introduction: with the newly implemented ao upper cervical spine classification system a modern, pragmatic system has been established. to what extent the simplification is helpful or whether an adjustment of the new ao classification may be discussed, forms the question of this work. material and methods: retrospective analysis of 60 upper cervical spine injuries with ct/mri diagnostics presented to 4 trauma surgeons with several years' experience to do classification and suggest treatment. results: the classification according to the known systems showed a relatively good agreement in the exact classification and therapy. the classification according to the new ao upper cervical spine was simple and consistent but revealed different treatment recommendations for two subtypes (iii type a and iii type b). conclusions: the new ao upper cervical spine classification system leads to a simplification. uncertainties remain with the most frequent fractures on the upper cervical spine, the c2 fractures. these will be managed under iii type a. however, just these injuries require completely different treatment concepts. further adaptation is required for type iii b because there uncertainties regarding the therapy also remain. case history: a 83-year-old woman, on treatment with acenocoumarol due to atrial fibrillation, and interatrial communication, suffered a compression fracture of the vertebrae l2 to l4 after a lowenergy trauma. due to poor pain control, she underwent a percutaneous transpedicular kyphoplasty, with no intraoperative complications. clinical findings: during the immediate postoperative period, she developed dysarthria and claudication of barré in her right upper limb. investigation/results: an angio-ct scan was performed, showing endovascular material in the left middle cerebral artery (mca) and within the lungs, compatible with cement emboli. mri showed cortico-subcortical ischemic areas in mca territory. cement-embolism stroke after percutaneous kyphoplasty therapy and progressions: conservative treatment was chosen due to the high number of emboli and the favorable evolution of the patient, with resolution of the neurologic symptoms in 48 h without sequelae. 15 days later, she suffered a transient ischemic attack, with no changes in the ct-scan compared to the previous images, which also solved with no residual deficits. one month after this episode, the patient died due to a spontaneous cerebellar hemorrhage related to acenocoumarol overdose. comments: kyphoplasty is a safe technique performed to treat vertebral compression fractures in elderly patients, with good clinical results and a low complication rate. its main complications are related to the leakage of cement from the vertebral body, usually well tolerated. other complications are exceptional, such as cerebral strokes, cardiac perforation, or death. the present case, although infrequent, shows us the need to assess the risk-benefit balance when operating fragile patients, as life-threatening complications may happen in these procedures. references: 1. marden fa, putman cm. cement-embolic stroke associated with vertebroplasty. ajnr am j neuroradiol. 2008 nov;29(10):1986-8. survival rate and application number of total hip arthroplasty in patients with femoral neck fracture: an analysis of clinical studies and national arthroplasty registers g. hauer 1 , a. heri 1 , s. klim 1 , p. puchwein 1 , a. leithner 1 , p. sadoghi 1 1 medical university of graz, department of orthopaedics and trauma, graz, austria introduction: total hip arthroplasty (tha) is an increasingly popular treatment option for fractured neck of femur (nof) [1, 2] . the aim of this study was to systematically review all literature on primary tha after fractured nof to calculate an overall revision rate. furthermore, we wanted to compare primary tha implantations after fractured nof between different countries in terms of tha number per inhabitant. material and methods: all clinical studies on tha for femoral neck fractures between 1999 and 2019 were reviewed and evaluated with a special interest on revision rate. revision rate was calculated as ''revision per 100 component years'' [3] . tha registers were compared between different countries with respect to the number of primary implantations per inhabitant. results: twenty-two studies showed a mean revision rate of 11.8% after ten years. we identified eight arthroplasty registers that revealed an annual average incidence of tha for fractured nof of 9.7 per 100,000 inhabitants (table 1) . conclusions: we found similar annual numbers of thas for fractured nof per inhabitant across countries. revision rates in clinical studies are higher compared to registry data [1, 2, 4] . the results of this analysis can be used to rank present and future national tha numbers within an international context. early clinical predictors of pneumonia in patients with acute spinal cord injury without bone injury: a retrospective study t. sakamoto 1 , s. kanezaki 1 , n. notani 1 1 oita university, oita, japan introduction: pneumonia is still significant complication that associates with mortality and duration of hospitalization in patient with acute spinal cord injury without bone injury (sciwobi). the purpose of this retrospective study is to clarify early clinical predictors of pneumonia in patients with sciwobi. material and methods: we reviewed the medical records of patients with sciwobi who admitted between january 2012 and november 2019. spearman's rank-correlation coefficient was used to test the relationship between each parameter. multiple logistic regression analysis was performed to determine the factors that influenced pneumonic morbidity. results: a total of 44 patients with acute sciwobi, who were evaluated for neurological impairment within 24 h after injury, were reviewed. pneumonia occurred in 11 patients (25%), seven patients injured at c4 and four at c5. according to spearman's rank method, asia motor score, beginning period of nutrition, ventilator use, neurological level of injury (nli) ] c5, low prognostic nutritional index (pni) were correlated with onset of pneumonia. logistic regression found ventilator use to be most predictive of pneumonia (odds ratio [or] = 12.7, 95% confidence interval [ci] 1.24-131), followed by nli ] c5 (or 2.3, 95% ci 0.36-14.4), beginning period of nutrition (or 2.1, 95% ci 0.95-4.8), pni (or 1.3, 95% ci 0.94-2.5). conclusions: in addition nli, low pni increases the risk of pneumonia. we consider that improving nutritional status, especially early initiation of enteral nutrition, decrease the incidence of pneumonia. bicycle-related cervical spine fractures e. helseth 1 , j. ramm-pettersen 1 , s. f. eng 1 , i. naess 1 , m. mejlaender-evjensvold 1 , h. linnerud 1 1 oslo university hospital, neurosurgery, oslo, norway introduction: the incidence of traumatic cervical spine fractures (cs-fx) in the norwegian population is 15/100,000/year, and 12% of these injuries are bicycle-related (1, 2) . materials and methods: prospective cohort study of all bicyclerelated cs-fx in the south-east norwegian population (3.0 million) in the time period 2015-2018. the data were retrieved from our quality control database for traumatic cs-fx in south-east norway. in the database all cs-fx patients (c0 (occipital condyle) to c7/th1) are prospectively registered. results: during the four-year study period 209 patients with bicyclerelated cs-fx were registered, 175 (84%) were males, and mean age was 52 years (range 16-87). the cs-fx was located in the upper cervical segment (c0-c2) in 68 (33%) patients, lower cervical segment (c3-th1) in 117 (56%), and at both segments in 24 (11%). the most common fx subtype was c0-fx. spinal cord injury secondary to cs-fx was registered in 26 patients (12%). fracture stabilization was achieved with open surgery in 41 (20%), external immobilization with a stiff collar alone in 147 (70%,) and without treatment in 21 (10%). conclusions: severe bicycle-related cervical spine injuries are not uncommon. the increasing political desire to move commuting from motorized vehicles to bicycles warrants a heightened focus on road safety. introduction: the need for cervical immobilization is predicted by the atls, the standard of care in trauma since 1980, because cervical trauma is a important cause of disability. however, its discontinuation was linked to x-rays, a fact that has been changed thanks to the development of two algorithms that assess the severity of cervical trauma: the canadian c-spine rule (ccr) and the national emergency x-radigraphy utilization study (nexus). material and methods: this study aims to compare the reduction values in the number of ct scans required after the application of both algorithms in a level-1 trauma center and to verify the degree of adherence of residents in the use of each. cohort study with randomized application by residents of the algorithms in all patients suffering from blunt trauma with cervical collars who were admitted from august to october 2019. the conducts had their frequencies analyzed to obtain an inference about the efficacy of each method in the abstention of x-rays and case resolution, in addition to verifying if the indicated conduct was followed by the resident, inferring on the confidence in the algorithm. results: 158 cases were evaluated during this period, of which 76 were by the ccr algorithm and 82 by the nexus. the indication rate for ccr imaging was 39.4% and nexus was 42.6%, showing no statistical difference between them (p = 0,682; ci = 95%). in the evaluation of the effective conduct, which evaluated the reliability of the algorithm, there was no disagreement between them (p [ 0,05; ci = 95%). conclusions: neither method demonstrated superiority to the other in reducing the indication of imaging exams and its uses had equal adherence by resident physicians. panacek case history: a 65 year old lady presented with severe neck pain following a fall and cervical hyper-extension injury. she had previously undergone anterior cervical discectomy and fusion at c6/7 with placement of artificial interbody bone graft. postoperatively, the patient reported an excellent clinical outcome and later imaging confirmed interbody fusion. clinical findings: on examination, the patient was neurologically intact but reported severe mid-cervical neck pain with reduced range of movement. investigation/results: imaging included ct and mri of the whole spine diagnosis: imaging revealed an unstable hyper-extension injury of the cervical spine. a fracture extended through the caudal end of the fused graft-vertebral interface at c6/7 with disruption of the posterior elements. therapy and progressions: given the severity of the injury surgery was recommended. the patient underwent uneventful c6-t1 posterior instrumentation and fusion with excellent outcome (follow up two years). comments: this is the first report of a cervical spine fracture through the site of an anterior cervical discectomy and fusion. it is hypothesised that the fused cervical segment resulted in increased stress at the fused caudal graft-vertebral interface during hyper-extension, this combined with reduced tensile strength at the graft-vertebral interface resulted in this unusual transverse fracture pattern. the clinician should be aware that patients presenting with cervical spine trauma in the context of previous cervical spine surgery are prone to greater mechanical forces. there should be a high index of suspicion for serious injury prompting thorough assessment and investigation. pr 445 s1-screw-fixation: computer aided study prevent unguided missile r. krassnig 1 , w. pichler 2 , e. viertler 3 , a. schwarz 4 , r. wildburger 1 , g. hohenberger 5 1 auva rehabilitation clinic tobelbad, tobelbad, austria, 2 boldin und pichler og, graz, austria, 3 medical university graz, graz, austria, 4 auva unfallkrankenhaus, graz, austria, 5 medical university graz, orthopaedics and trauma, graz, austria introduction: transiliosacral screw fixation of unstable dorsal pelvic ring fractures is not much present neither in literature nor in practice. in cause of the complex anatomy and the varying narrow safe bony corridors its a demanding procedure. limited information is available on optimal placement and the geometry of safe zones for screw insertion in the pelvis. material and methods: 3d-reconstructions of 50 consecutive ct scans of polytraumatic injured patients (15 female, 35 male) were the basis to insert two virtual cad bolts (representing screws) into the first two sacral segments as performing during screw fixation. results: in s1 the narrowest point was reached after a mean of 62.75 mm respectively 63.31 mm, depending on the selected way of measurement. for s2 the mean distance to the tricky constriction area amounted to 50.61 mm, respectively 51.54 mm. the average height in s1 measured 25.88 mm and the average width 25.49 mm. according, the average height for s2 was 17.54 mm and the average width 17.61 mm. the measurement results didn't show a significant difference between male and female pelvis bones for any distance of interest. conclusions: an optimal screw position is very important, because in the areas of bony narrowing are the exit points of the sacral nerves, which exit through the foramina anteriorly and posteriorly. damage to this nerve structures can cause severe long-term consequences such as numbness or paralysis. knowledge of predefined distances may aid in preoperative planning, decrease operative and radiation times and may prevent unguided missiles. clinical findings: there were absent breath sounds on the right side of the thorax, ultrasound showed an extensive pleural effusion. a chest tube was inserted and 2l of bloody-milky fluid was drained. investigation/results: ct scan showed fractured c1-c2 and th1-th3 vertebral bodies, fractured lateral osteophytes of th11-12 and probable injury of the thoracic duct at th11-12 level. pleural effusion analysis showed raised cholesterol and triglyceride levels. diagnosis: traumatic chylothorax; fractures th11-th12, th1-th3, c1-c2 therapy and progressions: patient was kept on ventilatory support for 3 days. primarily she was treated with total parenteral nutrition followed by no fat and hypolipidemic diet. the chest tube was removed after 8 days. she was discharged in stable condition the following day. at the 1 month check-up she was stable and eupnoic. comments: traumatic chylothorax caused by blunt chest trauma is extremely rare. there are hypotheses that injuries to the thoracic duct are caused by hyperextension of the spine or by increased thoracic/ abdominal pressure (seat-belt injuries). in our case, chylothorax probably resulted from fractured lateral osteophytes. patients are usually successfully treated with pleural drainage and total parenteral nutrition. if there is no improvement after 2 weeks or if drainage exceeds 1.5l/day or 1l/day for more than 5 days, thoracic duct ligation should be considered. conservative treatment resulting in t-l or lumbar kyphosis can worsen the quality of life of the patient whereas traditional open surgery may be an overtreatment in some cases, considering blood loss, possible complications, hospital stay and delayed functional recovery. in this setting, a good option can be a percutaneous minimally invasive surgery. the advantages of percutaneous pedicle screw fixation are: preservation of posterior musculature, less blood loss, shorter operative time, lower infection risk, less postoperative pain, shorter hospital stay and easier implant removal after bone union. limitations such as inability to achieve direct spinal canal decompression can be dealed by combination with open techniques. the objective of this study was to report the results of ppsf on these fractures and the technical problems we had to overcome. methods: 32 patients are included, treated with percutaneous transpedicular fixation and stabilization with minimally invasive technique from december 2015 to october 2019. 24 patients were males, 8 females; average age was 46,5 years (range from 18 to 82). in all cases, system pathfinder-nxt (zimmer) was used. results: most of the patients presented an early post-operative mobilization with amelioration concerning pain and a low complication rate. limitations in mobilization were mainly due to coexistent injuries, polytrauma or non-reversible neurological deficit. conclusion: ppsf is a reliable and safe procedure which does not replace the open technique but adds to treatment options by restoring a good sagittal alignment similar to those reported for open surgery. removal of hard material is advocated after fracture healing to preserve the lumbar spinal mobility and avoid zygapophyseal joint osteoarthritis. critical surgery within the first hour of presentation: is it a feasible intervention for better trauma care outcomes in low and middle income countries? introduction: in low and middle-income countries (lmic) golden hour care concept is almost nonexistence due to resource constraints. in this study, we analyzed one novel concept of critical surgery within the first hour of admission as a possible intervention which could be applied in the existing scenario in these countries without much resource requirement. material and methods: a retrospective analysis of a prospectively maintained data registry under a project named titco (towards improved trauma care outcome) was done. registry data from a level -1 trauma centre in india were analyzed from october 2013 to september 2015. all patients who admitted and underwent critical surgical interventions within the first hour of presentation were analyzed. these patients were divided into two groups depending upon primary presentation or referred from another facility. statistical analysis was done between these two groups to compare the outcome. results: sixty-one (57.6%) patients were directly admitted from the site of the incident whereas forty-five (42.4%) were transferred from other hospitals for surgical needs. the median time from injury to presentation for primary patients was 50 min with interquartile range (iqr) of 40. in the referred patient median time gap between the injury to our center (not referring center) was 230 min with iqr of 350. this difference was statistically significant. major outcome indicators in the form of median icu and total stay, as well as mortality, were not significantly different conclusions: proposed concept might be a useful hospital-based intervention in existing trauma system in lmic to improve the outcome of injured patients along with improving prehospital services. oslo university hospital, ullevål, orthopedic department, oslo, norway, 2 extrastiftelsen, oslo, norway introduction: it is well-known that physical activity is good for us. although the skeletal muscle is the main organ which is directly affected, exercise affects the whole body. the mechanisms responsible for these beneficial effects are gradually becoming known to us through extensive research. this might make it easier for physicians to prescribe exercise as a therapy equally and even more beneficial than drugs regarding effect and risk profile. the aim of this thesis was to review the current literature on the molecular mechanisms of exercise-induced health benefits. material and methods: a search in medline and embase resulted in 468 articles. they were sorted by title and abstract, then by reading the full text. relevant articles from the reference-lists were included. 18 sources were found outside of the search. results: when we exercise, the skeletal muscle is subjected to several mechanical and chemical stimuli, which in turn activate a set of kinases and phosphatases. these are molecules that regulate transcription-factors and co-activators, and this leads to adaption of the muscle-cells. i addition, the muscle secretes a number of proteins called myokines, which conduct the effect of exercise to other organs and tissues. some lead to increased cerebral neuroplasticity, hypertrophy and angiogenesis (bdnf, vegf and igf-1). several interleukins have also been identified as myokines, and they mediate an anti-inflammatory effect which is favorable in the prevention and management of conditions like atherosclerosis and type 2 diabetes. lastly, we found that exercise leads to epigenetic changes, altering the genetic expression in several types of tissues. some studies suggest that the epigenome is affected by exercise even before we are born, giving babies born to physically active mothers a favorable epigenetic expression. conclusions: we should use this knowledge to support the implementation of physical activity in treatment and preventive health care. impact on undertriage and mortality after changing from a twotiered to one-tiered trauma team activation protocol costs. prognostic factors may assist in identifying high cost groups with potentially modifiable factors for targeted preventive interventions, hence reducing costs and increase rtw rates. evaluation of long-term follow-up and consequences of gunshot and stab wounds in a french civilian population introduction: the data concerning long-temr follow-up of patients and consequences of gunshot wound (gsw) and stab wound (sw) are almost inexistent in the literature. in finland, a 2014 study showed that 12% of patients with trunk wounds died secondarily from alcohol-related or violent problems [1] , highlighting the secondary importance of long-term care for these patients. the main objective of our study was to analyze the hospital and posthospital follow-up of patients with gsw or sw and to evaluate late complications and the consequences of these traumas. material and methods: from january 2007 to january 2017, 165 patients were hospitalized for gsw or sw management in laveran military hospital. hospital data were collected via informatic patient file and post-hospital data via a telephone questionnaire with the general physician (gp). results: median hospital follow-up was 28 days . seventy-six patients had a follow-up visit with their gp (46%). median follow-up was 47 mois . twenty-four patients were totally lost to follow-up (14.5%). global follow-up identified 54 patients with longterm consequences (32.7%), 20 psychiatrics and 30 organics. seventeen cases of recurrence were found (10.3%). high iss, age, gsw and gp identified in patient medical file were significantly linked to long-term consequences occurrence. conclusion: this study showed a high number of long-term consequences occurrence among patients with gsw or sw. however, the extra-hospital follow-up seems insufficient. it is therefore imperative to strengthen the compliance and adherence to the care network of these patients. awareness and involvement of medical, paramedical teams and gp role seems essential to screening and management of these consequences. introduction: focused assessment with sonography for trauma(-fast) is an effective tool for assessments of severely injured patients, especially in the settings of helicopter emergency medical service(hems) because of limited devices and time. the objective of this study is to investigate accuracy of trauma ultrasound in helicopter emergency service compared with enhanced ct scan. material and methods: we investigated the trauma patients in 3 years which was demonstrated fast and delivered to the advanced critical care center in gifu university by hems. accuracy of the fast was determined by comparison to the presence of injury, primarily determined by computed tomography, and to required interventions. results: 108 patients were included in this criteria. there were 57 and 13 patients in which we found fluids in thoracic or abdominal cavity by enhanced ct scans and ultrasounds in hems, respectively. sensitivity and specificity, positive predictive value, negative predictive value, accuracy were 0.24, 0.963, 0.866, 0.559, 0.60. if we limited the data for abdominal fluids, each data were 0.409, 0.988, 0.9, 0.86, 0.87. in the patients of negative fast with positive ct, no patient died due to hemorrhage in thoracic or abdominal cavity. conclusions: it has been reported that sensitivity of fast in hems was lower compared with in er. in the settings of prehospital trauma care, advantages of portable ultrasound could be limited because of peculiar environments. and also, the thoracic or abdominal fluids could increase with time by organ injuries and it causes fast negative in acute phases.in this series, we could not find cases which has possibility of death because of negative fast and might influence the treatment. repeated fast or careful assessment of patients based on the other findings could be beneficial. references: the sensitivity of fast in hems was low and demonstrating fast for several times could be effective to detect the thoracic or abdominal hemorrhage. pre-hospital trauma care in switzerland and germany: do they speak the same language? 1 los angeles county ? usc medical center, department of surgery, divison of acute care surgery and surgical critical care, los angeles, united states introduction: field amputation can be life-saving for entrapped patients requiring surgical extrication. under these austere conditions, the procedure must be performed as rapidly as possible with limited equipment, often in a confined space, while minimizing provider risk. the aim of this study was to determine the optimal saw for a field amputation. material and methods: this was a prospective cadaver-based study. four saws (gigli, hand pruning, electric oscillating and reciprocating) were tested in human cadavers. each saw was used to transect four separate long bones (humerus, ulna/radius, femur and tibia/fibula). the time required for each saw to cut through the bone, the number of attempts, slippage, quality of proximal bone cut and extent of body fluid splatter as well as the physical space required by each device during the amputation were recorded. univariate analysis (fisher's exact and kruskal-wallis or mann-whitney u-test) was used to compare the outcomes between the different saws. results: the fastest saw was the reciprocating followed by oscillating (2.1 [1.4-3.7 ] sec vs 3.0 [1.6-4.9 ] sec, p = 0.007). the number of attempts required to amputate (5.8 [3.0-8.3] , p = 0.02) and the amount of slippage (3.0 [1.5-3.8 ], p = 0.03) were highest with the pruning saw. the reciprocating saw had the worst proximal bone cut quality (75% poor, p = 0.04) and the largest blood splatter (47.5 [41-63] , p = 0.044). the physical space required to perform an amputation ranged from 3500 cm 3 with the oscillating to 12000 cm 3 with the reciprocating saw. overall, the oscillating saw outperformed the others in number of attempts, slippage and quality of bone cut and physical space requirements, and was the second fastest ( table 1) . conclusions: the speed, precision, safety, space required, as well as the highly adjustable blade in the oscillating saw make it ideal for a field amputation. a gigli saw is an excellent backup for when electrical tools cannot be used or fail. impact of air medical transport on the survival of major trauma patients in thailand e. surakarn 1 , w. siriwanitchaphan 1 1 bangkok hospital headquarters, bangkok trauma center, bangkok, thailand introduction: air medical transport is an alternative mode of interfacility transfer for injured patients who required a higher level of trauma care in thailand. this study assessed the impact of air medical transport on the survival of major trauma patients transferred from local hospitals to a tertiary care hospital. material and methods: trauma registry of 2014-2018 was reviewed. major trauma patients transferred by air ambulance were identified. injury severity score (iss), predicted mortality and actual survival to hospital discharge were studied and compared between two subgroups, the seriously injured patients (iss 15-24) and the severely injured patients (iss [ 24) . the predicted mortality was calculated from the probability of survival (ps) of trauma and injury severity score (triss). results: there were 99 major trauma patients (iss [ 15) transferred by air ambulance in five years period. 62 patients were severely injured (median iss = 33), and 37 patients were seriously injured (median iss = 17). the range of flight time was 20-200 min. the overall survival rate was 88.88%. the predicted mortality in the severely injured group was 21 cases (33.87%), but the actual mortality was nine (14.51%), 19.36% lower than predicted mortality. the predicted mortality in the seriously injured group was one case (2.7%), while the actual number was two (5.4%). the eleven deaths in this study were eight cases of severe traumatic brain injury(tbi) patients, two cases of massive bleeding with subsequent multi-organ failure and one drowning. conclusions: air medical transport significantly improved the survival of severely injured patients who need higher level of trauma care. severe tbi and the presence of multi-organ failure associated with unfavorable outcomes. however, a detailed analysis of the trends and epidemiology of rtis affecting the most vulnerable children in qatar, under 5 years of age, has not been conducted. this study's primary objective of is to describe the epidemiology of rtis and deaths in young pediatric patients in qatar. material and methods: data, for all young pediatric [under 5 years] victims of rti''s and rti deaths from january 1, 2008 , through december 31, 2017 , from the trauma registry of the hamad trauma center [htc], the national level 1 trauma referral center of qatar, was analyzed. this data was correlated and compared with data from the hamad general hospital mortuary and vital statistics data from the qatar ministry of development planning and statistics, the vital statistics annual bulletin, for the years 2008-2017. results: the htc attended to 271 patients, under 5 years, with severe rtis and 15 in-hospital rti deaths were reported during the study period. males made up 83.7% of the injured and 60% of fatalities.the average age of the injured was 3 years and for fatalities was it was 2.8 years. the rti incidence rate per 100,000 for both sexes, under 5 years, has been unchanged (246 in 2007 and 225 in 2017) . the road mortality rate, per 100,000, has decreased significantly, from 46.3 in 2008 to 7.2 in 2017. since 2014, the proportion of pre-hospital deaths has been increasing, 25-100%, and the in-hospital death rates has been reduced to 0%. conclusions: rapid improvements in pre and in-hospital post-crash care in qatar have resulted in marked reductions in in-hospital deaths for young children with rtis. the emergence of pre-hospital road deaths of under 5''s must be made a priority for road safety in qatar. the implementation of proven prevention programsshould be fast tracked in order to directly address this issue. introduction: despite improving survival of patients in prehospital traumatic cardiac arrest (tca), initiation and/or discontinuation of resuscitation of tca patients remains a subject of debate among prehospital emergency medical service providers. the aim of this study was to identify factors that influence decision making by prehospital emergency medical service providers during resuscitation of patients with tca. methods: twenty-five semi-structured interviews were conducted with experienced ambulance nurses, hems nurses and hems physicians individually, followed by a focus group discussion. participants had to be currently active in prehospital medicine in the netherlands. interviews were encoded for analysis using atlas.ti. using qualitative analysis, different themes around decision making in tca were identified. results: the causes of bleeding were grouped into several categories.the most frequent cause with 7 cases in a row is attributed to diverticular bleeding,other causes of bleeding were angiodysplasia,post polypectomy bleeding,gist tumor,rectal ulcers and inflammatory disease.no case presented mortal or serious complications,secondary to the procedure. only 2 cases presented a mild complication: focal mucosal ischemia of the embolized intestinal segment that was resolved with conservative treatment.lesions in charge of bleeding in those 5 cases in which the angiographic treatment failed,were:ulcer in 2 cases,a case of bleeding after endoscopic polypectomy, a case of diverticular bleeding and bleeding secondary to a coagulation disorder.among these patients, the definitive treatment was the following: -a second angiographic treatment was effective in the case of bleeding due to coagulation disorder. -a case of self-limited bleeding. -surgical treatment was the definitive treatment in both cases of bleeding in the context of and patient with bleeding after polypectomy. we have not observed a significant relationship neither the type of lesion or its location with the probability of failure of the angiographic treatment. nor do we observe a significant relationship between the type of material used for embolization and the risk of treatment failure. comments: our data show that angioembolization is an effective and safe technique to treatment lgi bleeding. references: clin endosc 2019. endoscopic therapy for acute diverticular bleeding introduction: the use of resuscitative endovascular balloon occlusion of the aorta (reboa) as adjunct for temporary hemorrhage control in patients with major torso hemorrhage is increasing. specifications and characteristics of available aortic occlusion balloons (aob) are diverse. in order to minimize the risk of failure and complications it is important to choose a device that fits the requirements per medical situation. the aim of this study is to provide guidance in the choice of an aob in a specific situation. material and methods: 29 aob were assessed for characteristics and different properties of each are outlined. the bending stiffness was measured with a three-point bending device. results: although all aob tested are small caliber devices ranging from 6 (er-reboa tm ) to 10 french (codaò 46), some need large bore access sheaths up to 22 french (fogarty ò 45 and lemaitre tm 45) or even insertion via surgical cut-down (equalizer tm 40). the bending stiffness of the aob varied from 0.08 n/mm (± 0.008 sd) with the codaò 32 to 0.72 n/mm (± 0.024 sd) with the russian prototype. guidewire-free devices are generally stiffer than over-thewire catheters. the tokai rescue balloon tm showed kinking of the shaft at low bending pressures. the er-reboa tm , fogarty ò , lemaitre tm , reboa balloon ò , and rescue balloon tm are the only catheters with external length marks to assist blind positioning. the only aob using a non-compliant balloon is the reboa balloon ò . conclusions: specifications of available aob are diverse. in resource-limited settings, reboa should be performed with a rather stiff device that can be placed without wire and fluoroscopy, such as the er-reboa tm , fogarty ò , and lemaitre tm . of these aob, the er-reboa tm is the only catheter compatible with a small 7 french sheath. use of non-compliant balloons without real-time fluoroscopy is not advised given the potential risk of aortic rupture. when fluoroscopy is available, a guidewire can be considered. case history: 89 year old male patient presenting with an initially uncomplicated pertrochanteric fracture, treated by an intramedullary nailing system (figs. 1 and 2) . days after the operation and mobilization without any adverse events the patient was readmitted. clinical findings: massive swelling, hematoma and pain. investigation/results: sudden fall of hb values down to 4,4 g/dl, ct scans showed the lesser trochanter located directly to the deeper femoral artery after mobilization (fig. 3) . diagnosis: perforation of the deep femoral artery and several veins by the dislocated lesser trochanter therapy and progressions: blood transfusion, intraoperative cardiopulmonary resuscitation, several revision surgeries to stop the bleeding by oversewing the deep femoral artery and ligation of the veins, removal of the lesser trochanter fragment (fig. 4) . admission to intensive care unit. subsequent plastic coverage. comments: according to literature, bleeding complications and injuries of the deep femoral artery can occur even several days after an initially uncomplicated pertrochanteric hip fracture. besides acute life-threatening bleeding, false aneurysm can occur (1) (2) (3) . even if those late complications are very rare, the consequence for the patient can be devastating. these rare cases show the clear obligation to a thorough follow up treatment and regularly dressing changes. investigation/results: arterial colour doppler of the popliteal artery showed hypoechoeic contents and narrowed lumen. biphasic flow was seen in both popliteal and posterior tibial arteries. diagnosis: popliteal artery injury with delayed repair therapy and progressions: two incision and four compartment fasciotomy was done under regional block the next day which revealed a non contractile posterior compartment. superficial and deep muscles of the posterior compartment had doubtful viability. left distal sfa to infragenicular popliteal artery bypass graft was placed on day 4 post injury. blood flow was established upto the ankle and foot, confirmed on check angio. however, foot drop of the patient persisted. after appearance of a healthy granulation tissue at the wound site (7 days), a split thickness skin graft was placed to give coverage with 100% uptake of the graft. comments: blunt popliteal artery injury has been reported to result in amputation rates of nearly 30-60%.the importance of a detailed vascular examination of a blunt trauma patient is emphasized as a limb can be salvaged if timely intervention is done. in this case even with an unfavourable mess score. case history: a healthy 27-year-old male, with no history of interest, suffers a high-energy trauma as a water bottle rushes over his left knee. clinical findings: go to the emergency room with pain and functional impotence in the left knee, with its anatomical deformity. knee x-ray pa and l are performed and the distal pulses that are present are taken. ankle-brachial index [ 0.9. closed reduction is performed in emergencies under sedation and control x-ray is requested, aiming at correct reduction. it was decided to keep under observation for 24-48 h before discharge from hospital to schedule regulated ligament reconstruction surgery after studying with mri. therapy and progressions: at 12 h of evolution after the accident and after having reduced the dislocation, the patient who has the leg with a temperature equal to the contralateral is reassessed, however, there is no palpable dorsal pedis pulse or posterior tibial palpation in the affected leg. it is decided to urgently request an angiotc and it is objective thrombosis of popliteal artery. vascular surgeon is contacted and emergency surgery is decided. a by-pass is performed with vena safena. diagnosis: traumatic knee dislocation and popliteal artery injury comments: in the 21st century, complementary tests in diagnosis are becoming increasingly important. however, in this case we want to management of aseptic tibial nonunion anastasios g. c. reamed interlocking intramedullary nailing for the treatment of tibial diaphyseal fractures and aseptic nonunions. can we expect an optimum result? results of a systematic approach to exchange nailing for the treatment of aseptic tibial nonunion management of tibial non-union using reamed interlocking intramedullary nailing the radiographic union scale in tibial (rust) fractures: reliability of the outcome measure at an independent centre pelvic trauma: wses classification and guidelines damage control orthopaedics in unstable pelvic ring injuries references: beuran, m. trauma scores: a review of the literature glasgow coma scale, age, and arterial pressure (mgap): a new simple prehospital triage score to predict mortality in trauma patients. critical care medicine. champion hr. a revision of the trauma score proximal femoral nail antirotation versus gamma3 nail for intramedullary nailing of unstable trochanteric fractures. a randomised comparative study results of the femur fractures treated with the new selfdynamisable internal fixator (sif) dhs helical blade for elderly patients with osteoporotic femoral intertrochanteric fractures the hypermetabolic response to burn injury and interventions to modify this response racial differences in propranolol enantiomer kinetics following simultaneous i.v. and oral administration propranolol dosing practices in adult burn patients the hypermetabolic response to burn injury and modulation of this response: an overview. wound heal south africa management strategies and outcome of blunt traumatic abdominal wall defects: a single centre experience blunt traumatic abdominal wall hernias: a surgeon's dilemma blunt traumatic abdominal wall hernias: associated injuries and optimal timing and method of repair traumatic abdominal wall herniation: case series review and discussion trauma patients with open abdomen: do they differ from others? a single center experience h. fagertun 1 , a. seternes department of circulation and medical imaging, trondheim, norway introduction: treatment with open abdomen is demanding for patients, staff and hospital. a multidisciplinary approach is mandatory. the aim of this study was to compare trauma patients with open abdomen (oa) and patients treated with oa for other reasons, regarding outcome and resources spent. material and methods: retrospective study of patients treated with oa in a tertiary hospital in norway. ten were trauma patients vacuum-assisted wound closure and mesh-mediated fascial traction for open abdomen therapy-a systematic review prospective study examining clinical outcomes associated with a negative pressure wound therapy system and barker's vacuum packing technique thoracic-abdominal trauma with diaphragm lesions n. vlad 1 , i. streanga 1 , a. morar 1 , i st. spiridon'' hospital iasi. we have analyzed clinical data, trauma mechanism, pathology of the lesion, time trauma-diagnostic, associated lesions, treatment, and follow-up. results: there have been 18 patients (12 men, 6 women), mean age 42. location of diaphragmatic tears has been on the left hemidiaphragm (12 cases), on the right hemidiaphragm (3 cases), or bilateral (3 cases). the trauma mechanism has been blunt (10 cases) or penetrant (8 cases). all patients had associated visceral lesions and had been operated right diaphragmatic injury and lacerated liver during a penetrating abdominal trauma: case report and brief literaturereview traumatic diaphrag-matic ruptures: clinical presentation, diagnosis and surgicalapproach in adults traumatic rupture of the diaphragm: experiencewith 65 patients 9% (82/393) were aast grade 4 or 5. in the total group, median age was 32 years, 66.1% were male and 79.6% were blunt injuries. median iss in the nom group was 22 and 25 in the om group. median iss for those with grade 4 or 5 injury was 26. 64.6% (254/393) underwent nom, compared to 59.8% (49/82) of those with aast grade 4 or 5. for each 1 mmhg increase in systolic blood pressure, patients with grade 4 or 5 injury were 3% less likely to have an operation (or 0.97, p = 0.003) and for each 1 beat increase in heart rate intra-operative grade i was revealed in 57 patients (49,8%), grade ii in 24 (20,8%), grade iii in 8 (6,7%) grade iv in 21 (18,2%) and grade v in 5 (4,5%). histologic finding of catarral appendicitis was found in 32 (27,8%) patients, 39 (34%) had phlegmonous appendicitis and 44 (38,2%) had gangrenous appendicitis. the airs difference was statistically significant with histological findings quality of publications regarding the outcome of revision rate after arthroplasty swedish hip arthroplasty register annual report joon yung lee: risk factors for failure of nonoperative treatment for unilateral cervical facet fractures in 2018, 501patients were included in the trauma registry. median iss was 9 and 103 patients had an iss [ 15. of these patients 31/103 (30%) were undertriaged with a mortality of 5/31(16%). the total mortality in 2018 was 4,8% (24/501). i 2017, median age was 62 years for the patients with no tta vs 36 years for those patients who did receive a tta (p \ 0.001) prognostic factors for medical and productivity costs, and return to work after trauma: a prospective cohort study l results: a total of 3785 trauma patients (39% of total study population) responded to at least one follow-up questionnaire. mean medical costs per patient (€9,710) and mean productivity costs per patient (€9,000) varied widely. prognostic factors for high medical costs were higher age, female gender, spine injury, lower extremity injury, severe head injury, high injury severity, comorbidities, and pre-injury health status. productivity costs were highest in males, and in patients with spinal cord injury, high injury severity, longer length of stay at the hospital and patients admitted to the icu. prognostic factors for rtw were high educational level, male gender, low injury severity swiss and german (pre-)hospital systems, distribution and organisation of trauma centres differ from each other [1,2]. it is unclear if outcome in trauma patients differs as well. therefore, this study aims to determine differences in characteristics, therapy and outcome of trauma patients between both german-speaking countries. material and methods: the traumaregister dguò (tr-dgu) was between 01-2009 and 12-2017 were included if they required icu care or died. trauma pattern trauma care in germany trauma systems in europe practical assessment of different saw types for field amputation: a cadaver-based test study these themes were: factual information (e.g., electrocardiography rhythm)educational programs and future guidelines. references: rosemurgy as, prehospital traumatic cardiac arrest: the cost of futility blunt vertebral vascular injury in trauma patients: atlsò recommendations and review of current evidence treatment-relater outcomes fron blunt cerebrovascular injuries. importance of routine follow-up arteriography provided the catheters used for this study. no other support was provided diagnosis: the probe had perforated the ivc wall. therapy and progressions: open repair was performed through a xifopubic laparotomy and the cattel-braasch maneuver to expose the ivc (fig. 3). a retroperitoneal hematoma was observed anteriorly to the infrarenal ivc, without active bleeding. the ivc was dissected out sufficiently to permit proximal and distal vascular control (fig. 4), the probe was then removed and the laceration on the infrarenal ivc closed with a running suture. the postoperative course was uneventful. comments: to our knowledge this is the first reported case of symptomatic ivc laceration by an ice probe during ca. references: enriquez a. use of intracardiac echocardiography in interventional cardiology complications of catheter ablation for atrial fibrilla iatrogenic percutaneous vascular injuries: clinical, presentation, imaging, and management vascular complications during catheter ablation of cardiac arrhythmias: a comparison between vascular ultrasound guided access and conventional vascular access false aneurysm of the profunda artery resulting from intertrochanteric fracture. a case report profunda femoris arterial laceration secondary to intertrochanteric hip fracture fragments. a case report with major thoraco-abdominal vascular injuries (aorta, inferior vena cava and main branches). data on demographic, clinical status and imaging was recorded. descriptive and kaplan meir survival analysis was performed. results: 87 patients were included. median age was 33 years (iqr 45-25), 70 (80.5%) were male. aorta was the most frequently damaged vessel (40,2%) the median iss was 29 (iqr 38-25)interventional procedure. overall mortality was 46%, with 45% of deaths during the first hour, 37.5% in the first 24 h and 17.5% afterwards. median survival was 54 days (ic19-88). we compared survival curves in periods abdominal vascular trauma. trauma surg acute care open history: popliteal artery injuries are frequently seen with fractures, dislocations, or penetrating injuries. a thirty one year old pathologies. references: natsuhara, k.m. et al, what is the frequency of vascular injury after knee dislocation knee dislocation and vascular injury: 4-year experience at a uk major trauma centre and vascular hub can vascular injury be appropriately assessed with physical examination after knee dislocation? introduction: this retrospective cohort study investigated the prevalence of and risk factors for preoperative venous thromboembolism (vte) in patients with a hip fracture and a delay of [ 24 h from injury to surgery. material and methods: this observational study included 208 patients with a hip fracture surgically treated at 1 university hospital. patients underwent indirect multidetector computed tomographic (mdct) venography for preoperative vte detection after admission. overall vte risk and median time from injury to ct scan were calculated. age, sex, fracture type, time from injury to ct scan, body mass index, preinjury mobility score, previous anticoagulation treatment, previous hospitalization for vte, varicose veins, and medical comorbidities were considered potential risk factors. results: the prevalence of preoperative vte was 11.1% (23 of 208 patients). the mean time from injury to ct scan was 4.9 days. the delay from the time of injury to ct scan averaged 7.6 days for patients who developed preoperative vte, compared with 4.2 days for patients who had not developed vte. in the adjusted models, female sex, subtrochanteric fracture, pulmonary disease, cancer, previous hospitalization for vte, and varicose veins were risk factors for vte. the final multivariate logistic regression analysis introduction: vertebral compression fractures constitute a large percentage of traumatic injuries of spine. the initial management plays an important role in the final outcomes. the present study aims to study the profile of vertebral injuries in rural & semi urban population & to analyse the role of level two hospitals in initial management of vertebral injuries. material and methods: this study was a retrospective analysis of progressively collected data of patients presenting with vertebral injuries in a level two hospital catering to semi urban & rural population in india. the initial presentation along with the age & sex profile was noted. etiological factors leading to compression fractures were noted. any neurological deficit either at the time of admission or transfer to a tertiary care neurocentre was noted as per asia scale. initial management was carried out in accordance with the atls guidelines. results: a total of 44 out 3000 patients admitted with complaints of back pain were diagnosed to have compression fractures of the spine. the mean age was 49.4 years. male: female ratio was approx 5:1. the lumbo sacral spine region was the most comply affected region. two patients were incidentally detected to have vertebral fractures as a result of metastatic malignancy. a due note was made regarding patients who had deteriorated during the transfer in terms of neurological deficit & evidence of spinal shock. conclusions: road traffic accidents contribute a significant portion of vertebral trauma . smaller hospitals & general surgeons have an important role to play in terms of initial stabilisation of such patients particularly the ones presenting with neurogenic shock. a good initial management has sigificant bearing on outcomes. analysis of risk factors for tracheostomy in cervical spinal cord injury without bone injury n. notani 1 , s. kanezaki 1 , t. sakamoto 1 , h. tsumura 1 1 oita university, orthopaedic surgery, yuhu, oita, japan introduction: there are many cases that require tracheostomy in the acute phase of cervical spinal cord injury, and various risk factors have been reported so far. however, there has been no report on cervical spinal cord injury without bone injury. the aim of this study is to evaluate risk factors for tracheostomy in patients with cervical spinal cord injury without bone injury. material and methods: we conducted a retrospective observational study. patients who were treated for cervical spinal cord injury without bone injury in our hospital were divided into 2 groups: tracheostomy (tc) group and no tracheostomy (no tc) group. we compared variables, including age, sex, asia impairment scale (ais), neurological level of injury (nli), injury severity score (iss), vital signs, blood gas analysis, tracheal intubation, chest complication, smoking history between two groups. results: there were 8 patients in tc group, and 46 patients in no tc group. on univariate analysis, there were significant differences in age, ais a, tracheal intubation, nli ] c4. on multivariate analysis, nli ] c4 was an independent predictor of tracheostomy. conclusions: in this study, we demonstrated that nli ] tc4 could be useful to predict tracheostomy in patients with cervical spinal cord injury without bone injury. case history: many fractures of the articular processes of the cervical spine are associated with displacement and instability, approximately 5% of all traumatic cervical spine injuries involve isolated fracture of the articular processes non-displaced or minimally displaced. [1] this case demonstrates a isolated facet fracture of the cervical spine with c7 radiculapathy treated with minimally invasive spine surgery techniques clinical findings: a 47-year-old male was admitted to the neurosurgery department due to severe neck pain (vas 9/10). the pain radiating to the right upper extermity along dermatome c7. neck and trunk rotation worsened the pain. investigation/results: furthermore, physical examination revealed hyperaesthesia in the right index finger without muscle weakness. ailments suddenly appeared 4 weeks earlier after getting up in the morning. imaging demonstrated isolated, unilateral fracture of the right superior articular process of c7 diagnosis: imaging demonstrated isolated, unilateral fracture of the right superior articular process of c7 therapy and progressions: the patient was treated by microsurgical c7 decompression and fusion of c6-7 under navigation guidance. intraoperative ct scans were performed to evaluate sufficient bone removal.after the surgery, the neck and upper extremity pain subsided. the patient had returned to his usual job and sport activities. comments: this case illustrates the value of the navigation and intraoperative ct in the evaluation of bony decompression, anatomy and location of implants. navigation minimized iatrogenic injury resulting in reducing postoperative complications like chronic pain, kyphotic deformity and muscular atrophy.introduction: resuscitative endovascular balloon occlusion of aorta (reboa) is a technique initially developed in the military for trauma patients injured in combat 1 . recently, there has been much debate on its role in civilian trauma cases in controlling non-compressible torso haemorrhage (ncth) 2 . this review aims to provide an update on current literature on the outcomes and concerns of this procedure. material and methods: a systematic literature search according to prisma guidelines was performed over the period of january 2005 to august 2019 across embase, medline and cochrane databases. patient characteristics, mechanism and severity of injury, survival rates and post-reboa complications between survivors and non-survivors were compared. results: a total of 32 studies were included in this review. 8% and 92% of the 4042 reboa cases were penetrative and blunt cases respectively. the survival rates ranged from 6 to 100% across the studies. systolic blood pressure (sbp) was significantly elevated post-procedure, from 75.6 to 119.0 mmhg in the survivor group (p \ 0.001) and 61.4 to 96.8 mmhg in the non-survivor group (p = 0.001). the injury severity score (iss) was lower in the survivor group (31.9 vs 41.7; p \ 0.001) whereas their glasgow coma scale (gcs) was higher (12.3 vs 5.6; p = 0.008). the survivors also had a shorter duration of aortic occlusion (48.2 vs 93.3 min; p = 0.001). common complications noted following the procedure include renal injury, lower limb ischaemia and thrombosis. conclusions: pre-reboa sbp, iss, gcs and duration of aortic occlusion were found to be associated with survival. complications directly due to the procedure were difficult to ascertain. a prospective study in a multiple trauma centre is needed for further evaluation of the indications, feasibility and complications involved in reboa. references: introduction: traumatic vertebral artery injury (vai) is a wellknown complication of cervical spine injury and often causes posterior circulation stroke. we report preventive effect of acute phase endovascular intervention for traumatic vai. material and methods: all patients with cervical spine injury were surveyed with post-contrast computed tomography for vai. when vai was diagnosed, the affected vertebral artery (va) was occluded with endovascular intervention before spine reduction and fixation. brain ischemic lesion was evaluated before and after the treatment. results: forty-one patients with vai associated with cervical spine injury underwent endovascular intervention. the affected va was occluded with endovascular coils before cervical spine reduction and fixation in 38 patients, and after treatment in one patient. va stenting was done for another two. six presented new brain infarctions after spine surgery. of these, two had endovascular intervention after spine reduction. out of 38 patients who had endovascular embolization before spine reduction, four had newly developed infarctions after spine surgery, of which two were symptomatic. there were no complications related to the endovascular procedure. conclusions: in conclusion, endovascular embolization for traumatic vai before spine reduction and fixation was found to be effective to prevent symptomatic brain infarction. introduction: the use of drug coating balloons (dcb) in primary or secondary angioplasty for peripheral vascular disease is a new tendency. the use of paclitaxel decelerates the growth and hyperplasia of neo-intima tissue which can cause re-stenosis and total occlusion in the spot of pta is a very promising technique in long lasting results of balloon ptas. purpose: to demonstrate our experience and results of the technique of dcb pta with the use of drag coating balloons. material and method: in the period between march 2013 and september 2019, 65 patients with sfa lessions were treated with pta with dcb for acute limb ischemia. 41 were males and 24 females. mean age was 69,2 y.o (± 6.39). patients were examined pro operationally and immediate post operationally in abi difference and their post operational follow up included measurement of abi and u/s triplex scan on the 1st, 3rd, 6th and 12th month(where chronically available) after pta. results: the mean immediate post operative increase of abi was 0,32 (± 0,13). were chronically available the increase of abi remained to 0,26 in the 3 months follow up, 0,23 in the 6 months and 0,21 in the 12th month follow up while patency of the artery treated remained in all patients. 2 of the patients suffered from acute complications during or short after the pta (1 with peripheral embolization and 1 with retroperitoneal hematoma) which were treated immediately and left no consequences. conclusions: the use of dcb for pta in acute ischemia is a quite new, promising technique for maintaining patency of treated arteries for long time post operative period. the medium time results from its use in our clinic seem to be satisfactory. jichi medical university hospital, tochigi, japancase history: a 38-year-old male hit his neck hard against the fence. thereafter, he experienced difficulty in breathing and severe neck pain. he was brought to the emergency center by ambulance. clinical findings: his vital signs on arrival were gcs: e4v5m6, hr: 70, bp: 157/101, rr: 20, spo 2 : 100 (3lo 2 ). significant neck edema and tracheal deviation were noted. inspiratory stridor was not heard with no signs of retracted breathing or subcutaneous emphysema. investigation/results: an enhanced ct scan of the neck revealed tracheal deviation and compression with ruptures of the left thyroid lobe. a large hematoma and arterial extravasation from a branch of the inferior thyroid artery were noted. diagnosis: rupture of the left thyroid lobe and injury around the distal portion of the left inferior thyroid artery. therapy and progressions: after securing the airway by intubation, angiography of the neck was performed; extravasation from a branch of the left inferior thyroid artery was suspected. angioembolization was continued for hemostasis using gelatin sponge. neck edema improved in the intensive care unit. following extubation on the hospital day 6, the patient was discharged on the 8 th day with no complication. comments: thyroid injury due to blunt neck trauma is rare and surgical intervention such as hemithyroidectomy is generally prescribed. the patient''s condition, in this case, improved by angioembolization without any invasive surgical procedures. catheter procedure may, thus, be effective for hemostasis on thyroid injury after the confirmation of airway placement. introduction: the indication for resuscitative endovascular balloon occlusion of the aorta (reboa) is hemodynamically unstable patients in life-threatening hemorrhage below diaphragm. it was unclear that the difference of indications for reboa affects mortality in trauma.material and methods: this study used data from the japan trauma data bank (jtdb) (2004-2019), a nationwide trauma registry, to describe the epidemiology of reboa. adult trauma patients used reboa were included. patients were excluded if they had cardiac arrest at the scene or dead on arrival, or had an unsurvivable injury of any region of the body as defined by the abbreviated injury scale. patients were classified by whether patients had indications for reboa. the indications for reboa were defined by indications for hemostasis to intraabdominal, retroperitoneal, pelvic or extremity hemorrhage. the indications were decided by the delphi method with the cooperation of experts in trauma for this study. the contraindications were defined by brain injury needed intervention and hemorrhage above diaphragm. the logistic regression was used to assess the mortality after adjustment for injury severity score. as a sensitivity analysis, a generalized linear mixed model with random effects of a facility was performed. results: of 361,706 patients registered in the jtdb, 993 patients underwent reboa. 669 had indications for reboa and 294 underwent reboa without indications. the physiological variables were similar, but the consciousness was worse in the no-indications group. injury severity of brain and chest were higher in the no-indications group. the indications group had 6.7% and the no-indications group had 13.6% contraindications for reboa. the mortality was similar (43.6% versus 46.5%, or 0.80, 95%ci 0.58-1.10). a sensitivity analysis showed the same result as the primary analysis (or 0.82, 95%ci 0.60-1.12). introduction: most incident first responders have a primary nonmedical role, but are frequently the only professionals initially at the scene. early hemorrhage control via advanced techniques such as resuscitative endovascular balloon occlusion of the aorta (reboa) can save lives. training first responders these techniques has therefore the potential to improve outcomes. this study evaluates the ability to train quick response team fire fighters (qrt-ff) to gain percutaneous femoral artery access and place a reboa catheter, using a comprehensive theoretical and practical training program. material and methods: six qrt-ff participated in the training. sof medics from a previous training served as control group. a formalized training curriculum included basic anatomy and endovascular materials for percutaneous access and reboa catheter placement. key skills were: (1) preparation of an endovascular toolkit, (2) achieving vascular access in the model and (3) placement and positioning of the reboa catheter. results: qrt-ff had significantly better baseline knowledge of surgical anatomy (p = 0.048) compared to medics. they also scored significantly better on using endovascular materials (p = 0.003), performing the procedure without unnecessary attempts (p = 0.032) and overall technical skills (p = 0.030). the median time from start to reboa inflation was 3:23 min for qrt-ff and 5:05 min for medics. procedure times improved in all qrt-ff and 4 of the 5 medics in a second attempt of gaining vascular access and reboa placement. conclusions: our comprehensive theoretical and practical training program proves suitable for percutaneous femoral access and reboa placement training of qrt-ff without prior ultrasound or endovascular experience. repetition reduces procedure times. training in the use of advanced hemorrhage control techniques such as reboa, as a secondary occupational task, has the potential to improve outcomes for severely bleeding casualties in out-of-hospital settings. prytime medical tm devices, inc. provided the reboa access task trainer (ratt) and the catheters used for this study. no other support was provided.the authors declare that there are no conflicts of interest that could inappropriately influence (bias) their work. introduction: angioembolization (ae) has become an important component in the management of bleeding from severe pelvic fractures. timely availablity of ae is required for both, level 1 and 2 trauma centers. the aim of this study was to assess the utilization of this procedure in level 1 and 2 trauma centers and effect on oucomes. material and methods: retrospective, 3-year (2013-2016) study using the the american college of surgeons tqip database, including adult patients with isolated severe pelvic facture (ais [3] [4] [5] . patients who underwent laparotomy or preperitoneal packing within 4 h from admission were excluded, operative management for bleeding control between 4 and 24 h was considered as failure. univariate analysis was used to compare patients in level 1 vs 2 centers, multivariate regression analysis was performed to determine factors predictive for mortality and overall complications.results: 10102 patients (6960 in level 1; 3142 in level 2 centers) met the criteria for inclusion. overall, 610 (6.0%) underwent ae, with a trend toward higher ae rate in level 1 centers (6.3% vs 5.4%, p = 0.061). no significant differences were observed in timing and failure rate of ae between the 2 levels. particulary in the ae subgroup there was a significantly lower blood product utilization in the first 24 h in level i centers (prbc 5.6 vs 6.9 units, p = 0.015; plasma 3.8 vs 5.5 units, p = 0.003). mortality and overall complication rates were similar. table 1 the level of trauma center was not a predictive factor for mortality (or 1.306, p = 0.284) and overall complications (or 1.046, p = 0.591). conclusions: in isolated severe pelvic fractures, there was a trend toward higher ae rate and significantly lower utilization of blood products in level 1 centers. there were no significant differences in mortality or complications. the ae subgroup in level 2 centers had a higher blood products use without outcome benefit, suggesting more restrictive transfusion policy may be considered. portal vein thrombosis after distal splenopancreatectomy: successful recanalization using fogarty balloon catheter case history: intraoperative lesion of smv during distal splenopancreatectomy is repaired using peritoneal patch harvested from anterior abdominal wall clinical findings: postoperative increase in serum lactate and d-dimer without signs of peritonitis prompts bedside doppler us showing no blood flood within portal vein (pv) investigation/results: ct angiography is performed suspecting acute mesenteric ischemia, but no abnormal bowel enhancement/ thickness is seen despite complete pv thrombosis. anticoagulation with unfractioned heparin is started, but clinical conditions deteriorate diagnosis: at reintervention, bowel is viable, so the surgeon performs fogarty balloon catheter thrombectomy successfully reestablishing blood flow within pv. no intestinal resection is required therapy and progressions: pv patency is regularly evaluated with us. anticoagulation with low molecular weight heparin is prosecuted for 3 months and then suspended since no recurrence is recorded meanwhile comments: pv thrombosis is uncommon but can follow injury to portal venous axis during surgery. anticoagulation with heparin should be started as soon as the diagnosis is made and maintained for at least 3-6 months postoperatively to prevent recurrence. patients with persisting/worsening symptoms 48-72 h after initiation of anticoagulation, or those with peritonitis who are poor surgical candidates may be considered for interventional radiological treatment. otherwise, surgical intervention is required and may encompass resection of necrotic bowel. thrombectomy and/or balloon dilation/vascular stent placement may be helpful in recently developed pv thrombosis since risk of recurrence seems to be decreased references: acute mesenteric ischemia: guidelines of the world society of emergency surgery (world j emerg surg 2017); mesenteric venous thrombosis (j clin exp hepatol 2014); contemporary management of acute mesenteric ischemia in the endovascular era (vasc endovascular surg 2019) key: cord-022633-fr55uod6 authors: nan title: saem abstracts, plenary session date: 2012-04-26 journal: acad emerg med doi: 10.1111/j.1553-2712.2012.01332.x sha: doc_id: 22633 cord_uid: fr55uod6 nan objectives: we sought to determine if the ocp policy resulted in a meaningful and sustained improvement in ed throughput and output metrics. methods: a prospective pre-post experimental study was conducted using administrative data from 15 community and tertiary centers across the province. the study phases consisted of the 8 months from february to september 2010 compared against the same months in 2011. operational data for all centres were collected through the edis tracking systems used in the province. the ocp included 3 main triggers: ed bed occupancy >110%, at least 35% of ed stretchers blocked by patients awaiting inpatient bed or disposition decision, and no stretcher available for high acuity patients. when all criteria were met, selected boarded patients were moved to an inpatient unit (non-traditional care space if no bed available). the primary outcome was ed length of stay (los) for admitted patients. the ed load of boarded patients from 10-11 am was reported the editors of academic emergency medicine (aem) are honored to present these abstracts accepted for presentation at the 2012 annual meeting of the society for academic emergency medicine (saem), may 9 to 12 in chicago, illinois. these abstracts represent countless hours of labor, exciting intellectual discovery, and unending dedication by our specialty's academicians. we are grateful for their consistent enthusiasm, and are privileged to publish these brief summaries of their research. this year, saem received 1172 abstracts for consideration, and accepted 746. each abstract was independently reviewed by up to six dedicated topic experts blinded to the identity of the authors. final determinations for scientific presentation were made by the saem program scientific subcommittee co-chaired by ali s. raja, md, mba, mph and steven b. bird, md, and the saem program committee, chaired by michael l. hochberg, md. their decisions were based on the final review scores and the time and space available at the annual meeting for oral and poster presentations. there were also 125 innovation in emergency medicine education (ieme) abstracts submitted, of which 37 were accepted. the ieme subcommittee was co-chaired by joanna leuck, md and laurie thibodeau, md. we present these abstracts as they were received, with minimal proofreading and copy editing. any questions related to the content of the abstracts should be directed to the authors. presentation numbers precede the abstract titles; these match the listings for the various oral and poster sessions at the annual meeting in chicago, as well as the abstract numbers (not page numbers) shown in the key word and author indexes at the end of this supplement. all authors attested to institutional review board or animal care and use committee approval at the time of abstract submission, when relevant. abstracts marked as ''late-breakers'' are prospective research projects that were still in the process of data collection at the time of the december abstract deadline, but were deemed by the scientific subcommittee to be of exceptional interest. these projects will be completed by the time of the annual meeting; data shown here may be preliminary or interim. on behalf of the editors of aem, the membership of saem, and the leadership of our specialty, we sincerely thank our research colleagues for these contributions, and their continuing efforts to expand our knowledge base and allow us to better treat our patients. david background: two to ten percent of patients evaluated in the emergency departments (ed) present with altered mental status (ams). the prevalence of non-convulsive seizure (ncs) and other electroencephalographic (eeg) abnormalities in this population is not known. this information is needed to make recommendations regarding the routine use of emergent eeg in ams patients. objectives: to identify the prevalence of ncs and other eeg abnormalities in ed patients with ams. methods: an ongoing prospective study at two academic urban ed. inclusion: patients ‡ 13 years old with ams. exclusion: an easily correctable cause of ams (e.g. hypoglycemia, opioid overdose). a 30-minute eeg with the standard 19 electrodes was performed on each subject as soon as possible after presentation (usually within 1 hour). outcome: the rate of eeg abnormalities based on blinded review of all eegs by two boardcertified epileptologists. descriptive statistics are used to report eeg findings. frequencies are reported as percentages with 95% confidence intervals (ci), and inter-rater variability is reported with kappa. results: the interim analysis was performed on 130 consecutive patients (target sample size: 260) enrolled from may to october 2011 (median age: 61, range 13-100, 40% male). eegs for 20 patients were reported uninterpretable by at least one rater (6 by both raters). of the remaining 110, only 30 (27%, 95%ci 20-36%) were normal according to either rater (n = 15 by both). the most common abnormality was background slowing (n = 75, 68%, 95%ci 59-76%) by either rater (n = 47 by both), indicating underlying encephalopathy. ncs was diagnosed in 8 patients (7%, 95%ci, 4-14%) by at least one rater (n = 4 by both), including 6 (5%, 95%ci 2-12%) patients in non-convulsive status epilepticus (ncse). 29 patients (26%,95%ci 19-35%) had interictal epileptiform discharges read by at least one rater (n = 12 by both) indicating cortical irritability and an increased risk of spontaneous seizure. inter-rater reliability for eeg interpretations was modest (kappa: 0.53, 95%ci 0.39-0.67). objectives: to define diagnostic sbi and non-bacterial (non-sbi) biosignatures using rna microarrays in febrile infants presenting to emergency departments (eds). methods: we prospectively collected blood for rna microarray analysis in addition to routine screening tests including white blood cell (wbc) counts, urinalyses, cultures of blood, urine, and cerebrospinal fluid, and viral studies in febrile infants 60 days of age in 22 eds . we defined sbi as bacteremia, urinary tract infection (uti), or bacterial meningitis. we used class comparisons (mann-whitney p < 0.01, benjamini for mtc and 1.25 fold change filter), modular gene analysis, and k-nn algorithms to define and validate sbi and non-sbi biosignatures in a subset of samples. results: 81% (939/1162) of febrile infants were evaluated for sbi. 6.8% (64/939) had sbi (14 (1.5%) bac-teremia, 56 (6.0%) utis, and 4 (0.4%) bacterial meningitis). infants with sbis had higher mean temperatures, and higher wbc, neutrophil, and band counts. we analyzed rna biosignatures on 141 febrile infants: 35 sbis (2 meningitis, 5 bacteremia, 28 uti), 106 non-sbis (49 influenza, 29 enterovirus, 28 undefined viral infections), and 11 healthy controls. class comparisons identified 1,288 differentially expressed genes between sbis and non-sbis. modular analysis revealed overexpression of interferon related genes in non-sbis and inflammation related genes in sbis. 232 genes were differently expressed (p < 0.01) in each of the three non-sbi groups vs sbi group. unsupervised cluster analysis of these 232 genes correctly clustered 91% (128/141) of non-sbis and sbis. k-nn algorithm identified 33 discriminatory genes in training set (30 non-sbis vs 17 sbis) which classified an independent test (76 non-sbis vs 18 sbis) with 87% accuracy. four misclassified sbis had over-expression of interferon-related genes, suggesting viral-bacterial co-infections, which was confirmed in one patient. background: improving maternal, newborn, and child health (mnch) is a leading priority worldwide. however, limited frontline health care capacity is a major barrier to improving mnch in developing countries. objectives: we sought to develop, implement, and evaluate an evidence-based maternal, newborn, and child survival (mncs) package for frontline health workers (fhws). we hypothesized that fhws could be trained and equipped to manage and refer the leading mnch emergencies. methods: setting -south sudan, which suffers from some of the world's worst mnch indices. assessment/intervention -a multi-modal needs assessment was conducted to develop a best-evidence package comprised of targeted trainings, pictorial checklists, and reusable equipment and commodities ( figure 1 ). program implementation utilized a trainingof-trainers model. evalution -1) pre/post knowledge assessments, 2) pre/post objective structured clinical examinations (osces), 3) focus group discussions, and 4) closed-response questionnaires. results: between nov 2010 to oct 2011, 72 local trainers and 708 fhws were trained in 7 of the 10 states in south sudan. knowledge assessments among trainers (n = 57) improved significantly from 62.7% (sd 20.1) to 92.0% (sd 11.8) (p < 0.001). mean scores a maternal osce and a newborn osce pre-training, immediately post-training, and upon 2-3 month follow-up are shown in the table. closed-response questionnaires with 54 fhws revealed high levels of satisfaction, use, and confidence with mncs materials. participants reported an average of 3.0 referrals (range 0-20) to a higher level of care in the 2-3 months since training. furthermore, 78.3% of fhws were more likely to refer patients as a result of the training program. during seven focus group discussions with trained fhws, respondents (n = 41) reported high satisfaction with mncs trainings, commodities, and checklists, with few barriers to implementation or use. conclusion: these findings suggest mncs has led to improvements in south sudanese fhws' knowledge, skills, and referral practices with respect to appropriate management of mnch emergencies. no study has compared various lactate measurements to determine the optimal parameter to target. objectives: to compare the association of blood lactate kinetics with survival in patients with septic shock undergoing early quantitative resuscitation. methods: preplanned analysis of a multicenter edbased rct of early sepsis resuscitation targeting three physiological variables: cvp, map, and either central venous oxygen saturation or lactate clearance. inclusion criteria: suspected infection, two or more sirs criteria, and either sbp <90 mmhg after a fluid bolus or lactate >4 mmol/l. all patients had an initial lactate measured with repeat at two hours. normalization of lactate was defined a lactate decline to <2.0 mmol/l in a patient with an intial lactate ‡2.0. absolute lactate clearance (initial -delayed value), and relative ((absolute clearance)/(initial value)*100) were calculated if the initial lactate was ‡2.0. the outcome was in-hospital survival. receiver operating characteristic curves were constructed and areas under the curve (auc) were calculated. difference in proportions of survival between the two groups at different lactate cutoffs were analyzed using 95% ci and fisher exact tests. results: of 272 included patients, the median initial lactate was 3.1 mmol/l (iqr 1.7, 5.8), and the median absolute and relative lactate clearance were 1 mmol/l (iqr 0.3, 2.5) and 37% (iqr 14, 57 ). an initial lactate >2.0 mmol/l was seen in 187/272 (69%), and 68/187 (36%) patients normalized their lactate. overall sutures on trunk and extremity lacerations that present in the ed. the use of absorbable sutures in the ed setting confers several advantages: patients do not need to return for suture removal which results in a reduction in ed crowding, ed wait times, missed work or school days, and stressful procedures (suture removal) for children. objectives: the primary objective of this study is to compare the cosmetic outcome of trunk and extremity lacerations repaired using absorbable versus nonabsorbable sutures in children and adults. a secondary objective is to compare complication rates between the two groups. methods: eligible patients with lacerations were randomly allocated to have their wounds repaired with vicryl rapide (absorbable) or prolene (nonabsorbable) sutures. at a 10 day follow-up visit the wounds were evaluated for infection and dehiscence. after 3 months, patients were asked to return to have a photograph of the wound taken. two blinded plastic surgeons using a previously validated 100 mm visual analogue scale (vas) rated the cosmetic outcome of each wound. a vas score of 15 mm or greater was considered to be a clinically significant difference. results: of the 100 patients enrolled, 45 have currently completed the study including 19 in the vicryl rapide group and 26 in the prolene group. there were no significant differences in the age, race, sex, length of wound, number of sutures, or layers of repair in the two groups. the observer's mean vas for the vicryl rapide group was 55.76 mm ) and that for the prolene group was 55.9 mm (95%ci 44.77-67.03), resulting in a mean difference of 0.14 mm (95%ci-16.95 to 17.23, p = .98). there were no significant differences in the rates of infection, dehiscence, or keloid formation between the two groups. conclusion: the use of vicryl rapide instead of nonabsorbable sutures for the repair of lacerations on the trunk and extremities should be considered by emergency physicians as it is an alternative that provides a similar cosmetic outcome. objectives: to determine the relationship between infection and time from injury to closure, and the characteristics of lacerations closed before and after 12 hours of injury. methods: over an 18 month period, a prospective multi-center cohort study was conducted at a teaching hospital, trauma center and community hospital. emergency physicians completed a structured data form when treating patients with lacerations. patients were followed to determine whether they had suffered a wound infection requiring treatment and to determine a cosmetic outcome rating. we compared infection rates and clinical characteristics of lacerations with chisquare and t-tests as appropriate. results: there were 2663 patients with lacerations; 2342 had documented times from injury to closure. the mean times from injury to repair for infected and noninfected wounds were 2.4 vs. 3.0 hrs (p = 0.39) with 78% of lacerations treated within 3 hours and 4% (85) treated 12 hours after injury. there were no differences in the infection rates for lacerations closed before (2.9%, 95%ci 2.2-3.7) or after (2.1%, 95%ci 0.4-6.0) 6 hours and before (3.0%, 95% ci 2.3%-3.8%) or after (1.2%, 95% ci 0.03%-6.4%) 12 hours. the patients treated 12 hours after injury tended to be older (41 vs. 34 yrs p = 0.02) and fewer were treated with primary closure (85% vs. 96% p < 0.0001). comparing wounds 12 or more hours after injury with more recent wounds, there was no effect of location on decision to close. wounds closed after 12 hours did not differ from wounds closed before 12 hours with respect to use of prophylactic antibiotics, type of repair, length of laceration, or cosmetic outcome. conclusion: closing older lacerations, even those greater than 12 hours after injury, does not appear to be associated with any increased risk of infection or adverse outcomes. excellent irrigation and decontamination over the last 30 years may have led to this change in outcome. background: deep burns may result in significant scarring leading to aesthetic disfigurement and functional disability. tgf-b is a growth factor that plays a significant role in wound healing and scar formation. objectives: the current study was designed to test the hypothesis that a novel tgf-b antagonist would reduce scar contracture compared with its vehicle in a porcine partial thickness burn model. methods: ninety-six mid-dermal contact burns were created on the backs and flanks of four anesthetized young swine using a 150 gm aluminum bar preheated to 80°celsius for 20 seconds. the burns were randomized to treatment with topical tgf-b antagonist at one of three concentrations (0, 187, and 375 ll) in replicates of 8 in each pig. dressing changes and reapplication of the topical therapy were performed every 2 days for 2 weeks then twice weekly for an additional 2 weeks. burns were photographed and full thickness biopsies were obtained at 5, 7, 9, 14, and 28 days to determine reepithelialization and scar formation grossly and microscopically. a sample of 32 burns in each group had 80% power to detect a 10% difference in percentage scar contracture. results: a total of 32 burns were created in each of the three study groups. burns treated with the high dose tgf-b antagonist healed with less scar contracture than those treated with the low dose and control (52 ± 20%, 63 ± 15%, and 62 ± 14%; anova p = 0.02). additionally, burns treated with the higher, but not the lower dose of tgf-b antagonist healed with significantly fewer full thickness scars than controls (62.5% vs. 100% vs. 93.8% respectively; p < 0.001). there were no infections and no differences in the percentage wound reepithelialization among all study groups at any of the time points. conclusion: treatment of mid-dermal porcine contact burns with the higher dose tgf-b antagonist reduced scar contracture and rate of deep scars compared with the low dose and controls. background: diabetic ketoacidosis (dka) is a common and lethal complication of diabetes. the american diabetes association recommends treating adult patients with a bolus dose of regular insulin followed by a continuous insulin infusion. the ada also suggests a glucose correction rate of 75-100 mg/dl/hr to minimize complications. objectives: compare the effect of bolus dose insulin therapy with insulin infusion to insulin infusion alone on serum glucose, bicarbonate, and ph in the initial treatment of dka. methods: consecutive dka patients were screened in the ed between march '06 and june '10. inclusion criteria were: age >18 years, glucose >350 mg/dl, serum bicarbonate 15 or ketonemia or ketonuria. exclusion criteria were: congestive heart failure, current hemodialysis, pregnancy, or inability to consent. no patient was enrolled more than once. patients were randomized to receive either regular insulin 0.1 units/kg or the same volume of normal saline. patients, medical and research staff were blinded. baseline glucose, electrolytes, and venous blood gases were collected on arrival. bolus insulin or placebo was then administered and all enrolled patients received regular insulin at rate of 0.1 unit/kg/hr, as well as fluid and potassium repletion per the research protocol. glucose, electrolytes, and venous blood gases were drawn hourly for 4 hours. data between two groups were compared using unpaired t-test. results: 99 patients were enrolled, with 30 being excluded. 35 patients received bolus insulin; 34 received placebo. no significant differences were noted in initial glucose, ph, bicarbonate, age, or weight between the two groups. after the first hour, glucose levels in the insulin group decreased by 151 mg/dl compared to 94 mg/dl in the placebo group (p = 0.0391, 95% ci 2.7 to 102.0). changes in mean glucose levels, ph, bicarbonate level, and ag were not statistically different between the two groups for the remainder of the 4 hour study period. there was no difference in the incidence of hypoglycemia in the two groups. conclusion: administering a bolus dose of regular insulin decreased mean glucose levels more than placebo, although only for the first hour. there was no difference in the change in ph, serum bicarbonate or anion gap at any interval. this suggests that bolus dose insulin may not add significant benefit in the emergency management of dka. ihca; 3. return of spontaneous circulation (rsoc). traumatic cardiac arrests were excluded. we recorded baseline demographics, arrest event characteristics, follow-up vitals and laboratory data, and in-hospital mortality. apache ii scores were calculated at the time of rosc, and at 24 hrs, 48 hrs, and 72 hrs. we used simple descriptive statistics to describe the study population. univariate logistic regression was used to predict mortality with apache ii as a continuous predictor variable. discrimination of apache ii scores was assessed using the area under the curve (auc) of the receiver operator characteristic (roc) curve. results: a total of 229 patients were analyzed. the median age was 70 years (iqr: 56-79) and 32% were female. apache ii score was a significant predictor of mortality for both ohca and ihca at baseline and at all follow-up time points (all p < 0.01). discrimination of the score increased over time and achieved very good discrimination after 24 hrs (table, figure) . conclusion: the ability of apache ii score to predict mortality improves over time in the 72 hours following cardiac arrest. these data suggest that after 24 hours, apache ii scoring is a useful severity of illness score in all post-cardiac arrest patients. background: admission hyperglycemia has been described as a mortality risk factor for septic non-diabetics, but the known association of hyperglycemia with hyperlactatemia (a validated mortality risk factor in sepsis) has not previously been accounted for. objectives: to determine whether the association of hyperglycemia with mortality remains significant when adjusted for concurrent hyperlactatemia. methods: this was a post-hoc, nested analysis of a single-center cohort study. providers identified study subjects during their ed encounters; all data were collected from the electronic medical record. patients: nondiabetic adult ed patients with a provider-suspected infection, two or more systemic inflammatory response syndrome criteria, and concurrent lactate and glucose testing in the ed. setting: the ed of an urban teaching hospital; 2007 to 2009. analysis: to evaluate the association of hyperglycemia (glucose >200 mg/dl) with hyperlactatemia (lactate ‡ 4.0 mmol/l), a logistic regression model was created; outcome-hyperlactatemia; primary variable of interest-hyperglycemia. a second model was created to determine if concurrent hyperlactatemia affects hyperglycemia's association with mortality; outcome-28-day mortality; primary risk variablehyperglycemia with an interaction term for concurrent hyperlactatemia. both models were adjusted for demographics, comorbidities, presenting infectious syndrome, and objective evidence of renal, respiratory, hematologic, or cardiovascular dysfunction. results: 1236 ed patients were included; mean age 76 ± 19 years. 133 (9%) subjects were hyperglycemic, 182 (13%) hyperlactatemic, and 225 (16%) died within 28 days of the initial ed visit. after adjustment, hyperglycemia was significantly associated with simultaneous hyperlactatemia (or 3.9, 95%ci 2.48, 5.98). hyperglycemia with concurrent hyperlactatemia was associated with increased mortality risk (or 4.4, 95%ci 2.27, 8.59) , but hyperglycemia in the absence of simultaneous hyperlactatemia was not (or 0.86, 95%ci 0.45, 1.65) . conclusion: in this cohort of septic adult non-diabetic patients, mortality risk did not increase with hyperglycemia unless associated with simultaneous hyperlactatemia. the previously reported association of hyperglycemia with mortality in this population may be due to the association of hyperglycemia with hyperlactatemia. the background: near infrared spectroscopy (sto2) represents a measure of perfusion that provides the treating physician with an assessment of a patient's shock state and response to therapy. it has been shown to correlate with lactate and acid/base status. it is not known if using information from this monitor to guide resuscitation will result in improved patient outcomes. objectives: to compare the resuscitation of patients in shock when the sto2 monitor is or is not being used to guide resuscitation. methods: this was a prospective study of patients undergoing resuscitation in the ed for shock from any cause. during alternating 30 day periods, physicians were blinded to the data from the monitor followed by 30 days in which physicians were able to see the information from the sto2 monitor and were instructed to resuscitate patients to a target sto2 value of 75. adult patients (age>17) with a shock index (si) of >0.9 (si = heart rate/systolic blood pressure) or a blood pressure <80 mmhg systolic who underwent resuscitation were enrolled. patients had a sto 2 monitor placed on the thenar eminence of their least-injured hand. data from the sto 2 monitor were recorded continuously and noted every minute along with blood pressure, heart rate, and oxygen saturation. all treatments were recorded. patients' charts were reviewed to determine the diagnosis, icu-free days in the 28 days after enrollment, inpatient los, and 28-day mortality. data were compared using wilcoxon rank sum and chi-square tests. results: 107 patients were enrolled, 51 during blinded periods and 56 during unblinded periods. the median presenting shock index was 1.24 (range 0.5 to 4.0) for the blinded group and 1.10 (0.5-3.3) for the unblinded group (p = 0.13). the median time in department was 70 minutes (range 22-407) for the blinded and 76 minutes (range 11-275) for the unblinded groups (p = 0.99). the median hospital los was 1 day (range 0-30) for the blinded group, and 2 days (range 0-23) in the unblinded group (p = 0.63). the mean icu-free days was 22 ± 9 for the blinded group and 19 ± 11 for the unblinded group (p = 0.26). among patients where the physician indicated using the sto2 monitor data to guide patient care, the icu-free days were 21.4 ± 9 for the blinded group and 16.3 ± 12 for the blinded group (p = 0.06). background: inducing therapeutic hypothermia (th) using 4°c iv fluids in resuscitated cardiac arrest patients has been shown to be feasible and effective. limited research exists assessing the efficiency of this cooling method. objectives: the objective was to determine an efficient infusion method for keeping fluid close to 4°c upon exiting an iv. it was hypothesized that colder temperatures would be associated with both higher flow rate and insulation of the fluid bag. methods: efficiency was studied by assessing change in fluid temperature (0c) during the infusion, under three laboratory conditions. each condition was performed four times using 1 liter bags of normal saline. fluid was infused into a 1000 ml beaker through 10 gtts tubing. flow rate was controlled using a tubing clamp and in-line transducer with a flowmeter, while temperature was continuously monitored in a side port at the terminal end of the iv tubing using a digital thermometer. the three conditions included infusing chilled fluid at a rate of 40 ml/min, which is equivalent to 30 ml/kg/hr for an 80 kg patient, 105 ml/min, and 105 ml/min using a chilled and insulated pressure bag. descriptive statistics and analysis of variance was performed to assess changes in fluid temperature. results: the average fluid temperatures at time 0 were 3.40 (95% ci 3.12-3.69) (40 ml/min), 3.35 (95% ci 3.25-3.45) (105 ml/min), and 2.92 (95% ci 2.40-3.45) (105 ml/min + insulation). there was no significant difference in starting temperature between groups (p = 0.16). the average fluid temperatures after 100 ml had been infused were 10.02 (95% ci 9.30-10.74) (40 ml/min), 7.35 (95% ci 6.91-7.79) (105 ml/min), and 6.95 (95% ci 6.47-7.43) (105 ml/min + insulation). the higher flow rate groups had significantly lower temperature than the lower flow rate after 100 ml of fluid had been infused (p < 0.001). the average fluid temperatures after 1000 ml had been infused were 16.77 (95% ci 15.96-17.58) (40 ml/min), 11.40 (95% ci 11.18-11.61) (105 ml/min), and 7.75 (95% ci 7.55-7.99) (105 ml/min + insulation). there was a significant difference in temperature between all three groups after 1000 ml of fluid had been infused (p < 0.001). conclusion: in a laboratory setting, the most efficient method of infusing cold fluid appears to be a method that both keeps the bag of fluid insulated and is infused at a faster rate. fluid bolus. patients were categorized by presence of vasoplegic or tissue dysoxic shock. demographics and sequential organ failure assessment (sofa) scores were evaluated between the groups. the primary outcome was in-hospital mortality. data were analyzed using t-tests, chi-squared test, and proportion differences with 95% confidence intervals as appropriate. results: a total of 242 patients were included: 89 patients with vasoplegic shock and 153 with tissue dysoxic shock. there were no significant differences in age (61 vs. 58 years), caucasian race (53% vs. 58%), or male sex (57% vs. 52%) between the dysoxic shock and vasoplegic shock groups, respectively. the group with vasoplegic shock had a lower initial sofa score than did the group with tissue dysoxic shock (5.7 vs. 7.3 points, p = 0.0002). the primary outcome of in-hospital mortality occurred in 8/89 (9%) of patients with vasoplegic shock compared to 40/153 (26%) in the group with tissue dysoxic shock (proportion difference 17%, 95% ci 7-26%, p < 0.0001). conclusion: in this analysis of patients with septic shock, we found a significant difference in in-hospital mortality between patients with vasoplegic versus tissue dysoxic septic shock. these findings suggest a need to consider these differences when designing future studies of septic shock therapies. background: the pre-shock population, ed sepsis patients with tissue hypoperfusion (lactate of 2.0-3.9 mm), commonly deteriorates after admission and requires transfer to critical care. objectives: to determine the physiologic parameters and disease severity indices in the ed pre-shock sepsis population that predict clinical deterioration. we hypothesized that neither initial physiologic parameters nor organ function scores will be predictive. methods: design: retrospective analysis of a prospectively maintained registry of sepsis patients with lactate measurements. setting: an urban, academic medical center. participants: the pre-shock population, defined as adult ed sepsis patients with either elevated lactate (2.0-3.9 mm) or transient hypotension (any sbp <90 mmhg) receiving iv antibiotics and admitted to a medical floor. consecutive patients meeting pre-shock criteria were enrolled over a 1-year period. patients with overt shock in the ed, pregnancy, or acute trauma were excluded. outcome: primary patientcentered outcome of increased organ failure (sequential organ failure assessment [sofa] score increase >1 point, mechanical ventilation, or vasopressor utilization) within 72 hours of admission or in-hospital mortality. results: we identified 248 pre-shock patients from 2649 screened. the primary outcome was met in 54% of the cohort and 44% were transferred to the icu from a medical floor. patients meeting the outcome of increased organ failure had a greater shock index (1.02 vs 0.93, p = 0.042) and heart rate (115 vs 105, p < 0.001) with no difference in initial lactate, age, map, or exposure to hypotension (sbp <100 mmhg). there was no difference in the predisposition, infection, response, and organ dysfunction (piro) score between groups (6.4 vs 5.7, p = 0.052). outcome patients had similar initial levels of organ dysfunction but had higher sofa scores at 24, 48, and 72 hours, a higher icu transfer rate (60 vs 24%, p < 0.001), and increased icu and hospital lengths of stay. conclusion: the pre-shock sepsis population has a high incidence of clinical deterioration, progressive organ failure, and icu transfer. physiologic data in the ed were unable to differentiate the pre-shock sepsis patients who developed increased organ failure. this study supports the need for an objective organ failure assessment in the emergency department to supplement clinical decision-making. background: lipopolysaccharide (lps) has long been recognized to initiate the host inflammatory response to infection with gram negative bacteria (gnb). large clinical trials of potentially very expensive therapies continue to have the objective of reducing circulating lps. previous studies have found varying prevalence of lps in blood of patients with severe sepsis. compared with sepsis trials conducted 20 years ago, the frequency of gnb in culture specimens from emergency department (ed) patients enrolled in clinical trials of severe sepsis has decreased. objectives: test the hypothesis that prior to antibiotic administration, circulating lps can be detected in the plasma of fewer than 10% of ed patients with severe sepsis. methods: secondary analysis of a prospective edbased rct of early quantitative resuscitation for severe sepsis. blood specimens were drawn at the time severe sepsis was recognized, defined as two or more systemic inflammatory criteria and a serum lactate >4 mm or spb<90 mmhg after fluid challenge. blood was drawn in edta prior to antibiotic administration or within the first several hours, immediately centrifuged, and plasma frozen at )80°c. plasma lps was quantified using the limulus amebocyte lysate assay (lal) by a technician blinded to all clinical data. results: 180 patients were enrolled with 140 plasma samples available for testing. median age was 59 ± 17 years, 50% female, with overall mortality of 18%. forty of 140 patients (29%) had any culture specimen positive for gnb including 21 (15%) with blood cultures positive. only five specimens had detectable lps, including two with a gnb-positive culture specimen, and three were lps-positive without gnb in any culture. prevalence of detectable lps was 3.5% (ci: 1.5%-8.1%). the frequency of detectable lps in antibiotic-naive plasma is too low to serve as a useful diagnostic test or therapeutic target in ed patients with severe sepsis. the data raise the question of whether post-antibiotic plasma may have a higher frequency of detectable lps. background: egdt is known to reduce mortality in septic patients. there is no evidence to date that delineates the role of using a risk stratification tool, such as the mortality in emergency department sepsis (meds) score, to determine which subgroups of patients may have a greater benefit with egdt. objectives: our objective was to determine if our egdt protocol differentially affects mortality based on the severity of illness using meds score. methods: this study is a retrospective chart review of 243 patients, conducted at an urban tertiary care center, after implementing an egdt protocol on july 1, 2008 (figure) . this study compares in-hospital mortality, length of stay (los) in icu, and los in ed between the control group (126 patients from 1/1/07-12/31/07) and the postimplementation group (117 patients from 7/1/08-6/ 30/09), using meds score as a risk stratification tool. inclusion criteria: patients who presented to our ed with a suspected infection, and two or more sirs criteria, a map<65 mmhg, a sbp< 90 mmol/l. exclusion criteria: age<18, death on arrival to ed, dnr or dni, emergent surgical intervention, or those with an acute myocardial infarction or chf exacerbation. a two-sample t-test was used to show that the mean age and number of comorbidities was similar between the control and study groups (p = 0.27 and 0.87 respectively). mortality was compared and adjusted for meds score using logistic regression. the odds ratios and predicted probabilities of death are generated using the fitted logistic regression model. ed and icu los were compared using mood's median test. results: when controlling for illness severity using meds score, the relative risk (rr) of death with egdt is about half that of the control group (rr = 0.52, 95% ci [0.278-0.973], p=0.04). also, by applying meds score to risk stratify patients into various groups of illness severity, we found no specific groups where egdt is more efficacious at reducing the predicted probability of death (table 1) . without controlling for meds score, there is a trend in reduction of absolute mortality by 9.7% when egdt is used (control = 30.2%, study = 20.5%, p = 0.086). egdt leads to a 40.3% reduction in the median los in icu (control = 124 hours, study = 74 hours, p = 0.03), without increasing los in ed (control = 6 hours, study = 7 hours, p = 0.50). conclusion: egdt is beneficial in patients with severe sepsis or septic shock, regardless of their meds score. background: in patients experiencing acute coronary syndrome (acs), prompt diagnosis is critical in achieving the best health outcome. while ecg analysis is usually sufficient to diagnose acs in cases of st elevation, acs without st elevation is reliably diagnosed through serial testing of cardiac troponin i (ctni). pointof-care testing (poct) for ctni by venipuncture has been proven a more rapid means to diagnosis than central laboratory testing. implementing fingerstick testing for ctni in place of standard venipuncture methods would allow for faster and easier procurement of patients' ctni levels, as well as increase the likelihood of starting a rapid test for ctni in the prehospital setting, which could allow for even earlier diagnosis of acs. objectives: to determine if fingerstick blood samples yield accurate and reliable troponin measurements compared to conventional venous blood draws using the i-stat poc device. methods: this experimental study was performed in the ed of a quaternary care suburban medical center between june-august 2011. fingerstick blood samples were obtained from adult ed patients for whom standard (venipuncture) poc troponin testing was ordered. the time between fingerstick and standard draws was kept as narrow as possible. ctni assays were performed at the bedside using the i-stat 1 (abbott point of care). results: 94 samples from 87 patients were analyzed by both fingerstick and standard ed poct methods (see table) . four resulted in cartridge error. compared to ''gold standard'' ed poct, fingerstick testing has a positive predictive value of 100%, negative predictive value of 96%, sensitivity of 79%, and specificity of 100%. no significant difference in ctni level was found between the two methods, with a nonparametric intraclass correlation coefficient of 0.994 (95% ci 0.992-0.996, p-value < 0.001). conclusion: whole blood fingerstick ctni testing using the i-stat device is suitable for rapid evaluation of ctni level in prehospital and ed settings. however, results must be interpreted with caution if they are within a narrow territory of the cutoff for normal vs. elevated levels. additional testing on a larger sample would be beneficial. the practicality and clinical benefit of using fingerstick ctni testing in the ems setting must still be assessed. background: adjudication of diagnosis of acute myocardial infarction (ami) in clinical studies typically occurs at each site of subject enrollment (local) or by experts at an independent site (central). from 2000 from -2007 , the troponin (ctn) element of the diagnosis was predicated on the local laboratories, using a mix of the 99th percentile reference ctn and roc-determined cutpoints. in 2007, the universal definition of ami (ud-ami) defined it by the 99th percentile reference alone. objectives: to compare the diagnosis rates of ami as determined by local adjudication vs. central adjudication using udami criteria. methods: retrospective analysis of data from the myeloperoxidase in the diagnosis of acute coronary syndromes (acs) study (midas), an 18-center prospective study with enrollment from 12/19/06 to 9/20/07 of patients with suspected acs presenting to the ed < 8 hours after symptom onset and in whom serial ctn and objective cardiac perfusion testing was planned. adjudication of acs was done by single local principal investigators using clinical data and local ctn cutpoints from 13 different ctn assays, and applying the 2000 definition. central adjudication was done after completion of the midas primary analysis using the same data and local ctn assay, but by experts at three different institutions, using the udami and the manufacturer's 99th percentile ctn cutpoint, and not blinded to local adjudications. discrepant dignoses were resolved by consensus. local vs. central ctn cutpoints differed for six assays, with central cutpoints lower in all. statistics were by chi-square and kappa. results: excluding 11 cases deemed indeterminate by central adjudication, 1096 cases were successfully adjudicated. local adjudication resulted in 104 ami (9.5% of total) and 992 non-ami; central adjudication resulted in 134 (12.2%) ami and 962 non-ami. overall, 44 local diagnoses (4%) were either changed from non-ami to ami or ami to non-ami (p < 0.001). interrater reliability across both methods was found to be kappa = 0.79 (p < 0.001). for acs diagnosis, local adjudication identified 252 acs cases (23%) and 854 non-acs, while central adjudication identified 275 acs (25%) and 831 non-acs. overall, 61 local diagnoses (6%) were either changed from non-acs to acs or acs to non-acs (p < 0 .001). interrater reliability found kappa = 0.85 (p < 0.001). conclusion: central and local adjudication resulted in significantly different rates of ami and acs diagnosis. however, overall agreement of the two methods across these two diagnoses was acceptable. occur four times more often in cocaine users. biomarkers myeloperoxidase (mpo) and c-reactive protein (crp) have potential in the diagnosis of acs. objectives: to evaluate the utility of mpo and crp in the diagnosis of acs in patients presenting to the ed with cocaine-associated chest pain and compare the predictive value to nonusers. we hypothesized that these markers may be more sensitive for acs in nonusers given the underlying pathophysiology of enhanced plaque inflammation. methods: a secondary analysis of a cohort study of enrolled ed patients who received evaluation for acs at an urban, tertiary care hospital. structured data collection at presentation included demographics, chest pain history, lab, and ecg data. subjects included those with self-reported or lab-confirmed cocaine use and chest pain. they were matched to controls based on age, sex, and race. our main outcome was diagnosis of acs at index visit. we determined median mpo and crp values, calculated maximal auc for roc curves, and found cut-points to maximize sensitivity and specificity. data are presented with 95% ci. results: overall, 95 patients in the cocaine positivegroup and 86 patients in the nonusers group had mpo and crp levels measured. patients had a median age of 47 (iqr, (40) (41) (42) (43) (44) (45) (46) (47) (48) (49) (50) (51) (52) , 90% black or african american, and 62% male (p > 0.05 between groups). fifteen patients were diagnosed with acs: 8 patients in the cocaine group and 7 in the nonusers group. comparing cocaine users to nonusers, there was no difference in mpo (median 162 [iqr, ] v 136 ng/ml; p = 0.78) or crp (3 [1] [2] [3] [4] [5] [6] [7] [8] [9] v 5 [1] [2] [3] [4] [5] [6] [7] [8] [9] [10] [11] [12] [13] [14] [15] mg/l; p = 0.08). the auc for mpo was 0.65 (95% ci 0.39-0.90) v 0.54 (95% ci 0.19-0.73). the optimal cut-point to maximize sensitivity and specificity was 242 ng/ml which gave a sensitivity of 0.42 and specificity of 0.75. using this cutpoint, 57% v 29% of acs in cocaine users vs the nonusers would be identified. the auc for crp was 0.63 (95% ci 0.39-0.88) in cocaine users vs 0.73 (95% ci 0.52-0.95) in nonusers. the optimal cut point was 11.9 mg/l with a sensitivity of 0.67 and specificity of 0.79. using this cutpoint, 43% v 88% of acs in cocaine users and nonusers would have been identified. conclusion: the diagnostic accuracy of mpo and crp is not different in cocaine users than nonusers and does not appear to have sufficient discriminatory ability in either cohort. results: 18 hrs of moderate pe caused a significant decrease in rv heart function in rats treated with the solvent for bay 41-8543: peak systolic pressure (psp) decreased from 39 ± 1.5 mmhg, control to 16 ± 1.5, pe, +dp/dt decreased from 1192 ± 93 mmhg/sec to 463 ± 77, -dp/dt decreased from )576 ± 60 mmhg/sec to )251 ± 9. treatment of rats with bay 41-8543 significantly improved all three indices of rv heart function (psp 29 ± 2.6, +dp/dt 1109 ± 116, -dp/dt )426 ± 69). 5 hrs of severe pe also caused significant rv dysfunction (psp 25 ± 2, -dp/dt )356 ± 28) and treatment with bay 41-8543 produced protection of rv heart function (psp 34 ± 2, -dp/dt )535 ± 41) similar to the 18 hr moderate pe model. conclusion: experimental pe produced significant rv dysfunction, which was ameliorated by treatment of the animals with the soluble guanylate cyclase stimulator, bay 41-8543. 1 hospital of the university of pennsylvania, philadelphia, pa; 2 cooper university hospital, camden, nj background: patients who present to the ed with symptoms of potential acute coronary syndrome (acs) can be safely discharged home after a negative coronary computerized tomographic angiography (cta). however, the duration of time for which a negative coronary cta can be used to inform decision making when patients have recurrent symptoms is unknown. objectives: we examined patients who received more than one coronary cta for evaluation of acs to determine whether they had disease progression, as defined by crossing the threshold from noncritical (<50% maximal stenosis) to potentially critical disease. methods: we performed a structured comprehensive record search of all coronary ctas performed from 2005 to 2010 at a tertiary care health system. low-tointermediate risk ed patients who received two or more coronary ctas, at least one from an ed evaluation for potential acs, were identified. patients who were revascularized between scans were excluded. we collected demographic data, clinical course, time between scans, and number of ed visits between scans. record review was structured and done by trained abstractors. our main outcome was progression of coronary stenosis between scans, specifically crossing the threshold from noncritical to potentially critical disease. results: overall, 32 patients met study criteria (median age 45, interquartile range [iqr] (37.5-48); 56% female; 88% black). the median time between studies was 27.3 months (iqr, . 22 patients did not have stenosis in any vessel on either coronary cta, two studies showed increasing stenosis of <20%, and the rest showed ''improvement,'' most due to better imaging quality. no patient initially below the 50% threshold subsequently exceeded it (0%; 95% ci, 0-11.0%). patients also had varying numbers of ed visits (median number of visits 5, range 0-23), and numbers of ed visits for potentially cardiac complaints (median 1, range 0-6); 10 were re-admitted for potentially cardiac complaints (for example, chest pain or shortness of breath), and 9 received further provocative cardiac testing, all of which had negative results. conclusion: we did not find clinically significant disease progression within a 2 year time frame in patients who had a negative coronary cta, despite a high number of repeat visits. this suggests that prior negative coronary cta may be able to be used to inform decision making within this time period. 42.7-48.6) compared to non tro ct patients. there was no significant difference in image quality between tro ct images and those of dedicated ct scans in any studies performing this comparison. similarly, there was no significant difference between tro ct and other diagnostic modalities in regards to length of stay or admission rate. when compared to conventional coronary angiography as the gold standard for evaluation of cad, tro ct had the following pooled diagnostic accuracy estimates: sensitivity 0.94 conclusion: tro chest ct is comparable to dedicated pe, coronary, or ad ct in regard to image quality, length of stay, and admission rate and is highly accurate for detecting cad. the utility of tro ct depends on the relative pre-test probabilities of the conditions being assessed and its role is yet to be clearly defined. tro ct, however, involves increased radiation exposure and contrast volume and for this reason clinicians should be selective in its use. background: coronary computed tomographic angiography (ccta) has high sensitivity, specificity, accuracy, and prognostic value for coronary artery disease (cad) and acs. however, how a ccta informs subsequent use of prescription medication is unclear. objectives: to determine if detection of critical or noncritical cad on ccta is associated with initiation of aspirin and statins for patients who presented to the ed with chest pain. we hypothesized that aspirin and statins would be more likely to be prescribed to patients with noncritical disease relative to those without any cad. methods: prospective cohort study of patients who received ccta as part of evaluation of chest pain in the ed or observation unit. patients were contacted and medical records were reviewed to obtain clinical follow-up for up to the year after ccta. the main outcome was new prescription of aspirin or statin. cad severity on ccta was graded as absent, mild (1% to 49%), moderate (50% to 69%), or severe ( ‡70%) stenosis. logistic regression was used to assess the association of stenosis severity to new medication prescription; covariates were determined a priori. results: 859 patients who had ccta performed consented to participate in this study or met waiver of consent for record review only (median age, , 59% female, 71% black). median follow-up time was 333 days, iqr 70-725 days. at baseline, 13% of the total cohort was already prescribed aspirin and 8% on statin medication. two hundred seventy nine (32%) patients were found to have stenosis in at least one vessel. in patients with absent, mild, moderate, and severe cad on ccta, aspirin was initiated in 11%, 34%, 52%, and 55%; statins were initiated in 7%, 22%, 32%, and 53% of patients. after adjustment for age, race, sex, hypertension, diabetes, cholesterol, tobacco use, and admission to the hospital after ccta, higher grades of cad severity were independently associated with greater post-ccta use of aspirin (or 1.9 per grade, 95% ci 1.4-2.2, p < 0.001) and statins (or 1.9, 95% ci 1.5-2.4, p < 0.001). conclusion: greater cad severity on ccta is associated with increased medication prescription for cad. patients with noncritical disease are more likely than patients without any disease to receive aspirin and statins. future studies should examine whether these changes lead to decreased hospitalizations and improved cardiovascular health. background: hess et al. developed a clinical decision rule for patients with acute chest pain consisting of the absence of five predictors: ischemic ecg changes not known to be old, elevated initial or 6-hour troponin level, known coronary disease, ''typical'' pain, and age over 50. patients less than 40 required only a single troponin evaluation. objectives: to test the hypothesis that patients less than 40 years old without these criteria are at <1% risk for major adverse cardiovascular events (mace) including death, ami, pci, and cabg. methods: we performed a secondary analysis of several combined prospective cohort studies that enrolled ed patients who received an evaluation for acs in an urban ed from 1999 to 2009. cocaine users and stemi patients were excluded. structured data collection at presentation included demographics, pain description, history, lab, and ecg data for all studies. hospital course was followed daily. thirty-day follow up was done by telephone. our main outcome was 30-day mace using objective criteria. the secondary outcome was potential change in ed disposition due to application of the rule. descriptive statistics and 95% cis were used. results: of 9289 visits for potential acs, patients had a mean age of 52.4 ± 14.7 yrs; 68% were black and 59% female. there were 638 patients (6.9%) with 30-day cv events (93 dead, 384 ami, 298 pci). sequential removal of patients in order to meet the final rule for patients less than 40 excluded patients based upon: ischemic ecg changes not old (n = 434, 30% mace rate), elevated initial troponin level (n = 237, 60% mace), known coronary disease (n = 1622, 11% mace), ''typical'' pain (n = 3179, 3% mace), and age over 40 (n = 2690, 3.4% mace) leaving 1127 patients less than 40 with 0.8% mace [95% ci, 0.4-1.5%]. of this cohort, 70% were discharged home from the ed by the treating physician without application of this rule. adding a second negative troponin in patients 40-50 years old identified a group of 1139 patients with a 2.0% rate of mace [1.3-3 .0] and a 48% discharge rate. the hess rule appears to identify a cohort of patients at approximately 1% risk of 30-day mace, and may enhance discharge of young patients. however, even without application of this rule, the 70% of young patients at low risk are already being discharged home based upon clinical judgment. background: a clinical decision support system (cdss) incorporates evidence-based medicine into clinical practice, but this technology is underutilized in the ed. a cdss can be integrated directly into an electronic medical record (emr) to improve physician efficiency and ease of use. the christopher study investigators validated a clinical decision rule for patients with suspected pulmonary embolism (pe). the rule stratifies patients using wells' criteria to undergo either d-dimer testing or a ct angiogram (ct). the effect of this decision rule, integrated as a cdss into the emr, on ordering cts has not been studied. objectives: to assess the effect of a mandatory cdss on the ordering of d-dimers and cts for patients with suspected pe. methods: we assessed the number of cts ordered for patients with suspected pe before and after integrating a mandatory cdss in an urban community ed. physicians were educated regarding cdss use prior to implementation. the cdss advised physicians as to whether a negative d-dimer alone excluded pe or if a ct was required based on wells' criteria. the emr required physicians to complete the cdss prior to ordering the ct. however, physicians maintained the ability to order a ct regardless of the cdss recommendation. patients ‡18 years of age presenting to the ed with a chief complaint of chest pain, dyspnea, syncope, or palpitations were included in the data analysis. we compared the proportion of d-dimers and cts ordered during the 8-month periods immediately before and after implementing the cdss. all 27 physicians who worked in the ed during both time periods were included in the analysis. patients with an allergy to intravenous contrast agents, renal insufficiency, or pregnancy were excluded. results were analyzed using a chi-square test. results: a total of 11,931 patients were included in the data analysis (6054 pre-and 5877 post-implementation). cts were ordered for 215 patients (3.6%) in the pre-implementation group and 226 patients (3.8%) in the post-implementation group; p = 0.396. a d-dimer was ordered for 392 patients (6.5%) in the pre-implementation group and 382 patients (6.5%) in the post-implementation group; p = 0.958. in this single-center study, emr integration of a mandatory cdss for evaluation of pe did not significantly alter ordering patterns of cts and d-dimers. identification of patients with low-risk pulmonary emboli suitable for discharge from the emergency department mike zimmer, keith e. kocher university of michigan, ann arbor, mi background: recent data, including a large, multicenter randomized controlled trial, suggest that a low-risk cohort of patients diagnosed with pulmonary embolism (pe) exists who can be safely discharged from the ed for outpatient treatment. objectives: to determine if there is a similar cohort at our institution who have a low rate of complications from pe suitable for outpatient treatment. methods: this was a retrospective chart review at a single academic tertiary referral center with an annual ed volume of 80,000 patients. all adult ed patients who were diagnosed with pe during a 24-month period from 11/1/09 through 10/31/11 were identified. the pulmonary embolism severity index (pesi) score, a previously validated clinical decision rule to risk stratify patients with pe, was calculated. patients with high pesi (>85) were excluded. additional exclusion criteria included patients who were at high risk of complications from initiation of therapeutic anticoagulation and those patients with other clear indications for admission to the hospital. the remaining cohort of patients with low risk pe (pesi £ 85) was included in the final analysis. outcomes were measured at 14 and 90 days after pe diagnosis and included death, major bleeding, and objectively confirmed recurrent venous thromboembolism (vte). results: during the study period, 298 total patients were diagnosed with pe. there were 172 (58%) patients categorized as ''low risk'' (pesi £ 85), with 42 removed because of various pre-defined exclusion criteria. of the remaining 130 (44%) patients suitable for outpatient treatment, 5 patients (3.8%; 95% ci, 0.5% -7.2%) had one or more negative outcomes by 90 days. this included 2 (1.5%; 95% ci, 0% -3.7%) major bleeding events, 2 (1.5%; 95% ci, 0% -3.7%) recurrent vte, and 2 (1.5%; 95% ci, 0% -3.7%) deaths. none of the deaths were attributable to pe or anticoagulation. one patient suffered both a recurrent vte and died within 90 days. both patients who died within 90 days were transitioned to hospice care because of worsening metastatic burden. at 14 days, there was 1 bleeding event (0.8%; 95% ci, 0% -2.3%), no recurrent vte, and no deaths. the average hospital length of stay for these patients was 2.8 days (sd ±1.6). conclusion: over 40% of our patients diagnosed with pe in the ed may have been suitable for outpatient treatment, with 4% suffering a negative outcome within 90 days and 0.8% suffering a negative outcome within 14 days. in addition, the average hospital length of stay for these patients was 2.8 days, which may represent a potential cost savings if these patients had been managed as outpatients. our experience supports previous studies that suggest the safety of outpatient treatment of patients diagnosed with pe in the ed. given the potential savings related to a decreased need for hospitalization, these results have health policy implications and support the feasibility of creating protocols to facilitate this clinical practice change. background: chest x-rays (cxrs) are commonly obtained on ed chest pain patients presenting with suspected acute coronary syndrome (acs). a recently derived clinical decision rule (cdr) determined that patients who have no history of congestive heart failure, have never smoked, and have a normal lung examination do not require a cxr in the ed. objectives: to validate the diagnostic accuracy of the hess cxr cdr for ed chest pain patients with suspected acs. methods: this was a prospective observational study of a convenience sample of chest pain patients over 24 years old with suspected acs who presented to a single urban academic ed. the primary outcome was the ability of the cdr to identify patients with abnormalities on cxr requiring acute ed intervention. data were collected by research associates using the chart and physician interviews. abnormalities on cxr and specific interventions were predetermined, with a positive cxr defined as one with abnormality requiring ed intervention, and a negative cxr defined as either normal or abnormal but not requiring ed intervention. the final radiologist report was used as a reference standard for cxr interpretation. a second radiologist, blinded to the initial radiologist's report, reviewed the cxrs of patients meeting the cdr criteria to calculate inter-observer agreement. patients were followed up by chart review and telephone interview 30 days after presentation. results: between january and august 2011, 178 patients were enrolled, of whom 38 (21%) were excluded and 10 (5.6%) did not receive cxrs in the ed. of the 130 remaining patients, 74 (57%) met the cdr. the cdr identified all patients with a positive cxr (sensitivity = 100%, 95%ci 40-100%). the cdr identified 73 of the 126 patients with a negative cxr (specificity = 58%, 95%ci 49-67%). the positive likelihood ratio was 2.4 (95%ci 1.9-2.9). inter-observer agreement between radiologists was substantial (kappa = 0.63, 95%ci 0.41-0.85). telephone contact was made with 78% of patients and all patient charts were reviewed at 30 days. none had any adverse events related to a background: increasing the threshold to define a positive d-dimer in low-risk patients could reduce unnecessary computed tomographic pulmonary angiography (ctpa) for suspected pe. this strategy might increase rates of missed pe and missed pneumonia, the most common non-thromboembolic finding on ctpa that might not otherwise be diagnosed. objectives: measure the effect of doubling the standard d-dimer threshold for ' 'pe unlikely'' revised geneva (rgs) or wells' scores on the exclusion rate, frequency, and size of missed pe and missed pneumonia. methods: prospective enrollment at four academic us hospitals. inclusion criteria required patients to have at least one symptom or sign and one risk factor for pe, and have 64-channel ctpa completed. pretest probability data were collected in real time and the d-dimer was measured in a central laboratory. criterion standard for pe or pneumonia consisted of cpta interpretation by two independent radiologists combined with necessary treatment plan. subsegmental pe was defined as total vascular obstruction <5%. patients were followed for outcome at 30 days. proportions were compared with 95% cis. results: of 678 patients enrolled, 126 (19%) were pe+ and 93 (14%) had pneumonia. with rgs£6 and standard threshold (<500 ng/ml), d-dimer was negative in 110/678 (16%, 95% ci: 13-19%), and 4/110 were pe+ (posterior probability 3.8%, 95% ci: 1-9.3%). with rgs£6 and a threshold <1000 ng/ml, d-dimer was negative in 208/678 (31%, 27-44%) and 11/208 (5.3%, 2.8-9.3%) were pe+, but 10/11 missed pes were subsegmental, and none had concomitant dvt. the posterior probability for pneumonia among patients with rgs&#8804;6 and d-dimer<500 was 9/110 (8.2%, 4-15%) which compares favorably to the posterior probability of 12/208 (5.4%, 3-10%) observed with rgs& #8804;6 and d-dimer<1000 ng/ml. of the 200 (35%) patients who also had plain film cxr, radiologists found an infiltrate in only 58. use of wells£4 produced similar results as the rgs&#8804;6 for exclusion rate and posterior probability of both pe and pneumonia. conclusion: doubling the threshold for a positive d-dimer with a pe unlikely pretest probability can significantly reduce ctpa scanning with a slightly increased risk of missed isolated subsegmental pe, and no increase in rate of missed pneumonia. background: the limitations of developing world medical infrastructure require that patients are transferred from health clinics only when the patient care needs exceed the level of care at the clinic and the receiving hospital can provide definitive therapy. to determine what type of definitive care service was sought when patients were transferred from a general outpatient clinic operating monday through friday from 8:00 am to 3:00 pm in rural haiti to urban hospitals in port-au-prince. methods: design -prospective observational review of all patients for whom transfer to a hospital was requested or for whom a clinic ambulance was requested to an off-site location to assist with patient care. setting -weekday, daytime only clinic in titanyen, haiti. participants/subjects -consecutive series of all patients for whom transfer to another health care 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 . results: between 11/22/2010 -12/14/2010 and 3/28/2011 -5/13/2011 patients were identified who needed to be transferred to a higher level of care. sixteen patients (43.2%) presented with medical complaints, 12 (32.4%) were trauma patients, 6 (16.2%) were surgical, and 3 (8.1%) were in the obstetric category. within these categories, 6 patients were pediatric and 4 non-trauma patients required blood transfusion. conclusion: while trauma services are often focused on in rural developing world medicine, the need for obstetric care and blood transfusion constituted six (16.2%) cases in our sample. these patients raise important public health, planning, and policy questions relating to access to prenatal care and the need to better understand transfusion medicine utilization among rural haitian patients with non-trauma related transfusion needs. the data set is limited by sample size and single location of collection. another limitation of understanding the needs is that many patients may not present to the clinic for their health care needs in certain situations if they have knowledge that the resources to provide definitive care are unavailable. background: the practice of emergency medicine in japan has been unique in that emergency physicians are mostly engaged in critical care and trauma with a multi-specialty model. for the last decade with progress in medicine, an aging population with complicated problems, and institution of postgraduate general clinical training, the us model emergency medicine with single-specialty model has been emerging throughout japan. however, the current status is unknown. objectives: the objective of this study was to investigate the current status of implementation of the us model emergency medicine at emergency medicine training institutions accredited by the japanese association for acute medicine (jaam). methods: the er committee of the jaam, the most prestigious professional organization in japanese emergency medicine, conducted the survey by sending questionnaires to 499 accredited emergency medicine training institutions. results: valid responses obtained from 299 facilities were analyzed. us model em was provided in 211 facilities (71% of 299 facilities), either in full time (24 hours a day, seven days a week; 123 facilities) or in part time (less than 24 hours a day; 88 facilities). among these 211 us model facilities, 44% have a number of beds between 251-500. the annual number of ed visits was less than 20,000 in 64%, and 37% have ambulance transfers between 2,001-4,000 per year. the number of emergency physicians was less than 5 in 60% of the facilities. postgraduate general clinical training was offered at us model ed in 199 facilities, and ninety hospitals adopted us model em after 2004, when a 2-year period of postgraduate general clinical training became mandatory for all medical graduates. sixty-four facilities provided a residency program to be a us model emergency physician, and another 9 institutions were planning to establish it. conclusion: us model em has emerged and become commonplace in japan. the background including advance in medicine, aging population, and mandatory postgraduate general clinical training system are considered to be contributing factors. erkan gunay, ersin aksay, ozge duman atilla, nilay zorbalar, savas sezik tepecik research and training hospital, izmir, turkey background: workplace safety and occupational health problems are increasing issues especially in developing countries as a result of the industrial automatisation and technologic improvements. occupational injuries are preventable but they can occasionally cause morbidity and mortality resulting in work day loss and financial problems. hand injuries are one-third of all traumatic injuries and are the most injured parts after occupational accidents. objectives: we aim to evaluate patients with occupational upper extremity injuries for demographic characteristics, injury types, and work day loss. methods: trauma patients over 15 years old admitted to our emergency department with an occupational upper extremity injury were prospectively evaluated from 15.04.2010 to 30.04.2011. patients with one or more of digit, hand, forearm, elbow, humerus, and shoulder injuries were included. exclusion criteria were multitrauma, patient refusal to participate, and insufficient data. patients were followed up from the hospital information system and by phone for work day loss and final diagnosis. results: during the study period there were 570 patients with an occupational upper extremity injury. total of 521 (91.4%) patients were included. patients were 92.1% male, 36.5% between the age 25 to 34, and mean age was calculated 32.9 ± 9.6 years. 43.8% of the patients were from the metal and machinery sector, and primary education was the highest education level for the 74.7% of the patients. most injured parts were fingers with the highest rate for index finger and thumb. crush injury was the most common injury type. 96.3% (n = 502) of the patients were discharged after treatment in the emergency department. tendon injuries, open fractures, and high degree burns were the reasons for admission to clinics. mean work day loss was 12.8 ± 27.2 days and this increases for the patients with laboratory or radiologic studies, consultant evaluation, or admission. the 15-24 age group had a significantly lower work day loss average. conclusion: evaluating occupational injury characteristics and risks is essential for identifying preventive measures and actions. with the guidance of this study preventive actions focusing on high-risk sectors and patients may be the key factor for avoiding occupational injuries and creating safer workplace environments in order to reduce financial and public health problems. background: as emergency medicine (em) gains increased recognition and interest in the international arena, a growing number of training programs for emergency health care workers have been implemented in the developing world through international partnerships. objectives: to evaluate the quality and appropriateness of an internationally implemented emergency physician training program in india. methods: physicians participating in an internationally implemented em training program in india were recruited to participate in a program evaluation. a mixed methods design was used including an online anonymous survey and semi-structured focus groups. the survey assessed the research, clinical, and didactic training provided by the program. demographics and information on past and future career paths were also collected. the focus group discussions centered around program successes and challenges. results: fifty of 59 eligible trainees (85%) participated in the survey. of the respondents, the vast majority were indian; 16% were female, and all were between the ages of 25 and 45 years (mean age 31 years). all but two trainees (96%) intend to practice em as a career. one-third listed a high-income country first for preferred practice location and half listed india first. respondents directly endorsed the program structure and content, and they demonstrated gains in self-rated knowledge and clinical confidence over their years of training. active challenges identified include: (1) insufficient quantity and inconsistent quality of indian faculty, (2) administrative barriers to academic priorities, and (3) persistent threat of brain drain if local opportunities are inadequate. conclusion: implementing an international emergency physician training program with limited existing local capacity is a challenging endeavor. overall, this evaluation supports the appropriateness and quality of this partnership model for em training. one critical challenge is achieving a robust local faculty. early negotiations are recommended to set educational priorities, which includes assuring access to em journals. attrition of graduated trainees to high-income countries due to better compensation or limited in-country opportunities continues to be a threat to long-term local capacity building. background: with an increasing frequency and intensity of manmade and natural disasters, and a corresponding surge in interest in international emergency medicine (iem) and global health (gh), the number of iem and gh fellowships is constantly growing. there are currently 34 iem and gh fellowships, each with a different curriculum. several articles have proposed the establishment of core curriculum elements for fellowship training. to the best of our knowledge, no study has examined whether iem and gh fellows are actually fulfilling these criteria. objectives: this study sought to examine whether current iem and gh fellowships are consistently meeting these core curricula. methods: an electronic survey was administered to current iem and gh fellowship directors, current fellows, and recent graduates of a total of 34 programs. survey respondents stated their amount of exposure to previously published core curriculum components: em system development, humanitarian assistance, disaster response, and public health. a pooled analysis comparing overall responses of fellows to those of program directors was performed using two-sampled t-test. results: response rates were 88% (n = 30) for program directors and 53% (n = 17) for current and recent fellows. programs varied significantly in terms of their emphasis on and exposure to six proposed core curriculum areas: em system development, em education development, humanitarian aid, public health, ems, and disaster management. only 43% of programs reported having exposure to all four core areas. as many as 67% of fellows reported knowing their curriculum only somewhat or not at all prior to starting the program. conclusion: many fellows enter iem and gh fellowships without a clear sense of what they will get from their training. as each fellowship program has different areas of curriculum emphasis, we propose not to enforce any single core curriculum. rather, we suggest the development of a mechanism to allow each fellowship program to present its curriculum in a more transparent manner. this will allow prospective applicants to have a better understanding of the various programs' curricula and areas of emphasis. background: advance warning of probable intensive care unit (icu) admissions could allow the bed placement process to start earlier, decreasing ed length of stay and relieving overcrowding conditions. however, physicians and nurses poorly predict a patient's ultimate disposition from the emergency department at triage. a computerized algorithm can use commonly collected data at triage to accurately identify those who likely will need icu admission. objectives: to evaluate an automated computer algorithm at triage to predict icu admission and 28-day in-hospital mortality. methods: retrospective cohort study at a 55,000 visit/ year level i trauma center/tertiary academic teaching hospital. all patients presenting to the ed between 12/16/2008 and 10/1/2010 were included in the study. the primary outcome measure was icu admission from the emergency department. the secondary outcome measure was 28-day all-cause in-hospital mortality. patients discharged or transferred before 28 days were considered to be alive at 28 days. triage data includes age, sex, acuity (emergency severity index), blood pressure, heart rate, pain scale, respiratory rate, oxygen saturation, temperature, and a nurse's free text assessment. a latent dirichlet allocation algorithm was used to cluster words in triage nurses' free text assessments into 500 topics. the triage assessment for each patient is then represented as a probability distribution over these 500 topics. logistic regression was then used to determine the prediction function. results: a total of 94,973 patients were included in the study. 3.8% were admitted to the icu and 1.3% died within 28 days. these patients were then randomly allocated to train (n = 75,992; 80%) and test (n = 18,981; 20%) data sets. the area under the receiver operating characteristic curve (auc) when predicting icu background: at the 2011 saem annual meeting, we presented the derivation of two hospital admission prediction models adding coded chief complaint (ccc) data from a published algorithm (thompson et al. acad emerg med 2006; 13:774-782) to demographic, ed operational, and acuity (emergency severity index (esi)) data. objectives: we hypothesized that these models would be validated when applied to a separate retrospective cohort, justifying prospective evaluation. methods: we conducted a retrospective, observational validation cohort study of all adult ed visits to a single tertiary care center (census: 49,000/yr) (4/1/09-12/31/10). we downloaded from the center's clinical tracking system demographic (age, sex, race), ed operational (time and day of arrival), esi, and chief complaint data on each visit. we applied the derived ccc hospital admission prediction models (all identified ccc categories and ccc categories with significant odds of admission from multivariable logistic regression in the derivation cohort) to the validation cohort to predict odds of admission and compared to prediction models that consisted of demographic, ed operational, and esi data, adding each category to subsequent models in a stepwise manner. model performance is reported by areaunder-the-curve (auc) data and 95%ci. signs, pain level, triage level, 72-hour return, number of past visits in the previous year, injury, and one of 122 chief complaint codes (representing 90% of all visits in the database). outputs for training included ordering of a complete blood count, basic chemistry (electrolytes, blood urea nitrogen, creatinine), cardiac enzymes, liver function panel, urinalysis, electrocardiogram, x-ray, computed tomography, or ultrasound. once trained, it was used on the nhamcs-ed 2008 database, and predictions were generated. predictions were compared with documented physician orders. outcomes included the percent of total patients who were correctly pre-ordered, sensitivity (the percent of patients who had an order that were correctly predicted), and the percent over-ordered. waiting time for correctly pre-ordered patients was highlighted, to represent a potential reduction in length of stay achieved by preordering. los for patients overordered was highlighted to see if over-ordering may cause an increase in los for those patients. unit cost of the test was also highlighted, as taken from the 2011 medicare fee schedule. physician times. however, during peak ed census times, many patients with completed tests and treatment initiated by triage await discharge by the next assigned physician. objectives: determine if a physician-led discharge disposition (dd) team can reduce the ed length of stay (los) for patients of similar acuity who are ultimately discharged compared to standard physician team assignment. methods: this prospective observational study was performed from 10/2010 to 10/2011 at an urban tertiary referral academic hospital with an annual ed volume of 87,000 visits. only emergency severity index level 3 patients were evaluated. the dd team was scheduled weekdays from 14:00 until 23:00. several ed beds were allocated to this team. the team was comprised of one attending physician and either one nurse and a tech or two nurses. comparisons were made between los for discharged patients originally triaged to the main ed side who were seen by the dd team versus the main side teams. time from triage physician to team physician, team physician to discharge decision time, and patient age were compared by unpaired t-test. differences were studied for number of patients receiving x-rays, ct scan, labs, and medications. results: dd team mean los in hours for discharged patients was shorter at 3.4 (95% ci: 3.3-3.6, n = 1451) compared to 6.4 (95% ci: 6.3-6.5, n = 4601) on the main side, p < 0.01. the mean time from triage physician to dd team physician was 1.4 hours (95% ci: 1.4-1.5, n = 1447) versus to 2.7 hours (95% ci: 2.7-2.8, n = 4568) to main side physician, p < 0.01. the dd team physician mean time to discharge decision was 1.0 hour (95% ci: 1.0-1.1, n = 1432) compared to 2.5 hours (95% ci: 2.4-2.6, n = 4590) for main side physician, p < 0.01. the dd team patients' mean age was 42.6 years (95% ci: 41.9-43.6, n = 1454) compared to main side patients' mean age of 49.1 years (95% ci: 48.5-49.6, n = 4621.) the dd team patients (n = 1454) received fewer x-rays (40% vs. 59%), ct scans (13% vs. 23%), labs (64% vs. 85%), and medications (63% vs. 68%) than main side patients (n = 4621), p < 0.01 for all compared. conclusion: the dd team complements the advanced triage process to further reduce los for patients who do not require extended ed treatment or observation. the dd team was able to work more efficiently because its patients tended to be younger and had fewer lab and imaging tests ordered by the triage physician compared to patients who were later seen on the ed main side. ed objectives: to evaluate the association between ed boarding time and the risk of developing hapu. methods: we conducted a retrospective cohort study using administrative data from an academic medical center with an adult ed with 55,000 annual patient visits. all patients admitted into the hospital through the ed 6/30/2008-2/28/2011 were included. development of hapu was determined using the standardized, national protocol for cms reporting of hapu. ed boarding time was defined as the time between an order for inpatient admission and transport of the patient out of the ed to an in-patient unit. we used a multivariate logistic regression model with development of a hapu as the outcome variable, ed boarding time as the exposure variable, and the following variables as covariates: age, sex, initial braden score, and admission to an intensive care unit (icu) from the ed. the braden score is a scale used to determine a patient's risk for developing a hapu based on known risk factors. a braden score is calculated for each hospitalized patient at the time of admission. we included braden score as a covariate in our model to determine if ed boarding time was a predictor of hapu independent of braden score. results: of 46,704 patients admitted to the hospital through the ed during the study period, 243 developed a hapu during their hospitalization. clinical characteristics are presented in the table. per hour of ed boarding time, the adjusted or of developing a hapu was 1.02 (95% ci 1.01-1.04, p = 0.007). a median of 40 patients per day were admitted through the ed, accumulating 144 hours of ed boarding time per day, with each hour of boarding time increasing the risk of developing a hapu by 2%. conclusion: in this single-center, retrospective study, longer ed boarding time was associated with increased risk of developing a hapu. queried ed and inpatient nurses and compared their opinions toward inpatient boarding. it also assessed their preferred boarding location if they were patients. objectives: this study queried ed and inpatient nurses and compared their opinions toward inpatient boarding. methods: a survey was administered to a convenience sample of ed and ward nurses. it was performed in a 631-bed academic medical center (30,000 admissions/yr) with a 68-bed ed (60,000 visits/yr). nurses were identified as ed or ward and whether they had previously worked in the ed. the nurses were asked if there were any circumstances where admitted patients should be boarded in the ed or inpatient hallways. they were also asked their preferred location if they were admitted as a patient. six clinical scenarios were then presented and their opinions on boarding queried. results: ninety nurses completed the survey; 35 (39%) were current ed nurses (ced), 40 (44%) had previously worked in the ed (ped). for the entire group 46 (52%) believed admitted patients should board in the ed. overall, 52 (58%) were opposed to inpatient boarding, with 20% of ced versus 83% of current ward (cw) nurses (p < 0.0001) and 28% of ped versus 85% of nurses never having worked in the ed (ned) opposed (p < 0.001). if admitted as patients themselves, overall 43 (54%) preferred inpatient boarding, with 82% of ced versus 33% of cw nurses (p < 0.0001) and 74% of ped versus 34% ned nurses (p = 0.0007) preferring inpatient boarding. for the six clinical scenarios, significant differences in opinion regarding inpatient boarding existed in all but two cases: a patient with stable copd but requiring oxygen and an intubated, unstable sepsis patient. conclusion: ward nurses and those who have never worked in the ed are more opposed to inpatient boarding than ed nurses and nurses who have worked previously in the ed. nurses admitted as patients seemed to prefer not being boarded where they work. ed and ward nurses seemed to agree that unstable or potentially unstable patients should remain in the ed. 8 weeks. staff satisfaction was evaluated through pre/ post-shift and study surveys; administrative data (physician initial assessment (pia), length of stay (los), patients leaving without being seen (lwbs) and against medical advice [lama] ) were collected from an electronic, real-time ed information system. data are presented as proportions and medians with interquartile ranges (iqr); bivariable analyses were performed. results: ed physicians and nurses expected the intervention to reduce the los of discharged patients only. pia decreased during the intervention period (68 vs 74 minutes; p < 0.001). no statistically/clinically significant differences were observed in the los; however, there was a significant reduction in the lwbs (4.7% to 3.5% p = 0.003) and lama (0.7% to 0.4% p = 0.028) rates. while there was a reduction of approximately 5 patients seen per physician in the affected ed area, the total number of patients seen on that unit increased by approximately 10 patients/day. overall, compared to days when there was no extra shift, 61% of emergency physicians stated their workload decreased and 73% felt their stress level at work decreased. conclusion: while this study didn't demonstrate a reduction in the overall los, it did reduce pia times and the proportion of lwbs/lama patients. while physicians saw fewer patients during the intervention study period, the overall patient volume increased and satisfaction among ed physicians was rated higher. provider-and hospital-level variation in admission rates and 72-hour return admission rates jameel abualenain 1 , william frohna 2 , robert shesser 1 , ru ding 1 , mark smith 2 , jesse m. pines 1 1 the george washington university, washington, dc; 2 washington hospital center, washington, dc background: decisions for inpatient versus outpatient management of ed patients are the most important and costliest decision made by emergency physicians, but there is little published on the variation in the decision to admit among providers or whether there is a relationship between a provider's admission rate and the proportion of their patients who return within 72 hours of the initial visit and are subsequently admitted (72h-ra). objectives: we explored the variation in provider-level admission rates and 72h-ra rates, and the relationship between the two. methods: a retrospective study using data from three eds with the same information system over varying time periods: washington hospital center (whc) (2008-10), franklin square hospital center (fshc) , and union memorial hospital (umh) . patients were excluded if left without being seen, left against medical advice, fast-track, psychiatric patients, and aged <18 years. physicians with <500 ed encounters or an admission rate <15% were excluded. logistic regression was used to assess the relationship between physician-level 72h-ra and admission rates, adjusting for patient age, sex, race, and hospital. results: 389,120 ed encounters were treated by 90 physicians. mean patient age was 50 years sd 20, 42% male, and 61% black. admission rates differed between hospitals (whc = 40%, umh = 37%, and fshc = 28%), as did the 72h-ra (whc = 0.9%, umh = 0.6%, and fshc = 0.6%). across all hospitals, there was great variation in individual physician admission rates (15.4%-50.0%). the 72h-ra rates were quite low, but demonstrated a similar magnitude of individual variation (0.3%-1.2%). physicians with the highest admission rate quintile had lower odds of 72h-ra (or 0.8 95% ci 0.7-0.9) compared to the lowest admission rate quintile, after adjusting for other factors. no intermediate admission rate quintiles (2nd, 3rd, or 4th) were significantly different from the lowest admission rate quintile with regard to 72h-ra. conclusion: there is more than three-fold variation in individual physician admission rates indicating great variation among physicians in hospital admission rates and 72h-ra. the highest admitters have the lowest 72h-ra; however, evaluating the causes and consequences of such significant variation needs further exploration, particularly in the context of health reform efforts aimed at reducing costs. background: ed scribes have become an effective means to assist emergency physicians (eps) with clinical documentation and improve physician productivity. scribes have been most often utilized in busy community eds and their utility and functional integration into an academic medical center with resident physicians is unknown. objectives: to evaluate resident perceptions of attending physician teaching and interaction after introduction of scribes at an em residency training program, measured through an online survey. residents in this study were not working with the scribes directly, but were interacting indirectly through attending physician use of scribes during ed shifts. methods: an online ten question survey was administered to 31 residents of a midwest academic emergency medicine residency program (pgy1-pgy3 program, 12 annual residents), 8 months after the introduction of scribes into the ed. scribes were introduced as emr documentation support (epic 2010, epic systems inc.) for attending eps while evaluating primary patients and supervising resident physicians. questions investigated em resident demographics and perceptions of scribes (attending physician interaction and teaching, effect on resident learning, willingness to use scribes in the future), using likert scale responses (1 minimal, 9 maximum) and a graduated percentage scale used to quantify relative values, where applicable. data were analyzed using kruskal-wallis and mann-whitney u tests. results: twenty-one of 31 em residents (68%) completed the survey (81% male; 33% pgy1, 29% pgy2, 38% pgy3). four residents had prior experience with scribes. scribes were felt to have no effect on attending eps direct resident interaction time (mean score 4.5, sd 1.2), time spent bedside teaching (4.8, sd 0.9), or quality of teaching (4.9, sd 0.8), as well as no effect on residents' overall learning process (4.6, sd 1.1). however, residents felt positive about utilizing scribes at their future occupation site (6.0, sd 2.7). no response differences were noted for prior experience, training level, or sex. conclusion: when scribes are introduced at an em residency training site, residents of all training levels perceive it as a neutral interaction, when measured in terms of perceived time with attending eps and quality of the teaching when scribes are present. the effect of introduction of an electronic medical record on resident productivity in an academic emergency department shawn london, christopher sala university of connecticut school of medicine, farmington, ct background: there are little available data which describe the effect of implementation of an electronic medical record (emr) on provider productivity in the emergency department, and no studies which, to our knowledge, address this issue pertaining to housestaff in particular. objectives: we seek to quantify the changes in provider productivity pre-and post-emr implementation to support our hypothesis that resident clinical productivity based on patients seen per hour will be negatively affected by emr implementation. methods: the academic emergency department at hartford hospital, the principle clinical site in the university of connecticut emergency medicine residency, sees over 95,000 patients on an annual basis. this environment is unique in that pre-emr, patient tracking and orders were performed electronically using the sunrise system (eclipsys corp) for over 8 years prior to conversion to the allscripts ed emr in october, 2010 for all aspects of ed care. the investigators completed a random sample of days/evening/night/weekend shift productivity to obtain monthly aggregate productivity data (patients seen per hour) by year of training. results: there was an initial 4.2% decrease of in productivity for pgy-3 residents on average from 1.44 patients per hour on average in the three blocks preceding activation of the emr to 1.38 patients seen per hour compared in the subsequent three prior blocks. pgy 3 performance returned to baseline in the subsequent three months to 1.48 patients per hour. there was no change noted in patients seen per hour of pgy-1 and pgy-2 residents. conclusion: while many physicians tend to assume that emrs pose a significant barrier to productivity in the ed, in our academic emergency department, there was no lasting change on resident productivity based on the patients seen per hour metric. the minor decrease which did occur in pgy-3 residents was transient and was not apparent 3 months after the emr was implemented. our experience suggests that decrease in the rate of patients seen per hour in the resident population should not be considered justification to delay or avoid implementation of an emr in the emergency department. emory university, atlanta, ga; 2 children's healthcare of atlanta, atlanta, ga background: variation in physician practice is widely prevalent and highlights an opportunity for quality improvement and cost containment. monitoring resources used in the management of common pediatric emergency department (ed) conditions has been suggested as an ed quality metric. objectives: to determine if providing ed physicians with severity-adjusted data on resource use and outcomes, relative to their peers, can influence practice patterns. methods: data on resource use by physicians were extracted from electronic medical records at a tertiary pediatric ed for four common conditions in mid-acuity (emergency severity index level 3): fever, head injury, respiratory illness, and gastroenteritis. condition-relevant resource use was tracked for lab tests (blood count, chemistry, crp), imaging (chest x-ray, abdominal x-ray, head ct scan, abdominal ct scan), intravenous fluids, parenteral antibiotics, and intravenous ondansetron. outcome measures included admission to hospital and ed length of stay (los); 72-hr return to ed (rr) was used as a balancing measure. scorecards were constructed using box plots to show physicians their practice patterns relative to peers (the figure shows an example of the scorecard for gatroenteritis for one physician, showing resources use rates for iv fluids and labs). blinded scorecards were distributed quarterly for five quarters using rolling-year averages. a pre/post-intervention analysis was performed with sep 1, 2010 as the intervention date. fisher's exact and wilcoxon rank sum tests were used for analysis. results: we analyzed 45,872 patient visits across two hospitals (24,834 pre-and 21,038 post-intervention), comprising 17.6% of the total ed volume during the study period. patients were seen by 100 physicians (mean 462 patients/physician). the table shows overall physician practice in the pre-and post-intervention periods. significant reduction in resource use was seen for abdominal/pelvic ct scans, head ct scan, chest x-rays, iv ondansetron, and admission to hospital. ed los decreased from 129 min to 126 min (p = 0.0003). there was no significant change in 72-hr return rate during the study period (2.2% pre-, 2.0% post-intervention). conclusion: feedback on comprehensive practice patterns including resource use and quality metrics can influence physician practice on commonly used resources in the ed. billboards, via iphone application, twitter, and text messaging. there is a paucity of data describing the accuracy of publically posted ed wait times. objectives: to examine the accuracy of publicly posted wait times of four emergency departments within one hospital system. methods: a prospective analysis of four ed-posted wait times in comparison to the wait times for actual patients. the main hospital system calculated and posted ed wait times every twenty minutes for all four system eds. a consecutive sample of all patients who arrived 24/7 over a 4-week period during july and august 2011 was included. an electronic tracking system identified patient arrival date and the actual incurred wait time. data consisted of the arrival time, actual wait time, hospital census, budgeted hospital census, and the posted ed wait time. for each ed the difference was calculated between the publicly posted ed wait time at the time of patient's arrival and the patient's actual ed wait time. the average wait times and average wait time error between the ed sites were compared using a two-tailed student's t-test. the correlation coefficient between the differences in predicted/ actual wait times was also calculated for each ed. results: there were 8890 wait times within the four eds included in the analysis. the average wait time (in minutes) at each facility was: 64.0 (±62.4) for the main ed, 22.0 (±22.1) for freestanding ed (fed) #1, 25.0 (±25.6) for fed #2, and 10.0 (±12.6) for the small community ed. the average wait time error (in minutes) for each facility was 31(±61.2) for the main ed, 13 (±23.65) for fed #1, 17 (±26.65) for fed #2, and 1 (±11.9) for the community hospital ed. the results from each ed were statistically significant for both average wait time and average wait time error (p < 0.0001). there was a positive correlation between the average wait time and average wait time error, with r-values of 0.84, 0.83, 0.58, and 0.48 for the main ed, fed #1, fed #2, and the small community hospital ed, respectively. each correlation was statistically significant; however, no correlation was found between the number of beds available (budgeted-actual census) and average wait times. conclusion: publically posted ed wait times are accurate for facilities with less than 2000 ed visits per month. they are not accurate for eds with greater than 4000 visits per month. reduction of pre-analytic laboratory errors in the emergency department using an incentive-based system benjamin katz, daniel pauze, karen moldveen albany medical center, albany, ny background: over the last decade, there has been an increased effort to reduce medical errors of all kinds. laboratory errors have a significant effect on patient care, yet they are usually avoidable. several studies suggest that up to 90% of laboratory errors occur during the pre-or post-analytic phase. in other words, errors occur during specimen collection and transport or reporting of results, rather than during laboratory analysis itself. objectives: in an effort to reduce pre-analytic laboratory errors, the ed instituted an incentive-based program for the clerical staff to recognize and prevent specimen labeling errors from reaching the patient. this study sought to demonstrate the benefit of this incentive-based program. methods: this study examined a prospective cohort of ed patients over a three year period in a tertiary care academic ed with annual census of 72,000. as part of a continuing quality improvement process, laboratory specimen labeling errors are screened by clerical staff by reconciling laboratory specimen label with laboratory requisition labels. the number of ''near-misses'' or mismatched specimens captured by each clerk was then blinded to all patient identifiers and was collated by monthly intervals. due to poor performance in 2009, an incentive program was introduced in early 2010 by which the clerk who captured the most mismatched specimens would be awarded a $50 gift card on a quarterly basis. the total number of missed laboratory errors was then recorded on a monthly basis. investigational data were analyzed using bivariate statistics. background: most studies on operational research have been focused in academic medical centers, which typically have larger volumes of patients and are located in urban metropolitan areas. as cms core measures in 2013 begin to compare emergency departments (eds) on treatment time intervals, especially length of stay (los), it is important to explore if any differences exist inherent to patient volume. objectives: the objective of this study is to look at differences in operational metrics based on annual patient census. the hypothesis is that treatment time intervals and operational metrics differ amongst these different categories. methods: the ed benchmarking alliance has collected yearly operational metrics since 2004. as of 2010, there are 499 eds providing data across the united states. eds are stratified by annual volume for comparison in the following categories: <20k, 20-40k, 40-60k, and over 80k. in this study, metrics for eds with <20k visits per year were compared to those of different volumes, averaged from 2004-2010. mean values were compared to <20k visits as a reference point for statistical difference using t-tests to compare means with a p-value < 0.05 considered significant. results: as seen in the table, a greater percentage of high acuity of patients was seen in higher volume eds than in <20k eds. the percentage of patients transferred to another hospital was higher in <20k eds. a higher percentage arrived by ems and a higher percentage were admitted in higher volume eds when compared to <20k visits. in addition, the median los for both discharged and admitted patients and percentage who left before treatment was complete (lbtc) were higher in the higher volume eds. conclusion: lower volume eds have lower acuity when compared to higher volume eds. lower volume eds have shorter median los and left before treatment complete percentages. as cms core measures require hospitals to report these metrics, it will be important to compare them based on volume and not in aggregate. does the addition of a hands-free communication device improve ed interruption times? amy ernst, steven j. weiss, jeffrey a. reitsema university of new mexico, albuquerque, nm background: ed interruptions occur frequently. recently a hands-free communication device (vocera) was added to a cell phone and a pager in our ed. objectives: the purpose of the present study was to determine whether this addition improved interruption times. our hypothesis was that the device would significantly decrease length of time of interruptions. methods: this study was a prospective cohort study of attending ed physician calls and interruptions in a level i trauma center with em residency. interruptions included phone calls, ekg interpretations, pages to resuscitation, and other miscellaneous interruptions (including nursing issues, laboratory, ems, and radiology). we studied a convenience sampling intended to include mostly evening shifts, the busiest ed times. length of time the interruption lasted was recorded. data were collected for a comparison group pre-vocera. three investigators collected data including seven different addendings' interruptions. data were collected on a form, then entered into an excel file. data collectors' agreement was determined during two additional four hour shifts to calculate a kappa statistic. spss was used for data entry and statistical analysis. descriptive statistics were used for univariate data. chi-square and mann whitney u nonparametric test were used for comparisons. results: of the total 511 interruptions, 33% were phone calls, 24% were ekgs to be read, 18% were pages to resuscitation, and 25% miscellaneous. there were no significant differences in types of interruptions pre-vs. post-vocera. pre-vocera we collected 40 hours of data with 65 interruptions with a mean 1.6 per hour. post-vocera, 180 hours of data were collected with 446 interruptions with a mean 2.5 per hour. there was a significant difference in length of time of interruptions with an average of 9 minutes pre-vocera vs. 4 minutes post-vocera (p = 0.012, diff 4.9, 95% ci 1.8-8.1). vocera calls were significantly shorter than non-vocera calls (1 vs 6 minutes, p < 0.001). comparing data collectors for type of interruption during the same 4-hour shift resulted in a kappa (agreement) of 0.73. conclusion: the addition of a hands-free communication device may improve interruptions by shortening call length. '' talk background: analyses of patient flow through the ed typically focus on metrics such as wait time, total length of stay (los), or boarding time. however, little is known about how much interaction a patient has with clinicians after being placed in a room, or what proportion of the in-room visit is also spent ''waiting,'' rather than directly interacting with care providers. objectives: the objective was to assess the proportion of time, relative to the time in a patient care area, that a patient spends actively interacting with providers during an ed visit. methods: a secondary analysis of 29 audiotaped encounters of patients with one of four diagnoses (ankle sprain, back pain, head injury, laceration) was performed. the setting was an urban, academic ed. ed visits of adult patients were recorded from the time of room placement to discharge. audiotapes were edited to remove all downtime and non-patient-provider conversations. los and door-to-doctor times were abstracted from the medical record. the proportion of time the patient spent in direct conversation with providers (''talk-time'') was calculated as the ratio of the edited audio recording time to the time spent in a patient care area (talk-time = [edited audio time/(los -door-to-doctor)]). multiple linear regression controlling for time spent in patient care area, age, and sex was performed. results: the sample was 31% male with a mean age of 37 years. median los: 133 minutes (iqr: 88-169), median door-to-doctor: 42 minutes (iqr: 29-67), median time spent in patient care area: 65 minutes (iqr: 53-106). median time spent in direct conversation with providers was 16 minutes (iqr: 12-18), corresponding to a talk-time percentage of 19.2% (iqr: 14.7-24.6%). there were no significant differences based on diagnosis. regression analysis showed that those spending a longer time in a patient care area had a lower percentage of talk time (b = )0.11, p = 0.002). conclusion: although limited by sample size, these results indicate that approximately 80% of a patients' time in a care area is spent not interacting with providers. while some of the time spent waiting is out of the providers' control (e.g. awaiting imaging studies), this significant ''downtime'' represents an opportunity for both process improvement efforts to decrease downtime as well as the development of innovative patient education efforts to make the best use of the remaining downtime. degradation of emergency department operational data quality during electronic health record implementation michael j. ward, craig froehle, christopher j. lindsell university of cincinnati, cincinnati, oh background: process improvement initiatives targeted at operational efficiency frequently use electronic timestamps to estimate task and process durations. errors in timestamps hamper the use of electronic data to improve a system and may result in inappropriate conclusions about performance. despite the fact that the number of electronic health record (ehr) implementations is expected to increase in the u.s., the magnitude of this ehr-induced error is not well established. objectives: to estimate the change in the magnitude of error in ed electronic timestamps before and after a hospital-wide ehr implementation. methods: time-and-motion observations were conducted in a suburban ed, annual census 35,000, after receiving irb approval. observation was conducted 4 weeks pre-and 4 weeks post-ehr implementation. patients were identified on entering the ed and tracked until exiting. times were recorded to the nearest second using a calibrated stopwatch, and are reported in minutes. electronic data were extracted from the patient-tracking system in use pre-implementation, and from the ehr post-implementation. for comparison of means, independent t-tests were used. chi-square and fisher's t-tests were used for proportions, as appropriate. results: there were 263 observations; 126 before and 137 after implementation. the differences between observed times and timestamps were computed and found to be normally distributed. post-implementation, mean physician seen times along with arrival to bed, bed to physician, and physician to disposition intervals occurred before observation. physician seen timestamps were frequently incorrect and did not improve postimplementation. significant discrepancies (ten minutes or greater) from observed values were identified in timestamps involving disposition decision and exit from the ed. calculating service time intervals resulted in every service interval (except arrival to bed) having at least 15% of the times with significant discrepancies. it is notable that missing values were more frequent post-ehr implementation. conclusion: ehr implementation results in reduced variability of timestamps but reduced accuracy and an increase in missing timestamps. using electronic timestamps for operational efficiency assessment should recognize the magnitude of error, and the compounding of error, when computing service times. background: procedural sedation and analgesia is used in the ed in order to efficiently and humanely perform necessary painful procedures. the opposing physiological effects of ketamine and propofol suggest the potential for synergy, and this has led to interest in their combined use, commonly termed ''ketofol'', to facilitate ed procedural sedation. objectives: to determine if a 1:1 mixture of ketamine and propofol (ketofol) for ed procedural sedation results in a 13% or more absolute reduction in adverse respiratory events compared to propofol alone. methods: participants were randomized to receive either ketofol or propofol in a double-blind fashion according to a weight-based dosing protocol. inclusion criteria were age 14 years or greater, and asa class 1-3 status. the primary outcome was the number and proportion of patients experiencing an adverse respiratory event according to pre-defined criteria (the ''quebec criteria''). secondary outcomes were sedation consistency, sedation efficacy, induction time, sedation time, procedure time, and adverse events. results: a total of 284 patients were enrolled, 142 per group. forty-three (30%) patients experienced an adverse respiratory event in the ketofol group compared to 46 (32%) in the propofol group (difference 2%; 95% ci )9% to 13%; p = 0.798). thirty-eight (27%) patients receiving ketofol and 36 (25%) receiving propofol developed hypoxia, of whom three (2%) ketofol patients and 1 (1%) propofol patient received bag-valve-mask ventilation. sixty-five (46%) patients receiving ketofol and 93 (65%) receiving propofol required repeat medication dosing or lightened to a ramsay sedation score of 4 or less during their procedure (difference 19%; 95% ci 8% to 31%; p = 0.001). procedural agitation occurred in 5 patients (3.5%) receiving ketofol compared to 15 (11%) receiving propofol (difference 7.5%, 95% ci 1% to 14%). recovery agitation requiring treatment occurred in six patients (4%, 95% ci 2.0% to 8.9%) receiving ketofol. other secondary outcomes were similar between the groups. patients and staff were highly satisfied with both agents. conclusion: ketofol for ed procedural sedation does not result in a reduced incidence of adverse respiratory events compared to propofol alone. induction time, efficacy, and sedation time were similar; however, sedation depth appeared to be more consistent with ketofol. with propofol and its safety is well established. however, in 2010 cms enacted guidelines defining propofol as deep sedation and requiring administration by a physician. common edps practice had been one physician performing both the sedation and procedure. edps has proven safe under this one-physician practice. however, the 2010 guidelines mandated separate physicians perform each. objectives: the study hypothesis was that one-physician propofol sedation complication rates are similar to two-physician. methods: before and after, observational study of patients >17 years of age consenting to edps with propofol. edps completed with one physician were compared to those completed with two (separate physicians performing the sedation and the procedure). all data were prospectively collected. the study was completed at an urban level i trauma center. standard monitoring and procedures for edps were followed with physicians blinded to the objectives of this research. the frequency and incremental dosing of medication was left to the discretion of the treating physicians. the study protocol required an ed nurse trained in data collection to be present to record vital signs and assess for any prospectively defined complications. we used chi-square tests to compare the binary outcomes and asa scores across the time periods, and two-sample t-tests to test for differences in age between the two time periods. results: during the 2-year study period we enrolled 481 patients: 252 one-physician edps sedations and 229 3 (-7 to 13) also received bag-valve-mask 3 (2) [0.7 to 6) 1 (1) [0.1 to 4] 1 (-2 to 5) two-physician. all patients meeting inclusion criteria were included in the study. total adverse event rates were 4.4% and 3.1%, respectively (p = 0.450). the most common complications were hypotension and oxygen desaturation, and they respectively showed one-physcian rates of 2.0% and 0.8% and two-physician rates of 1.8% and 0.9% (p = 0.848 and 0.923.) the unsuccessful procedure rates were 4.0% vs 3.9% (p = 0.983). conclusion: this study demonstrated no significant difference in complication rates for propofol edps completed by one physician as compared to two. background: overdose patients are often monitored using pulse oximetry, which may not detect changes in patients on high-flow oxygen. objectives: to determine whether changes in end-tidal carbon dioxide (etco 2 ) detected by capnographic monitoring are associated with clinical interventions due to respiratory depression (crd) in patients undergoing evaluation for a decreased level of consciousness after a presumed drug overdose. methods: this was a prospective, observational study of adult patients undergoing evaluation for a drug overdose in an urban county ed. all patients received supplemental oxygen. patients were continuously monitored by trained research associates. the level of consciousness was recorded using the observer's assessment of alertness/sedation scale (oaa/s). vital signs, pulse oximetry, and oaa/s were monitored and recorded every 15 minutes and at the time of occurrence of any crd. respiratory rate and etco 2 were measured at five second intervals using a capno-stream20 monitor. crd included an increase in supplemental oxygen, the use of bag-valve-mask ventilations, repositioning to improve ventilation, and physical or verbal stimulus to induce respiration, and were performed at the discretion of the treating physicians and nurses. changes from baseline in etco 2 values and waveforms among patients who did or did have a clinical intervention were compared using wilcoxon rank sum tests. results: 100 patients were enrolled in the study (age 35, range 18 to 67, 62% male, median oaas 4, range 1 to 5). suspected overdoses were due to opioids in 34, benzodiazepines in 14, an antipsychotic in 14, and others in 38. the median time of evaluation was 165 minutes (range 20 to 725). crd occurred in 47% of patients, including an increase in o 2 in 38%, repositioning in 14%, and stimulation to induce respiration in 23%. 16% had an o 2 saturation of <93% (median 88, range 73 to 92) and 8% had a loss of etco 2 waveform at some time, all of whom had a crd. the median change in etco 2 from baseline was 5 mmhg, range 1 to 30. among patients with crd it was 14 mmhg, range 10 to 30, and among patients with no crd it was 5 mmhg, range 1 to 13 (p = 0.03). conclusion: the change in etco 2 from baseline was larger in patients who required clinical interventions than in those who did not. in patients on high-flow oxygen, capnographic monitoring may be sensitive to the need for airway support. how reliable are health care providers in reporting changes in etco 2 waveform anas sawas 1 , scott youngquist 1 , troy madsen 1 , matthew ahern 1 , camille broadwater-hollifield 1 , andrew syndergaard 1 , jared phelps 2 , bryson garbett 1 , virgil davis 1 1 university of utah, salt lake city, ut; 2 midwestern university, glendale, az background: etco 2 changes have been used in procedural sedation analgesia (psa) research to evaluate subclinical respiratory depression associated with sedation regiments. objectives: to evaluate the accuracy of bedside clinician reporting of changes in etco 2 . methods: this was a prospective, randomized, singleblind study conducted in ed setting from june 2010 until the present time. this study took place at an academic adult ed of a 405-bed (21 in the ed) and a level i trauma center. subjects were randomized to receive either ketamine-propofol or propofol according to a standardized protocol. loss of etco 2 waveforms for ‡ 15 sec were recorded. following sedation, questionnaires were completed by the sedating physicians. digitally recorded etco 2 waveforms were also reviewed by an independent physician and a trained research assistant (ra). to ensure the reliability of trained research assistants, we compared their analyses with the analyses of an independent physician for the first 41 recordings. the target enrollment was 65 patients in each group (n = 130 total). statistics were calculated using sas statistical software. results: 91 patients were enrolled; 53 (58.2%) are males and 38 (41.8%) are females. mean age was 44.93 ± 17.93 years. most participants did not have major risk factors for apnea or for further complications (86.3% were asa class 1 or 2). etco 2 waveforms were reviewed by 87 (95.6%) sedating physicians and 84 (92.3%) nurses at the bedside. there were 70 (76.9%) etco 2 waveforms recordings, 42 (60.0%) were reviewed by an independent physician and 70 (100%) were reviewed by an ra. a kappa test for agreement between independent physicians and ras was conducted on 41 recordings and there were no discordant pairs (kappa = 1). compared to sedating physicians, the independent physician was more likely to report etco 2 wave losses (or 1.37, 95% ci 1.08-1.73). compared to sedating physicians, ras were more likely to report etco 2 wave losses (or 1.39, 95% ci 1.14-1.70). conclusion: compared to sedating physicians at the bedside, independent physicians and ras were more likely to note etco 2 waveform losses. an independent review of recorded etco 2 waveform changes will be more reliable for future sedation research. background: comprehensive studies evaluating current practices of ed airway management in japan are lacking. many emergency physicians in japan still experience resistance regarding rapid sequence intubation (rsi). objectives: we sought to describe the success and complication rate of rsi with non-rsi. methods: design and setting: we conducted a multicenter prospective observational study using the jean registry of eds at 11 academic and community hospitals in japan during between 2010 and 2011. data fields include ed characteristics, patient and operator demographics, method of airway management, number of attempts, and adverse events. we defined non-rsi as intubation with sedation only, neuromuscular blockade only, and without medication. participants: all patients undergoing emergency intubation in ed were eligible for inclusion. cardiac arrest encounters were excluded from the analysis. primary analysis: we described rsi with non-rsi in terms of success rate on first attempt, within three attempts, and complication rate. we present descriptive data as proportions with 95% confidence intervals (cis). we report odds ratios (or) with 95% ci via chi-square testing. results: the database recorded 2710 intubations (capture rate 98%) and 1670 met the inclusion criteria. rsi was the initial method chosen in 489 (29%) and non-rsi in 1181 (71%). use of rsi varied among institutes from 0% to 79%. success cases of rsi on first and within three attempts are 353 intubations (72%, 95%ci 68%-76%) and 474 intubations (97%, 95%ci 95%-98%), respectively. the success cases of non-rsi on first and within three attempts are 724 intubations (61%, 95%ci 58%-64%) and 1105 intubations (94%, 95%ci 92%-95%). success rates of rsi on first and within three attempts are higher than non-rsi (or 1.64, 95%ci 1.30-2.06 and or 2.14, 95% ci 1.22-3.77, respectively). we recorded 67 complications in rsi (14%) and 165 in non-rsi (14%). there is no significant difference of complication rate between rsi and non-rsi (or 0.98, 95% ci 0.72-1.32). conclusion: in this multi-center prospective study in japan, we demonstrated a high degree of variation in use of rsi for ed intubation. additionally we found that success rate of rsi on first and within three attempts were both higher than non-rsi. this study has the limitation of reporting bias and confounding by indication. (originally submitted as a ''late-breaker.'') methods: this was a prospective, randomized, singleblind study conducted in the ed setting from june 2010 until the present time. this study took place at an academic adult ed of a 405-bed (21 in the ed) and a level i trauma center. subjects were randomized to receive either ketamine-propofol or propofol according to a standardized protocol. etco 2 waveforms were digitally recorded. etco 2 changes were evaluated by the sedating physicians at the bedside. recorded waveforms were reviewed by an independent physician and a trained research assistant (ra). to ensure the reliability of trained ras, we computed a kappa test for agreement between the analysis of independent physicians and ras for the first 41 recordings. a post-hoc analysis of the association between any loss, the number of losses, and total duration of loss of etco 2 waveform and crp was performed. on review we recorded the absence or presence of loss of etco 2 and the total duration in seconds of all lost etco 2 episodes ‡15 seconds. ors were calculated using sas statistical software. results: 91 patients were enrolled; 53 (58.2%) are males and 38 are (41.8%) females. 86.3% participants were asa class 1 or 2. waveforms were reviewed by 87 (95.6%) sedating physicians. there were 70 (76.9%) waveforms recordings, 42 (60.0%) were reviewed by an independent physician and 70 (100%) were reviewed by ras, where there were no discordant pairs (kappa = 1). there were 24 (26.4%) crp events. any loss of etco 2 was associated with a non-significant or of 4.06 (95% ci 0.75-21.9) for crp. however, the duration of etco 2 loss was significantly associated with crp with an or of 1.38 (95% ci 1.08-1.76) for each 30 second interval of lost etco 2 . the number of losses was significantly associated with the outcome (or 1.48, 95% ci 1.15-1.91). conclusion: defining subclinical respiratory depression as present or absent may be less useful than quantitative measurements. this suggests that risk is cumulative over periods of loss of etco 2 , and the duration of loss may be a better marker of sedation depth and risk of complications than classification of any loss. background: ed visits present an opportunity to deliver brief interventions (bis) to reduce violence and alcohol misuse among urban adolescents at risk for future injury. previous analyses demonstrated that a brief intervention resulted in reductions in violence and alcohol consequences up to 6 months. objectives: this paper describes findings examining the efficacy of bis on peer violence and alcohol misuse at 12 months. methods: patients (14-18 yrs) at an ed reporting past year alcohol use and aggression were enrolled in the rct, which included computerized assessment, and randomization to control group or bi delivered by a computer (cbi) or therapist assisted by a computer (tbi). baseline and 12 months included violence (peer aggression, peer victimization, violence related consequences) and alcohol (alcohol misuse, binge drinking, alcohol-related consequences). results: 3338 adolescents were screened (88% participation). of those, 726 screened positive for violence and alcohol use and were randomized; 84% completed 12-month follow-up. as compared to the control group, the tbi group showed significant reductions in peer aggression (p < 0.01) and peer victimization (p < 0.05) at 12 months. bi and control groups did not differ on alcohol-related variables at 12 months. conclusion: evaluation of the saferteens intervention one year following an ed visit provides support for the efficacy of computer-assisted therapist brief intervention for reducing peer violence. violence against ed health care workers: a 9-month experience terry kowalenko 1 , donna gates 2 , gordon gillespie 2 , paul succop 2 1 university of michigan, ann arbor, mi; 2 university of cincinnati, cincinnati, oh background: health care (hc) support occupations have an injury rate nearly 10 times that of the general sector due to assaults, with doctors and nurses nearly 3 times greater. studies have shown that the ed is at greatest risk of such events compared to other hc settings. objectives: to describe the incidence of violence in ed hc workers over 9 months. specific aims were to 1) identify demographic, occupational, and perpetrator factors related to violent events; 2) identify the predictors of acute stress response in victims; and 3) identify predictors of loss of productivity after the event. methods: longitudinal, repeated methods design was used to collect monthly survey data from ed hc workers (w) at six hospitals in two states. surveys assessed the number and type of violent events, and feelings of safety and confidence. victims also completed specific violent event surveys. descriptive statistics and a repeated measure linear regression model were used. results: 213 ed hcws completed 1795 monthly surveys, and 827 violent events were reported. the average per person violent event rate per 9 months was 4.15. 601 events were physical threats (3.01 per person in 9 months). 226 events were assaults (1.13 per person in 9 months). 501 violent event surveys were completed, describing 341 physical threats and 160 assaults with 20% resulting in injuries. 63% of the physical threats and 52% of the assaults were perpetrated by men. comparing occupational groups revealed significant differences between nurses and physicians for all reported events (p = 0.0048), with the greatest difference in physical threats (p = 0.0447). nurses felt less safe than physicians (p = 0.0041). physicians felt more confident than nurses in dealing with the violent patient (p = 0.013). nurses were more likely to experience acute stress than physicians (p < 0.001). acute stress significantly reduced productivity in general (p < 0.001), with a significant negative effect on ''ability to handle/ manage workload'' (p < 0.001) and ''ability to handle/ manage cognitive demands'' (p < 0.05). conclusion: ed hcws are frequent victims of violence perpetrated by visitors and patients. this violence results in injuries, acute stress, and loss of productivity. acute stress has negative consequences on the workers' ability to perform their duties. this has serious potential consequences to the victim as well as the care they provide to their patients. a randomized controlled feasibility trial of vacant lot greening to reduce crime and increase perceptions of safety eugenia c. garvin, charles c. branas perelman school of medicine at the university of pennsylvania, philadelphia, pa background: vacant lots, often filled with trash and overgrown vegetation, have been associated with intentional injuries. a recent quasi-experimental study found a significant decrease in gun crimes around vacant lots that had been greened compared with control lots. objectives: to determine the feasibility of a randomized vacant lot greening intervention, and its effect on police-reported crime and perceptions of safety. methods: for this randomized controlled feasibility trial of vacant lot greening, we partnered with the pennsylvania horticulture society (phs) to perform the greening intervention (cleaning the lots, planting grass and trees, and building a wooden fence around the perimeter). we analyzed police crime data and interviewed people living around the study vacant lots (greened and control) about perceptions of safety before and after greening. results: a total of 5200 sq ft of randomly selected vacant lot space was successfully greened. we used a master database of 54,132 vacant lots to randomly select 50 vacant lot clusters. we viewed each cluster with the phs to determine which were appropriate to send to the city of philadelphia for greening approval. the vacant lot cluster highest on the random list to be approved by the city of philadelphia was designated the intervention site, and the next highest was designated the control site. overall, 29 participants completed baseline interviews, and 21 completed follow-up interviews after 3 months. 59% of participants were male, 97% were black or african american, and 52% had a household income less than $25,000. unadjusted difference-in-differences estimates showed a decrease in gun assaults around greened vacant lots compared to control. regression-adjusted estimates showed that people living around greened vacant lots reported feeling safer after greening compared to those who lived around control vacant lots (p < 0.01). conclusion: conducting a randomized controlled trial of vacant lot greening is feasible. greening may reduce certain gun crimes and make people feel safer. however, larger prospective trials are needed to further investigate this link. screening for violence identifies young adults at risk for return ed visits for injury abigail hankin-wei, brittany meagley, debra houry emory university, atlanta, ga background: homicide is the second leading cause of death among youth ages 15-24. prior studies, in nonhealth care settings, have shown associations between violent injury and risk factors including exposure to community violence, peer behavior, and delinquency. objectives: to assess whether self-reported exposure to violence risk factors can be used to predict future ed visits for injuries. methods: we conducted a prospective cohort study in the ed of a southeastern us level i trauma center. patients aged 15-24 presenting for any chief complaint were included unless they were critically ill, incarcerated, or could not read english. recruitment took place over six months, by a trained research assistant (ra). the ra was present in the ed for 3-5 days per week, with shifts scheduled such that they included weekends and weekdays, over the hours from 8 am-8 pm. patients were offered a $5 gift card for participation. at the time of initial contact in the ed, patients completed a written questionnaire which included validated measures of the following risk factors: a) aggression, b) perceived likelihood of violence, c) recent violent behavior, d) peer behavior, e) community exposure to violence, and f) positive future outlook. at 12 months following the initial ed visit, the participants' medical records were reviewed to identify any subsequent ed visits for injury-related complaints. data were analyzed with chi-square and logistic regression analyses. results: 332 patients were approached, of whom 300 patients consented. participants' average age was 21.1 years, with 57% female, and 86% african american. return visits for injuries were significantly associated with hostile/aggressive feelings (rr 3.7, ci 1.42, 9) , self-reported perceived likelihood of violence (rr 5.16, ci 1.93, 13.78) , recent violent behavior (rr 3.16, ci 1.01, 9.88) , and peer group violence (rr 4.4, ci 1.72, 11.25) . these findings remained significant when controlling for participant sex. conclusion: a brief survey of risk factors for violence is predictive of return visit to the ed for injury. these findings identify a potentially important tool for primary prevention of violent injuries among young adults visiting the ed for both injury and non-injury complaints. background: sepsis is a commonly encountered disease in ed, with high mortality. while several clinical prediction rules (cpr) including meds, sirs, and curb-65 exist to facilitate clinicians in early recognition of risk of mortality for sepsis, most are of suboptimal performance. objectives: to derive a novel cpr for mortality of sepsis utilizing clinically available and objective predictors in ed. methods: we retrospectively reviewed all adult septic patients who visited the ed at a tertiary hospital during the year 2010 with two sets of blood cultures ordered by physicians. basic demographics, ed vital signs, symptoms and signs, underlying illnesses, laboratory findings, microbiological results, and discharge status were collected. multivariate logistic regressions were used to obtain a novel cpr using predictors with <0.1 p-value tested in univariate analyses. the existing cprs were compared with this novel cpr using auc. results: of 8699 included patients, 7.6% died in hospital, 51% had diabetes, 49% were older than 65 years of age, 21% had malignancy, and 16% had positive blood bacterial culture tests. predisposing factors including history of malignancy, liver disease, immunosuppressed status, chronic kidney disease, congestive heart failure, and older than 65 years of age were found to be associated with mortality (all p < 0.05). patients who developed mortality tended to have lower body temperature, narrower pulse pressure, higher percentage of red cell distribution width (rdw) and bandemia, higher blood urea nitrogen (bun), ammonia, and c-reactive protein level, and longer prothrombin time and activated partial thromboplastin time (aptt) (all p < 0.05). the most parsimonious cpr incorporating history of malignancy (or 2.3, 95% ci 1.9-2.7), prolonged aptt (3.0, 2.4-3.8), presence of bandemia (1.7, 1.4-2.0 results: there was poor agreement between the physician's unstructured assessment used in clinical practice and the guidelines put forth by the aha/acc/acep task force. ed physicians were more likely to assess a patient as low risk (42%), while aha guidelines were more likely to classify patients as intermediate (50%) or high (40%) risk. however, when comparing the patient's final acs diagnosis and the relation to the risk assessment value, ed physicians proved better predictors of high-risk patients who in fact had acs, while the aha/acc/acep guidelines proved better at correctly identifying low-risk patients who did not have acs. conclusion: in the ed, physicians are far more efficient at correctly placing patients with underlying acs into a high-risk category, while established criteria may be overly conservative when applied to an acute care population. further research is indicated to look at ed physicians' risk stratification and ensuing patient care to assess for appropriate decision making and ultimate outcomes. compartative conclusion: the amuse score was more specific, but the wells score was more sensitive for acute lower limb dvt in this cohort. there is no significant advantage in using the amuse over the wells score in ed patient with suspected dvt. background: the direct cost of medical care is not accurately reflected in charges or reimbursement. the cost of boarding admitted patients in the ed has been studied in terms of opportunity costs, which are indirect. the actual direct effect on hospital expenses has not been well defined. objectives: we calculate the difference to the hospital in the cost of caring for an admitted patient in the ed and in a non-critical care in-patient unit. methods: time-directed activity-based costing (tdabc) has recently been proposed as a method of determining the actual cost of providing medical services. tdabc was used to calculate the cost per patient bed-hour both in the ed and for an in-patient unit. the costs include nursing, nursing assistants, clerks, attending and resident physicians, supervisory salaries, and equipment maintenance. boarding hours were determined from placement of admission order to transfer to in-patient unit. a convenience sample of 100 consecutive non-critical care admissions was assessed to find the degree of ed physician involvement with boarded patients. results: the overhead cost per patient bed-hour in the ed was $60.80. the equivalent cost per bed-hour inpatient was $23.39, a differential of $37.41. there were 27,618 boarding hours for medical-surgical patients in 2010, a differential of $1,033,189.38 for the year. for the short-stay unit (no residents), the cost per patient hour was $11.36 and the boarding hours were 11,804. this resulted in a differential cost of $583,389.76, a total direct cost to the hospital of $1,616,579.14. review of 100 consecutive admissions showed no orders placed by the ed physician after decision-toadmit. conclusion: concentration of resources in the ed means considerably higher cost per unit of care as compared to an in-patient unit. keeping admitted patients boarding in the ed results in expensive underutilization. this is exclusive of significant opportunity costs of lost revenue from walk-out and diverted patients. this study includes the cost of teaching attendings and residents (ed and in-patient) . in a non-teaching setting, the differential would be less and the cost of boarding would be shared by a fee-for-service ed physician group as well as the hospital. improving identification of frequent emergency department users using a regional health information background: frequent ed users consume a disproportionate amount of health care resources. interventions are being designed to identify such patients and direct them to more appropriate treatment settings. because some frequent users visit more than one ed, a health information exchange (hie) may improve the ability to identify frequent ed users across sites of care. objectives: to demonstrate the extent to which a hie can identify the marginal increase in frequent ed users beyond that which can be detected with data from a single hospital. methods: data from 6/1/10 to 5/31/11 from the new york clinical information exchange (nyclix), a hie in new york city that includes ten hospitals, were analyzed to calculate the number of frequent ed users ( ‡4 visits in 30 days) at each site and across the hie. results: there were 10,555 (1% of total patients) frequent ed users, with 7,518 (71%) of frequent users having all their visits at a single ed, while 3,037 (29%) frequent users were identified only after counting visits to multiple eds (table 1) . site-specific increases varied from 7% to 62% (sd 16.5). frequent ed users accounted for 1% of patients, but for 6% of visits, averaging 9.74 visits per year, versus 1.55 visits per year for all other patients. 28.5% of frequent users visited two or more eds during the study period, compared to 10.6% of all other patients. conclusion: frequent ed users commonly visited multiple nyclix eds during the study period. the use of a hie helped identify many additional frequent users, though the benefits were lower for hospitals not located in the relative vicinity of another nyclix hospital. measures that take a community, rather than a single institution, into account may be more reflective of the care that the patient experiences. indocyanine background: due to their complex nature and high associated morbidity, burn injuries must be handled quickly and efficiently. partial thickness burns are currently treated based upon visual judgment of burn depth by the clinician. however, such judgment is only 67% accurate and not expeditious. laser doppler imaging (ldi) is far more accurate -nearly 96% after 3 days. however, it is too cumbersome for routine clinical use. laser assisted indocyanine green angiography (laicga) has been indicated as an alternative for diagnosing the depth of burn injuries, and possesses greater utility for clinical translation. as the preferred outcome of burn healing is aesthetic, it is of interest to determine if wound contracture can be predicted early in the course of a burn by laic-ga. objectives: determine the utility of early burn analysis using laicga in the prediction of 28-day wound contracture. methods: a prospective animal experiment was performed using six anesthetized pigs, each with 20 standardized wounds. differences in burn depth were created by using a 2.5 · 2.5 cm aluminum bar at three exposure times and temperatures: 70 degrees c for 30 seconds, 80 degrees c for 20 seconds, and 80 degrees c for 30 seconds. we have shown in prior validation experiments that these burn temperatures and times create distinct burn depths. laicga scanning, using lifecell spy elite, took place at 1 hour, 24 hours, 48 hours, 72 hours, and 1 week post burn. imaging was read by a blinded investigator, and perfusion trends were compared with day 28 post-burn contraction outcomes measured using imagej software. biopsies were taken on day 28 to measure scar tissue depth. results: deep burns were characterized by a blue center indicating poor perfusion while more superficial burns were characterized by a yellow-red center indicating perfusion that was close to that of the normal uninjured adjacent skin (see figure) . a linear relationship between contraction outcome and burn perfusion could be discerned as early as 1 hour post burn, peaking in strength at 24-48 hours post-burn. burn intensity could be effectively identified at 24 hours post-burn, although there was no relationship with scar tissue depth. conclusion: pilot data indicate that laicga using lifecell spy has the ability to determine the depth of injury and predict the degree of contraction of deep dermal burns within 1-2 days of injury with greater accuracy than clinical scoring. the objectives: we hypothesize that real-time monitoring of an integrated electronic medical records system and the subsequent firing of a ''sepsis alert'' icon on the electronic ed tracking board results in improved mortality for patients who present to the ed with severe sepsis or septic shock. methods: we retrospectively reviewed our hospital's sepsis registry and included all patients diagnosed with severe sepsis or septic shock presenting to an academic community ed with an annual census of 73,000 visits and who were admitted to a medical icu or stepdown icu bed between june 2009 and october 2011. in may 2010 an algorithm was added to our integrated medical records system that identifies patients with two sirs criteria and evidence of endorgan damage or shock on lab data. when these criteria are met, a ''sepsis alert'' icon (prompt) appears next to that patient's name on the ed tracking board. the system also pages an in-house, specially trained icu nurse who can respond on a prn basis and assist in the patient's management. 18 months of intervention data are compared with 11 months of baseline data. statistical analysis was via z-test for proportions. results: for ed patients with severe sepsis, the preand post-alert mortality was 19 of 125 (15%) and 34 of 378 (9%), respectively (p = 0.084; n = 503). in the septic shock group, the pre-and post-alert mortality was 27 of 92 (29%) and 48 of 172 (28%), respectively (p = 0.977). with ed and inpatient sepsis alerts combined, the severe sepsis subgroup mortality was reduced from 17% to 9% (p = 0.013; n = 622). conclusion: real-time ed ehr screening for severe sepsis and septic shock patients did not improve mortality. a positive trend in the severe sepsis subgroup was noted, and the combined inpatient plus ed data suggests statistical significance may be reached as more patients enter the registry. limitations: retrospective study, potential increased data capture post intervention, and no ''gold standard'' to test the sepsis alert sensitivity and specificity. ) . descriptive statistics were calculated. principal component analysis was used to determine questions with continuous response formats that could be aggregated. aggregated outcomes were regressed onto predictor demographic variables using multiple linear regression. results: 80/100 physicians completed the survey. physicians had a mean of 9.8 ± 9.0 years experience in the ed. 23.8% were female. eight physicians (10%) reported never having used the tool, while 70.8% of users estimated having used it more than five times. 75% of users cited the ''p'' alert on the etb as the most common notification method. most felt the ''p'' alert did not help them identify patients with pneumonia earlier (mean = 2.5 ± 1.2), but found it moderately useful in reminding them to use the tool (3.5 ± 1.3). physicians found the tool helpful in making decisions regarding triage, diagnostic studies, and antibiotic selection for outpatients and inpatients (3.7 ± 1.0, 3.6 ± 1.1, 3.6 ± 1.1, and 4.2 ± 0.9, respectively). they did not feel it negatively affected their ability to perform other tasks (1.6 ± 0.9). using multiple linear regression, neither age, sex, years experience, nor tool use frequency significantly predicted responses to questions about triage and antibiotic selection, technical difficulties, or diagnostic ordering. conclusion: ed physicians perceived the tool to be helpful in managing patients with pneumonia without negatively affecting workflow. perceptions appear consistent across demographic variables and experience. objectives: we seek to examine whether use of the salt device can provide reliable tracheal intubation during ongoing cpr. the dynamic model tested the device with human powered cpr (manual) and with an automated chest compression device (physio control lucas 2). the hypothesis is that the predictable movement of an automated chest compression device will make tracheal intubation easier than the random movement from manual cpr. methods: the project was an experimental controlled trial and took place in the ed at a tertiary referral center in peoria, illinois. this project was an expansion arm of a similarly structured study using traditional laryngoscopy. emergency medicine residents, attending physicians, paramedics, and other acls-trained staff were eligible for participation. in randomized order, each participant attempted intubation on a mannequin using the salt device with no cpr ongoing, during cpr with a manual compression, and during cpr with an automatic chest compression. participants were timed in their attempt and success was determined after each attempt. results: there were 43 participants in the trial. the success rates in the control group and the automated cpr group were both 86% (37/43) and the success rate in the manual cpr group was 79% (34/43 objectives: our primary hypothesis was that in fasting, asymptomatic subjects, larger fluid boluses would lead to proportional aortic velocity changes. our secondary endpoints were to determine inter-and intra-subject variation in aortic velocity measurements. methods: the authors performed a prospective randomized double-blinded trial using healthy volunteers. we measured the velocity time integral (vti) and maximal velocity (vmax) with an estimated 0-20°pulsed wave doppler interrogation of the left ventricular outflow in the apical-5 cardiac window. three physicians reviewed optimal sampling gate position, doppler angle and verified the presence of an aortic closure spike. angle correction technology was not used. subjects with no history of cardiac disease or hypertension fasted for 12 hours and were then randomly assigned to receive a normal saline bolus of 2 ml/kg, 10 ml/kg or 30 ml/kg over 30 minutes. aortic velocity profiles were measured before and after each fluid bolus. results: forty-two subjects were enrolled. mean age was 33 ± 10 (range 24 to 61) and mean body mass index 24.7 ± 3.2 (range 18.7 to 32). mean volume (in ml) for groups receiving 2 ml/kg, 10 ml/kg, and 30 ml/kg were 151, 748, and 2162, respectively. mean baseline vmax (in cm/s) of the 42 subjects was 108.4 ± 12.5 (range 87 to 133). mean baseline vti (in cm) was 23.2 ± 2.8 (range 18.2 to 30.0). pre-and post-fluid mean differences for vmax were )1.7 (± 10.3) and for vti 0.7 (± 2.7). aortic velocity changes in groups receiving 2 ml/kg, 10 ml/kg, and 30 ml/kg were not statistically significant (see table) . heart rate changes were not significant. background: clinicians recognize that septic shock is a highly prevalent, high mortality disease state. evidence supports early ed resuscitation, yet care delivery is often inconsistent and incomplete. the objective of this study was to discover latent critical barriers to successful ed resuscitation of septic shock. objectives: clinicians recognize that septic shock is a highly prevalent, high mortality disease state. evidence supports early ed resuscitation, yet care delivery is often inconsistent and incomplete. the objective of this study was to discover latent critical barriers to successful ed resuscitation of septic shock. methods: we conducted five 90-minute risk-informed in-situ simulations. ed physicians and nurses working in the real clinical environment cared for a standardized patient, introduced into their existing patient workload, with signs and symptoms of septic shock. immediately after case completion clinicians participated in a 30minute debriefing session. transcripts of these sessions were analyzed using grounded theory, a method of qualitative analysis, to identify critical barrier themes. results: fifteen clinicians participated in the debriefing sessions: four attending physicians, five residents, five nurses, and one nurse practitioner. the most prevalent critical barrier themes were: anchoring bias and difficulty with cognitive framework adaptation as the patient progressed to septic shock (n = 26), difficult interactions between the ed and ancillary departments (n = 22), difficulties with physician-nurse commu-nication and teamwork (n = 18), and delays in placing the central venous catheter due to perceptions surrounding equipment availability and the desire to attend to other competing interests in the ed prior to initiation of the procedure (n = 17 and 14). each theme was represented in at least four of the five debriefing sessions. participants reported the in-situ simulations to be a realistic representation of ed sepsis care. conclusion: in-situ simulation and subsequent debriefing provides a method of identifying latent critical areas for improvement in a care process. improvement strategies for ed-based septic shock resuscitation will need to address the difficulties in shock recognition and cognitive framework adaptation, physician and nurse teamwork, and prioritization of team effort. the background: the association between blood glucose level and mortality in critically ill patients is highly debated. several studies have investigated the association between history of diabetes, blood sugar level, and mortality of septic patients; however, no consistent conclusion could be drawn so far. objectives: to investigate the association between diabetes and initial glucose level and in-hospital mortality in patients with suspected sepsis from the ed. methods: we conducted a retrospective cohort study that consisted of all adult septic patients who visited the ed at a tertiary hospital during the year 2010 with two sets of blood cultures ordered by physicians. basic demographics, ed vital signs, symptoms and signs, underlying illnesses, laboratory findings, microbiological results, and discharge status were collected. logistic regressions were used to evaluate the association between risk factors, initial blood sugar level, and history of diabetes and mortality, as well as the effect modification between initial blood sugar level and history of diabetes. results: a total of 4997 patients with available blood sugar levels were included, of whom 48% had diabetes, 46% were older than 65 years of age, and 56% were male. the mortality was 6% (95% ci 5.3-6.7%). patients with a history of diabetes tended to be older, female, and more likely to have chronic kidney disease, lower sepsis severity (meds score), and positive blood culture test results (all p < 0.05). patients with a history of diabetes tended to have lower in-hospital mortality after ed visits with sepsis, controlling for initial blood sugar level (aor 0.72, 95% ci 0.56-0.92, p = 0.01). initial normal blood sugar seemed to be beneficial compared to lower blood sugar level for in-hospital mortality, controlled history of diabetes, sex, severity of sepsis, and age (aor 0.61, 95% ci 0.44-0.84, p = 0.002). the effect modification of diabetes on blood sugar level and mortality, however, was found to be not statistically significant (p = 0.09). conclusion: normal initial blood sugar level in ed and history of diabetes might be protective for mortality of septic patients who visited the ed. further investigation is warranted to determine the mechanism for these effects. methods: this irb-approved retrospective chart review included all patients treated with therapeutic hypothermia after cardiac arrest during 2010 at an urban, academic teaching hospital. every patient undergoing therapeutic hypothermia is treated by neurocritical care specialists. patients were identified by review of neurocritical care consultation logs. clinical data were dually abstracted by trained clinical study assistants using a standardized data dictionary and case report form. medications reviewed during hypothermia were midazolam, lorazepam, propofol, fentanyl, cisatracurium, and vecuronium. results: there were 33 patients in the cohort. median age was 57 (range 28-86 years), 67% were white, 55% were male, and 49% had a history of coronary artery disease. seizures were documented by continuous eeg in 11/33 (33%), and 20/33 (61%) died during hospitalization. most, 30/33 (91%), received fentanyl, 21/33 (64%) received benzodiazepine pharmacotherapy, and 23/33 (70%) received propofol. paralytics were administered to 23/33 (68%) patients, 14/33 (42%) with cisatracurium and 9/33 (27%) with vecuronium. of note, one patient required pentobarbital for seizure management. conclusion: sedation and neuromuscular blockade are common during management of patients undergoing therapeutic hypothermia after cardiac arrest. patients in this cohort often received analgesia with fentanyl, and sedation with a benzodiazepine or propofol. given the frequent use of sedatives and paralytics in survivors of cardiac arrest undergoing hypothermia, future studies should investigate the potential effect of these drugs on prognostication and survival after cardiac arrest. background: the use of therapeutic hypothermia (th) is a burgeoning treatment modality for post-cardiac arrest patients. objectives: we performed a retrospective chart review of patients who underwent post cardiac arrest th at eight different institutions across the united states. our objective was to assess how th is currently being implemented in emergency departments and assess the feasibility of conducting more extensive th research using multi-institution retrospective data. methods: a total of 94 charts with dates from 2008-2011 were sent for review by participating institutions of the peri-resuscitation consortium. of those reviewed, eight charts were excluded for missing data. two independent reviewers performed the review and the results were subsequently compared and discrepancies resolved by a third reviewer. we assessed patient demographics, initial presenting rhythm, time until th initiation, duration of th, cooling methods and temperature reached, survival to hospital discharge, and neurological status on discharge. results: the majority of cases of th had initial cardiac rhythms of asystole or pulseless electrical activity (55.2%), followed by ventricular tachycardia or fibrillation (34.5%), and in 10.3% the inciting cardiac rhythm was unknown. time to initiation of th ranged from 0-783 minutes with a mean time of 99 min (sd 132.5). length of th ranged from 25-2171 minutes with a mean time of 1191 minutes (sd 536). average minimum temperature achieved was 32.5°c, with a range from 27.6-36.7°c (sd 1.5°c). of the charts reviewed, 29 (33.3%) of the patients survived to hospital discharge and 19 (21.8%) were discharged relatively neurologically intact. conclusion: research surrounding cardiac arrest has always been difficult given the time and location span from pre-hospital care to emergency department to intensive care unit. also, as witnessed cardiac arrest events are relatively rare with poor survival outcomes, very large sample sizes are needed to make any meaningful conclusions about th. our varied and inconsistent results show that a multi-center retrospective review is also unlikely to provide useful information. a prospective multi-center trial with a uniform th protocol is needed if we are ever to make any evidence-based conclusions on the utility of th for post-cardiac arrest patients. serum results: mean la was 2.04, sd = 1.45. mean age was 4.5 years old, sd = 5.20. a statistically significant positive correlation was found between la and pulse, respiratory rate (rr), wbc, platelets, and los, while a significant negative correlation was seen with temperature and hco 3 -. when two subjects were dropped as possible outliers with la >10, it resulted in non-significant temperature correlation, but a significant negative correlation with age and bun was revealed. patients in the higher la group were more likely to be admitted (p = 0.0001) and have longer los. of the discharged patients, there was no difference in mean la level between those who returned (n = 25, mean la of 1.88, sd = 0.88) and those who did not (n = 154, mean la of 1.88, sd = 1.35), p = 0.99. furthermore, mean la levels for those with sepsis (n = 138, mean la of 2.18, sd = 1.75) did not differ from those without sepsis (n = 147, mean la of 1.9, sd = 1.08), p = 0.11. conclusion: higher la in pediatric patients presenting to the ed with suspected infection correlated with increased pulse, rr, wbc, platelets, and decreased bun, hco 3 -, and age. la may be predictive of hospitalization, but not of 3-day return rates or pediatric sepsis screening in the ed. background: mandibular fractures are one of the most frequently seen injuries in the trauma setting. in terms of facial trauma, madibular fractures account for 40-62% of all facial bone fractures. prior studies have demonstrated that the use of a tongue blade to screen these patients to determine whether a mandibular fracture is present may be as sensitive as x-ray. one study showed the sensitivity and specificity of the test to be 95.7% and 63.5%, respectively. in the last ten years, high-resolution computed tomography (hct) has replaced panoramic tomography (pt) as the gold standard for imaging of patients with suspected mandibular fractures. this study determines if the tongue blade test (tbt) remains as sensitive a screening tool when compared to the new gold standard of ct. objectives: the purpose of the study was to determine the sensitivity and specificity of the tbt as compared to the new gold standard of radiologic imaging, hct. the question being asked: is the tbt still useful as a screening tool for patients with suspected mandibular fractures when compared to the new gold standard of hct? methods: design: prospective cohort study. setting: an urban tertiary care level i trauma center. subjects: this study took place from 8/1/10 to 8/31/11 in which any person suffering from facial trauma presented. intervention: a tbt was performed by the resident physician and confirmed by the supervising attending physician. ct facial bones were then obtained for the ultimate diagnosis. inter-rater reliability (kappa) was calculated, along with sensitivity, specificity, accuracy, ppv, npv, likelihood ratio (lr) (+), and likelihood ratio (lr) (-) based on a 2 · 2 contingency tables generated. results: over the study period 85 patients were enrolled. inter-rater reliability was kappa = 0.93 (se +0.11). the table demonstrates the outcomes of both the tbt and ct facial bones for mandibular fracture. the following parameters were then calculated based on the contingency table: sensitivity 0.97 (ci 0.81-0.99), specificity 0.72 (ci 0.58-0.83), ppv 0.67 (ci 0.52-0.78), npv 0.97 (ci 0.87-0.99), accuracy 0.81, lr(+) 3.48 ), lr (-) 0.04 (ci 0.01-0.31). conclusion: the tbt is still a useful screening tool to rule out mandibular fractures in patients with facial trauma as compared to the current gold standard of hct. background: appendicitis is the most common surgical emergency occurring in children. the diagnosis of pediatric appendicitis is often difficult and computerized tomography (ct) scanning is utilized frequently. ct, although accurate, is expensive, time-consuming, and exposes children to ionizing radiation. radiologists utilize ultrasound for the diagnosis of appendicitis, but it may be less accurate than ct, and may not incorporate emergency physician (ep) clinical impression regarding degree of risk. objectives: the current study compared ep clinical diagnosis of pediatric appendicitis pre-and post-bedside ultrasonography (bus). methods: children 3-17 years of age were enrolled if their clinical attending physician planned to obtain a consultative ultrasound, ct scan, or surgical consult specific for appendicitis. most children in the study received narcotic analgesia to facilitate bus. subjects were initially graded for likelihood of appendicitis based on research physician-obtained history and physical using a visual analogue scale (vas). immediately subsequent to initial grading, research physicians performed a bus and recorded a second vas impression of appendicitis likelihood. two outcome measures were combined as the gold standard for statistical analysis. the post-operative pathology report served as the gold standard for subjects who underwent appendectomy, while post 2-week telephone follow-up was used for subjects who did not undergo surgery. various specific ultrasound measures used for the diagnosis of appendicitis were assessed as well. results: 29/56 subjects had pathology-proven appendicitis. one subject was pathology-negative post-appendectomy. of the 26 subjects who did not undergo surgery, none had developed appendicitis at the post 2-week telephone follow-up. pre-bus sensitivity was 48% (29-68%) while post-bus sensitivity was 79% (60-92%). both pre-and post-bus specificity was 96% (81-100%). pre-bus lr+ was 13 (2-93), while post-bus lr+ was 21 (3-148). pre-and post-bus lr-were 0.5 and 0.2, respectively. bus changed the diagnosis for 20% of subjects (9-32%). background: there are very little data on the normal distance between the glenoid rim and the posterior aspect of the humeral head in normal and dislocated shoulders. while shoulder x-rays are commonly used to detect shoulder dislocations, they may be inadequate, exacerbate pain in the acquisition of some views, and lead to delay in treatment, compared to bedside ultrasound evaluation. objectives: our objective was to compare the glenoid rim to humeral head distance in normal shoulders and in anteriorly dislocated shoulders. this is the first study proposing to set normal and abnormal limits. methods: subjects were enrolled in this prospective observation study if they had a chief complaint of shoulder pain or injury, and received a shoulder ultrasound as well as a shoulder x-ray. the sonographers were undergraduate students given ten hours of training to perform the shoulder ultrasound. they were blinded to the x-ray interpretation, which was used as the gold standard. we used a posterior-lateral approach, capturing an image with the glenoid rim, the humeral head, as well as the infraspinatus muscle. two parallel lines were applied to the most posterior aspect of the humeral head and the most posterior aspect of the glenoid rim. a line perpendicular to these lines was applied, and the distance measured. in anterior dislocations, a negative measurement was used to denote the fact that the glenoid rim is now posterior to the most posterior aspect of the humeral head. descriptive analysis was applied to estimate the mean and 25th to 75th interquartile range of normal and anteriorly dislocated shoulders. results: eighty subjects were enrolled in this study. there were six shoulder dislocations, however only four were anterior dislocations. the average distance between the posterior glenoid rim and the posterior humeral head in normal shoulders was 8.7 mm, with a 25th to 75th inter-quartile range of 6.7 mm to 11.9 mm. the distance in our four cases of anterior dislocation was )11 mm, with a 25th to 75th interquartile range of )10 mm to )12 mm. conclusion: the distance between the posterior humeral head to posterior glenoid rim may be 7 mm to 12 mm in patients presenting to the ed with shoulder pain but no dislocation. in contrast, this distance in anterior dislocations was greater than )10 mm. shoulder ultrasound may be a useful adjunct to x-ray for diagnosing anterior shoulder dislocations. conclusion: in this retrospective study, the presence of rv strain on focus significantly increases the likelihood of an adverse short term event from pulmonary embolism and its combination with hypotension performs similarly to other prognostic rules. background: burns are expensive and debilitating injuries, compromising both the structural integrity and vascular supply to skin. they exhibit a substantial potential to deteriorate if left untreated. jackson defined three ''zones'' to a burn. while the innermost coagulation zone and the outermost zone of hyperemia display generally predictable healing outcomes, the zone of stasis has been shown to be salvageable via clinical intervention. it has therefore been the focus of most acute therapies for burn injuries. while laser doppler imaging (ldi) -the current gold standard for burn analysis -has been 96% effective at predicting the need for second degree burn excision, its clinical translation is problematic, and there is little information regarding its ability to analyze the salvage of the stasis zone in acute injury. laser assisted indocyanine green dye angiography (laicga) also shows potential to predict such outcomes with greater clinical utility. objectives: to test the ability of ldi and laicga to predict interspace (zone of stasis) survival in a horizontal burn comb model. methods: a prospective animal experiment was performed using four pigs. each pig had a set of six dorsal burns created using a brass ''comb'' -creating four rectangular 10 · 20 mm full thickness burns separated by 5 · 20 mm interspaces. laicga and ldi scanning took place at 1 hour, 24 hours, 48 hours, and 1 week post burn using novadaq spy and moor ldi respectively. imaging was read by a blinded investigator, and perfusion trends were compared with interspace viability and contraction. burn outcomes were read clinically, evaluated via histopathology, and interspace contraction was measured using image j software. results: laicga data showed significant predictive potential for interspace survival. it was 83.3% predictive at 24 hours post burn, 75% predictive 48 hours post burn, and 100% predictive 7 days post burn using a standardized perfusion threshold. ldi imaging failed to predict outcome or contraction trends with any degree of reliability. the pattern of perfusion also appears to be correlated with the presence of significant interspace contraction at 28 days, with an 80% adherence to a power trendline. ventions, 11 isolation, 4 testing, 4 treatment, and 1 ''other'' category intervention were identified. one intervention involving school closures was associated with a 28% decrease in pediatric ed visits for respiratory illness. conclusion: most interventions were not tested in isolation, so the effect of individual interventions was difficult to differentiate. interventions associated with statistically significant decreases in ed crowding were school closures, as well as interventions in all categories studied. further study and standardization of intervention input, process, and outcome measures may assist in identifying the most effective methods of mitigating ed crowding and improving surge capacity during an influenza or other respiratory disease outbreak. communication background: the link between extended shift lengths, sleepiness, and occupational injury or illness has been shown, in other health care populations, to be an important and preventable public health concern but heretofore has not been fully described in emergency medical services (ems objectives: to assess the effect of an ed-based computer screening and referral intervention for ipv victims and to determine what characteristics resulted in a positive change in their safety. we hypothesized that women who were experiencing severe ipv and/or were in contemplation or action stages would be more likely to endorse safety behaviors. methods: we conducted the intervention for female ipv victims at three urban eds using a computer kiosk to deliver targeted education about ipv and violence prevention as well as referrals to local resources. all adult english-speaking non-critically ill women triaged to the ed waiting room were eligible to participate. the validated universal violence prevention screening protocol was used for ipv screening. any who disclosed ipv further responded to validated questionnaires for alcohol and drug abuse, depression, and ipv severity. the women were assigned a baseline stage of change (precontemplation, contemplation, action, or maintenance) based on the urica scale for readiness to change behavior surrounding ipv. participants were contacted at 1 week and 3 months to assess a variety of pre-determined actions such as moving out, to prevent ipv during that period. statistical analysis (chi-square testing) was performed to compare participant characteristics to the stage of change and whether or not they took protective action. results: a total of 1,474 people were screened and 154 disclosed ipv and participated in the full survey. 53.3% of the ipv victims were in the precontemplative stage of change, and 40.3% were in the contemplation stage. 110 women returned at 1 week of follow-up (71.4%), and 63 (40.9%) women returned at 3 months of followup. 55.5% of those who returned at 1 week, and 73% of those who returned at 3 months took protective action against further ipv. there was no association between the various demographic characteristics and whether or not a woman took protective action. conclusion: ed-based kiosk screening and health information delivery is both a feasible and effective method of health information dissemination for women experiencing ipv. stage of change was not associated with actual ipv protective measures. objectives: we present a pilot, head-to-head comparison of x26 and x2 effectiveness in stopping a motivated person. the objective is to determine comparative injury prevention effectiveness of the newer cew. methods: four humans had metal cew probe pairs placed. each volunteer had two probe pairs placed (one pair each on the right and left of the abdomen/inguinal region). superior probes were at the costal margin, 5 inches lateral of midline. inferior probes were vertically inferior at predetermined distances of 6, 9, 12, and 16 inches apart. each volunteer was given the goal of slashing a target 10 feet away with a rubber knife during cew exposure. as a means of motivation, they believed the exposure would continue until they reached the goal (in reality, the exposure was terminated once no further progress was made). each volunteer received one exposure from a x26 and a x2 cew. the exposure order was randomized with a 2-minute rest between them. exposures were recorded on a hi-speed, hi-resolution video. videos were reviewed and scored by six physician, kinesiology, and law officer experts using standardized criteria for effectiveness including degree of upper and lower extremity, and total body incapacitation, and degree of goal achievement. reviews were descriptively compared independently for probe spread distances and between devices. results: there were 8 exposures (4 pairs) for evaluation and no discernible, descriptive reviewer differences in effectiveness between the x26 and the x2 cews when compared. background: the trend towards higher gasoline prices over the past decade in the u.s. has been associated with higher rates of bicycle use for utilitarian trips. this shift towards non-motorized transportation should be encouraged from a physical activity promotion and sustainability perspective. however, gas price induced changes in travel behavior may be associated with higher rates of bicycle-related injury. increased consideration of injury prevention will be a critical component of developing healthy communities that help safely support more active lifestyles. objectives: the purpose of this analysis was to a) describe bicycle-related injuries treated in u.s. emergency departments between 1997 and 2009 and b) investigate the association between gas prices and both the incidence and severity of adult bicycle injuries. we hypothesized that as gas prices increase, adults are more likely to shift away from driving for utilitarian travel toward more economical non-motorized modes of transportation, resulting in increased risk exposure for bicycle injuries. methods: bicycle injury data for adults (16-65 years) were obtained from the national electronic injury surveillance system (neiss) database for emergency department visits between 1997-2009. the relationship between national seasonally adjusted monthly rates of bicycle injuries, obtained by a seasonal decomposition of time series, and average national gasoline prices, reported by the energy information administration, was examined using a linear regression analysis. results: monthly rates of bicycle injuries requiring emergency care among adults increase significantly as gas prices rise (p < 0.0001, see figure) . an additional 1,149 adult injuries (95% ci 963-1,336) can be predicted to occur each month in the u.s. (>13,700 injuries annually) for each $1 rise in average gasoline price. injury severity also increases during periods of high gas prices, with a higher percentage of injuries requiring admission. conclusion: increases in adult bicycle use in response to higher gas prices are accompanied by higher rates of significant bicycle-related injuries. supporting the use of non-motorized transportation will be imperative to address public health concerns such as obesity and climate change; however, resources must also be dedicated to improve bicycle-related injury care and prevention. background: this is a secondary analysis of data collected for a randomized trial of oral steroids in emergency department (ed) musculoskeletal back pain patients. we hypothesized that higher pain scores in the ed would be associated with more days out of work. objectives: to determine the degree to which days out of work for ed back pain patients are correlated with ed pain scores. methods: design: prospective cohort. setting: suburban ed with 80,000 annual visits. participants: patients aged 18-55 years with moderately severe musculoskeletal back pain from a bending or twisting injury £ 2 days before presentation. exclusion criteria included nonmusculoskeletal etiology, direct trauma, motor deficits, and employer-initiated visits. observations: we captured initial and discharge ed visual analog pain scores (vas) on a 0-10 scale. patients were contacted approximately 5 days after discharge and queried about the days out of work. we plotted days out of work versus initial vas, discharge vas, and change in vas and calculated correlation coefficients. using the bonferroni correction because of multiple comparisons, alpha was set at 0.02. results: we analyzed 67 patients for whom complete data were available. the mean age was 40 ± 9 years and 30% were female. the average initial and discharge ed pain scales were 8.0 ± 1.5 and 5.7 ± 2.2, respectively. on follow-up, 88% of patients were back to work and 36% did not lose any days of work. for the plots of the days out of work versus the initial and discharge vas and the change in the vas, the correlation coefficients (r 2 ) were 0.03 (p = 0.17), 0.08 (p = 0.04), and 0.001 (p = 0.87), respectively. conclusion: for ed patients with musculoskeletal back pain, we found no statistically significant correlation between days out of work and ed pain scores. background: conducted electrical weapons (cews) are common law enforcement tools used to subdue and repel violent subjects and, therefore, prevent further injury or violence from occurring in certain situations. the taser x2 is a new generation of cew that has the capability of firing two cartridges in a ''semi-automatic'' mode, and has a different electrical waveform and different output characteristics than older generation technology. there have been no data presented on the human physiologic effects of this new generation cew. objectives: the objective of this study was to evaluate the human physiologic effects of this new cew. methods: this was a prospective, observational study of human subjects. an instructor shot subjects in the abdomen and upper thigh with one cartridge, and subjects received a 10-second exposure from the device. measured variables included: vital signs, continuous spirometry, pre-and post-exposure ecg, intra-exposure echocardiography, venous ph, lactate, potassium, ck, and troponin. results: ten subjects completed the study (median age 31.5, median bmi 29.4, 80% male). there were no important changes in vital signs or in potassium. the median increase in lactate during the exposure was 1.2, range 0.6 to 2.8. the median change in ph was )0.031, range )0.011 to 0.067. no subject had a clinically relevant ecg change, evidence of cardiac capture, or positive troponin up to 24 hours after exposure. the median change in creatine kinase (ck) at 24 hours was 313, range )40 to 3418. there was no evidence of impairment of breathing by spirometry. baseline median minute ventilation was 14.2, which increased to 21.6 during the exposure (p = 0.05), and remained elevated at 21.6 post-exposure (p = 0.01). conclusion: we detected a small increase in lactate and decrease in ph during the exposure, and an increase in ck 24 hours after the exposure. the physiologic effects of the x2 device appear similar to previous reports for ecd devices. use background: public bicycle sharing (bikeshare) programs are becoming increasingly common in the us and around the world. these programs make bicycles easily accessible for hourly rental to the public. there are currently 15 active bikeshare programs in cities in the us, and more than 30 programs are being developed in cities including new york and chicago. despite the importance of helmet use, bikeshare programs do not provide the opportunity to purchase or rent helmets. while the programs encourage helmet use, no helmets are provided at the rental kiosks. objectives: we sought to describe the prevalence of helmet use among adult users of bikeshare programs and users of personal bicycles in two cities with recently introduced bicycle sharing programs (boston, ma and washington, dc). methods: we performed a prospective observational study of bicyclists in boston, ma and washington, dc. trained observers collected data during various times of the day and days of the week. observers recorded the sex of the bicycle operator, type of bicycle, and helmet use. all bicycles that passed a single stationary location in any direction for a period of between 30 and 90 minutes were recorded. data are presented as frequencies of helmet use by sex, type of bicycle (bikeshare or personal), time of the week (weekday or weekend), and city. logistic regression was used to estimate the odds ratio for helmet use controlling for type of bicycle, sex, day of week, and city. results: there were 43 observation periods in two cities at 36 locations. 3,073 bicyclists were observed. there were 562 (18.2%) bicylists riding bikeshare bicycles. overall helmet use was 45.5%, although helmet use varied significantly with sex, day of use, and type of bicycle (see figure) . bikeshare users were helmeted at a lower rate compared to users of personal bicycles (19.2% vs 51.4%). logistic regression, controlling for type of bicycle, sex, day of week, and city demonstrate that bikeshare users had higher odds of riding unhelmeted (or 4.34, 95% ci 3.47-5.50). women had lower odds of riding unhelmeted (or 0.62, 0.52-0.73), while weekend riders were more likely to ride unhelmeted (or 1.32, 1.12-1.55). conclusion: use of bicycle helmets by users of public bikeshare programs is low. as these programs become more popular and prevalent, efforts to increase helmet use among users should increase. background: abusive head trauma (aht) represents one of the most severe forms of traumatic brain injury (tbi) among abused infants with 30% mortality. young adult males account for 75% of the perpetrators. most aht prevention programs are hospital-based and reach a predominantly female audience. there are no published reports of school-based aht prevention programs to date. objectives: 1. to determine whether a high schoolbased aht educational program will improve students' knowledge of aht and parenting skills. 2. to evaluate the feasibility and acceptability of a school-based aht prevention program. methods: this program was based on an inexpensive commercially available program developed by the national center on shaken baby syndrome. the program was modified to include a 60-minute interactive presentation that teaches teenagers about aht, parenting skills, and caring for inconsolable crying infants. the program was administered in three high schools in flint, michigan during spring 2011. student's knowledge was evaluated with a 17-item written test administered pre-intervention, post-intervention, and two months after program completion. program feasibility and acceptability were evaluated through interviews and surveys with flint area school social workers, parent educators, teachers, and administrators. results: in all, 342 high school students (40% male) participated. of these, 317 (92.7%) completed the pretest and post-test with 171 (50%) completing the twomonth follow-up test. the mean pre-intervention, postintervention, and two-month follow-up scores were 53%, 87%, and 90% respectively. from pre-test to posttest, mean score improved 34%, p < 0.001. this improvement was even more profound in young males, whose mean post-test score improved by 38%, p < 0.001. of the 69 participating social workers, parent educators, teachers, and administrators, 97% ranked the program as feasible and acceptable. conclusion: students participating in our program showed an improvement in knowledge of aht and parenting skills which was retained after two months. teachers, social workers, parent educators, and school administrators supported the program. this local pilot program has the potential to be implemented on a larger scale in michigan with the ultimate goal of reducing aht amongst infants. will background: fear of litigation has been shown to affect physician practice patterns, and subsequently influence patient care. the likelihood of medical malpractice litigation has previously been linked with patient and provider characteristics. one common concern is that a patient may exaggerate symptoms in order to obtain monetary payouts; however, this has never been studied. objectives: we hypothesize that patients are willing to exaggerate injuries for cash settlements and that there are predictive patient characteristics including age, sex, income, education level, and previous litigation. methods: this prospective cross-sectional study spanned june 1 to december 1, 2011 in a philadelphian urban tertiary care center. any patient medically stable enough to fill out a survey during study investigator availability was included. two closed-ended paper surveys were administered over the research period. standard descriptive statistics were utilized to report incidence of: patients who desired to file a lawsuit, patients previously having filed lawsuits, and patients willing to exaggerate the truth in a lawsuit for a cash settlement. chi-square analysis was performed to determine the relationship between patient characteristics and willingness to exaggerate injuries for a cash settlement. results: of 126 surveys, 11 were excluded due to incomplete data, leaving 115 for analysis. the mean age was 39 with a standard deviation of 16, and 40% were male. the incidence of patients who had the desire to sue at the time of treatment was 9%. the incidence of patients who had filed a lawsuit in the past was 35%. of those patients, 26% had filed multiple lawsuits. fifteen percent [95% ci 9-23%] of all patients were willing to exaggerate injuries for cash settlement. sex and income were found to be statistically significant predictors of willingness to exaggerate symptoms: 22% of females vs. 4% of males were willing to exaggerate (p = 0.01), and 20% of people with income less than $100,000/yr vs. 0% of those with income over $100,000/ yr were willing to exaggerate (p = 0.03). conclusion: patients at a philadelphian urban tertiary center admit to willingness to exaggerate symptoms for a cash settlement. willingness to exaggerate symptoms is associated with female sex and lower income. background: current data suggest that as many as 50% of patients presenting to the ed with syncope leave the hospital without a defined etiology. prior studies have suggested a prevalence of psychiatric disease as high as 26% in patients with syncope of unknown etiology. objectives: to determine whether psychiatric disease and substance abuse are associated with an increased incidence of syncope of unknown etiology. methods: prospective, observational, cohort study of consecutive ed patients ‡18 presenting with syncope was conducted between 6/03 and7/06. patients were queried in the ed and charts reviewed about a history of psychiatric disease, use of psychiatric medication, substance abuse, and duration. data were analyzed using sas with chi-square and fisher's exact tests. results: we enrolled 519 patients who presented to the ed after syncope, 159 of whom did not have an identifiable etiology for their syncopal event. 36.5% of those without an identifiable etiology were male. 166 (32%) patients had a history of or current psychiatric disease (42% male), and 55 patients (11%) had a history of or current substance abuse (60% male). among males with psychiatric disease, 39% had an unknown etiology of their syncopal event, compared to 22% of males without psychiatric disease (p = 0.009). similarly, among all males with a history of substance abuse, 45% had an unknown etiology, as compared to 24% of males without a history of substance abuse (p = 0.01). a similar trend was not identified in elderly females with psychiatric disease (p = 0.96) or substance abuse (p = 0.19). however, syncope of unknown etiology was more common among both men and women under age 65 with a history of substance abuse (47%) compared to those without a history of substance abuse (27%; p = 0.01). conclusion: our results suggest that psychiatric disease and substance abuse are associated with increased incidence of syncope of unknown etiology. patients evaluated in the ed or even hospitalized with syncope of unknown etiology may benefit from psychiatric screening and possibly detoxification referral. this is particularly true in men. (originally submitted as a ''late-breaker.'') scope background: after discharge from an emergency department (ed), pain management often challenges parents, who significantly under-treat their children's pain. rapid patient turnover and anxiety make education about home pain treatment difficult in the ed. video education standardizes information and circumvents insufficient time and literacy. objectives: to evaluate the effectiveness of a 6-minute instructional video for parents that targets common misconceptions about home pain management. methods: we conducted a randomized, double-blinded clinical trial of parents of children ages 1-18 years who presented with a painful condition, were evaluated, and discharged home in june and july 2011. parents were randomized to a pain management video or an injury prevention control video. primary outcome was the proportion of parents who gave pain medication at home. these data were recorded in a home pain diary and analyzed using a chi-square test. parents' knowledge about pain treatment was tested before, immediately following, and 2 days after intervention. mcnemar's test statistic determined odds that knowledge correlated with the intervention group. results: 100 parents were enrolled: 59 watched the pain education video, and 41 the control video. 72.9% completed follow up, providing information about home pain education use. significantly more parents provided at least one dose of pain medication to their children after watching the educational video: 96% vs. 80% (difference 16%, 95% ci 7.8%, 31.3%). the odds the parent had correct knowledge about pain treatment significantly improved immediately following the educational video for knowledge about pain scores (p = 0.04), the effect of pain on function (p < 0.01), and pain medication misconceptions (p < 0.01). these significant differences in knowledge remained 3 days after the video intervention. the educational video about home pain treatment viewed by parents significantly increased the proportion of children receiving pain medication at home and significantly improved knowledge about at-home pain management. videos are an efficient tool to provide medical advice to parents that improves outcomes for children. methods: this was a prospective, observational study of consecutive admitted cpu patients in a large-volume academic urban ed. cardiology attendings round on all patients and stress test utilization is driven by their recommendation. eligibility criteria include: age>18, aha low/intermediate risk, nondynamic ecgs, and normal initial troponin i. patients >75 and with a history of cad or co-existing active medical problem were excluded. based on prior studies and our estimated cpu census and demographic distribution, we estimated a sample size of 2,242 patients in order to detect a difference in stress utilization of 7% (2-tailed, a = 0.05, b = 0.8). we calculated a timi risk prediction score and a diamond & forrester (d&f) cad likelihood score on each patient. t-tests were used for univariate comparisons of demographics, cardiac comorbidities, and risk scores. logistic regression was used to estimate odds ratios (ors) for receiving testing based on race, controlling for insurance and either timi or d&f score. results: over 18 months, 2,451 patients were enrolled. mean age was 53 ± 12, and 54% (95% ci 52-56) were female. sixty percent (95% ci 58-62) were caucasian, 12% (95% ci 10-13) african american, and 24% (95% ci 23-26) hispanic. mean timi and d&f scores were 0.5 (95% ci 0.5-0.6) and 38% (95% ci 37-39). the overall stress testing rate was 52% (95% ci 50-54). after controlling for insurance status and timi or d&f scores, african american patients had significantly decreased odds of stress testing (or timi 0.67 (95% ci 0.52-0.88), or d&f 0.68 (95% ci 0.51-0.89)). hispanics had significantly decreased odds of stress testing in the model controlling for d&f (or d&f 0.78 (95% ci 0.63-0.98)). conclusion: this study confirms that disparities in the workup of african american patients in the cpu are similar to those found in the general ed and the outpatient setting. further investigation into the specific provider or patient level factors contributing to this bias is necessary. the outcomes for hf and copd were sae 11.6%, 7.8%; death 2.3%, 1.0%. we found univariate associations with sae for these walk test components: too ill to walk (both hf, copd p < 0.0001); highest heart rate ‡110 (hf p = 0.02, copd p = 0.10); lowest sao 2 < 88% (hf p = 0.42, copd p = 0.63); borg score ‡5 (hf p = 0.47, copd p = 0.52); walk test duration £ 1 minute (hf p = 0.07. copd p = 0.22). after adjustment for multiple clinical covariates with logistic regression analyses, we found ''walk test heart rate ‡110'' had an odds ratio of 1.9 for hf patients and ''too ill to start the walk test'' had an odds ratio of 3.5 for copd patients. conclusion: we found the 3-minute walk test to be easy to administer in the ed and that maximum heart rate and inability to start the test were highly associated with adverse events in patients with exacerbations of hf and copd, respectively. we suggest that the 3-minute walk test be routinely incorporated into the assessment of hf and copd patients in order to estimate risk of poor outcomes. the objectives: the objective of this study was to investigate differences in consent rates between patients of different demographic groups who were invited to participate in minimal-risk clinical trials conducted in an academic emergency department. methods: this descriptive study analyzed prospectively collected data of all adult patients who were identified as qualified participants in ongoing minimal risk clinical trials. these trials were selected for this review because they presented minimal factors known to be associated background: increasing rates of patient exposure to computerized tomography (ct) raise questions about appropriateness of utilization, as well as patient awareness of radiation exposure. despite rapid increases in ct utilization and published risks, there is no national standard to employ informed consent prior to radiation exposure from diagnostic ct. use of written informed consent for ct (icct) in our ed has increased patient understanding of the risks, benefits, and alternatives to ct imaging. our team has developed an adjunct video educational module (vem) to further educate ed patients about the ct procedure. objectives: to assess patient knowledge and preferences regarding diagnostic radiation before and after viewing vem. methods: the vem was based on icct currently utilized at our tertiary care ed (census 37,000 patients/ year). icct is written at an 8th grade reading level. this fall, vem/icct materials were presented to a convenience sample of patients in the ed waiting room 9 am-7 pm, monday-sunday. patients who were <18 years of age, critically ill, or with language barrier were excluded. to quantify the educational value of the vem, a six-question pretest was administered to assess baseline understanding of ct imaging. the patients then watched the vem via ipad (macintosh) and reviewed the consent form. an eight-question post-test was then completed by each subject. no phi were collected. pre-and post-test results were analyzed using mcnemar's test for individual questions and a paired t-test for the summed score (sas version 9.2). results: 100 patients consented and completed the survey. the average pre-test score for subjects was poor, 66% correct. review of vem/icct materials increased patient understanding of medical radiation as evidenced by improved post-test score to 79%. mean improvement between tests was 13% (p < 0.0001). 78% of subjects responded that they found the materials helpful, and that they would like to receive icct. conclusion: the addition of a video educational module improved patient knowledge regarding ct imaging and medical radiation as quantified by pre-and posttesting. patients in our study sample reported that they prefer to receive icct. by educating patients about the risks associated with ct imaging, we increase informed, shared decision making -an essential component of patient-centered care. does objectives: we sought to determine the relationship between patients' pain scores and their rate of consent to ed research. we hypothesized that patients with higher pain scores would be less likely to consent to ed research. methods: retrospective observational cohort study of potential research subjects in an urban academic hospital ed with an average annual census of approximately 70,000 visits. subjects were adults older than 18 years with chief complaint of chest pain within the last 12 hours, making them eligible for one of two cardiac biomarker research studies. the studies required only blood draws and did not offer compensation. two reviewers extracted data from research screening logs. patients were grouped according to pain score at triage, pain score at the time of approach, and improvement in pain score (triage score -approach score). the main outcome was consent to research. simple proportions for consent rates by pain score tertiles were calculated. two multivariate logistic regression analyses were performed with consent as outcome and age, race, sex, and triage or approach pain score as predictors. results: overall, 396 potential subjects were approached for consent. patients were 58% caucasian, 49% female, and with an average age of 57 years. six patients did not have pain scores recorded at all and 48 did not have scores documented within 2 hours of approach and were excluded from relevant analyses. overall, 80.1% of patients consented. consent rates by tertiles at triage, at time of approach, and by pain score improvement are shown in tables 1 and 2. after adjusting for age, race, and sex, neither triage (p = 0.75) nor approach (p = 0.65) pain scores predicted consent. conclusion: research enrollment is feasible even in ed patients reporting high levels of pain. patients with modest improvements in pain levels may be more likely to consent. future research should investigate which factors influence patients' decisions to participate in ed research. conclusion: in this multicenter study of children hospitalized with bronchiolitis neither specific viruses nor their viral load predicted the need for cpap or intubation, but young age, low birth weight, presence of apnea, severe retractions, and oxygen saturation <85% did. we also identified that children requiring cpap or intubation were more likely to have mothers who smoked during pregnancy and a rapid respiratory worsening. mechanistic research in these high-risk children may yield important insights for the management of severe bronchiolitis. brigham & women's hospital, boston, ma background: siblings and children who share a home with a physically abused child are thought to be at high risk for abuse. however, rates of injury in these children are unknown. disagreements between medical and child protective services professionals are common and screening is highly variable. objectives: our objective was to measure the rates of occult abusive injuries detected in contacts of abused children using a common screening protocol. methods: this was a multi-center, observational cohort study of 20 child abuse teams who shared a common screening protocol. data were collected between jan 15, 2010 and april 30, 2011 for all children <10 years undergoing evaluation for physical abuse and their contacts. for contacts of abused children, the protocol recommended physical examination for all children <5 years, skeletal survey and physical exam for children <24 months, and physical exam, skeletal survey, and neuroimaging for children <6 months old. results: among 2,825 children evaluated for abuse, 618 met criteria as ''physically abused'' and these had 477 contacts. for each screening modality, screening was completed as recommended by the protocol in approximately 75% of cases. of 134 contacts who met criteria for skeletal survey, new injuries were identified in 16 (12.0%). none of these fractures had associated findings on physical examination. physical examination identified new injuries in 6.2% of eligible contacts. neuroimaging failed to identify new injuries among 25 eligible contacts less than 6 months old. twins were at significantly increased risk of fracture relative to other nontwin contacts (or 20.1). conclusion: these results support routine skeletal survey for contacts of physically abused children <24 months old, regardless of physical examination findings. even for children where no injuries are identified, these results demonstrate that abuse is common among children who share a home with an abused child, and support including contacts in interventions (foster care, safety planning, social support) designed to protect physically abused children. methods: this was a retrospective study evaluating all children presenting to eight paediatric, universityaffiliated eds during one year in 2010-2011. in each setting, information regarding triage and disposition were prospectively registered by clerks in the ed database. anonymized data were retrieved from the ed computerized database of each participating centre. in the absence of a gold standard for triage, hospitalisation, admission to intensive care unit (icu), length of stay in the ed, and proportion of patients who left without being seen by a physician (lwbs) were used as surrogate markers of severity. the primary outcome measure was the association between triage level (from 1 to 5) and hospitalisation. the association between triage level and dichotomous outcomes was evaluated by a chi-square test, while a student's t-test was used to evaluate the association between triage level and length of stay. it was estimated that the evaluation of all children visiting these eds for a one year period would provide a minimum of 1,000 patients in each triage level and at least 10 events for outcomes having a proportion of 1% or more. results: a total of 404,841 children visited the eight eds during the study period. pooled data demonstrated hospitalisation proportions of 59%, 30%, 10%, 2%, and 0.5% for patients triaged at level 1, 2,3, 4, and 5 respectively (p < 0.001). there was also a strong association between triage levels and admission to icu (p < 0.001), the proportion of children who lwbs (p < 0.001), and length of stay (p < 0.001). background: parents frequently leave the emergency department (ed) with incomplete understanding of the diagnosis and plan, but the relationship between comprehension and post-care outcomes has not been well described. objectives: to explore the relationship between comprehension and post-discharge medication safety. methods: we completed a planned secondary analysis of a prospective observational study of the ed discharge process for children aged 2-24 months. after discharge, parents completed a structured interview to assess comprehension of the child's condition, the medical team's advice, and the risk of medication error. limited understanding was defined as a score of 3-5 from 1 (excellent) to 5 (poor). risk of medication error was defined as a plan to use over-the-counter cough/cold medication and/or an incorrect dose of acetaminophen (measured by direct observation at discharge or reported dose at follow-up call). parents identified as at risk received further instructions from their provider. the primary outcome was persistent risk of medication error assessed at phone interview 5-10 days post-discharge. a major barrier to administering analgesics to children is the perceived discomfort of intravenous access. the delivery of intranasal analgesia may be a novel solution to this problem. objectives: we investigated whether the addition of the mucosal atomizer device (mad) as an alternative for fentanyl delivery would improve overall fentanyl administration rates in pediatric patients transported by a large urban ems system. we performed a historical control trial comparing the rate of pediatric fentanyl administration 6 months before and 6 months after the introduction of the mad. study subjects were pediatric trauma patients (age <16 years) transported by a large urban ems agency. the control group was composed of patients treated in the 6 months before introduction of the mad. the experimental group included patients treated in the 6 months after the addition of the mad. two physicians reviewed each chart and determined whether the patient met predetermined criteria for the administration of pain medication. a third reviewer resolved any discrepancies. fentanyl administration rates were measured and compared between the two groups. we used two-sample t-tests and chi-square tests to analyze our data. results: 228 patients were included in the study: 137 patients in the pre-mad group and 91 in the post-mad group. there were no significant differences in the demographic and clinical characteristics of the two groups. 42 (30.4%) patients in the control arm received fentanyl. 34 (37.8%) of patients in the experimental arm received fentanyl with 36% of the patients receiving fentanyl via the intranasal route. the addition of the mad was not associated with a statistically significant increase in analgesic administration. age and mechanism of injury were statistically more predictive of analgesia administration. conclusion: while the addition of the mucosal atomizer device as an alternative delivery method for fentanyl shows a trend towards increased analgesic administration in a prehospital pediatric population, age and mechanism of injury are more predictive in who receives analgesia. further research is necessary to investigate the effect of the mad on pediatric analgesic delivery. methods: this was a prospective study evaluating php-se before (pre) and after (post) a ppp introduction and 13 months later (13-mo). php groups received either ppp review and education or ppp review alone. the ppp included a pain assessment tool. the se tool, developed and piloted by pediatric ems experts, uses a ranked ordinal scale ranging from 'certain i cannot do it' (0) to 'completely certain i can do it' (100) for 10 items: pain assessment (3 items), medication administration (4) and dosing (1) , and reassessment (2). all 10 items and an averaged composite were evaluated for three age groups (adult, child, toddler). paired sample t-tests compared post-and 13-mo scores to pre-ppp scores. results: of 264 phps who completed initial surveys, 146 phps completed 13-mo surveys. 106 (73%) received education and ppp review and 40 (27%) review only. ppp education did not affect php-se (adult p = 0.87, child p = 0.69, toddler p = 0.84). the largest se increase was in pain assessment. this increase persisted for child and toddler groups at 13 months. the immediate increase in composite se scores for all age groups persisted for the toddler group at 13 months. conclusion: increases in composite and pain assessment php-se occur for all age groups immediately after ppp introduction. the increase in pain assessment se persisted at 13 months for pediatric age groups. composite se increase persisted for the toddler age group alone. background: pediatric medications administered in the prehospital setting are given infrequently and dosage may be prone to error. calculation of dose based on known weight or with use of length-based tapes occurs even less frequently and may present a challenge in terms of proper dosing. objectives: to characterize dosing errors based on weight-based calculations in pediatric patients in two similar emergency medical service (ems) systems. methods: we studied the five most commonly administered medications given to pediatric patients weighing 36 kg or less. drugs studied were morphine, midazolam, epinephrine 1:10,000, epinephrine 1:1000, and diphenhydramine. cases from the electronic record were studied for a total of 19 months, from january 2010 to july 2011. each drug was administered via intravenous, intramuscular, or intranasal routes. drugs that were permitted to be titrated were excluded. an error was defined as greater than 25% above or below the recommended mg/kg dosage. results: out of 248,596 total patients, 13,321 were pediatric patients. 7885 had documented weights of <36 kg and 241 patients were given these medications. we excluded 72 patients for weight above the 97%ile or below the 3%ile, or if the weight documentation was missing. of the 169 patients and 187 doses, errors were noted in 53 (28%; 95% ci 22%, 35%). midazolam was the most common drug in errors (29 of 53 doses or 55%; 95% ci 40%, 68%), followed by diphenhydramine (11/53 or 21%; 95% ci 11%, 34%), epinephrine (7/53 or 13%; 95% ci 5%, 25%), and morphine sulfate (6/53 or 11%; 95% ci, 4%, 23%). underdosing was noted in 34 of 53 (64%; 95% ci 50%, 77%) of errors, while excessive dosing was noted in 19 of 53 (36%; 95% ci 23%, 50%). conclusion: weight-based dosing errors in pediatric patients are common. while the clinical consequences of drug dosing errors in these patients are unknown, a considerable amount of inaccuracy occurs. strategies beyond provision of reference materials are needed to prevent pediatric medication errors and reduce the potential for adverse outcomes. drivers background: homelessness affects up to 3.5 million people a year. the homeless present more frequently to eds, their ed visits are four times more likely to occur within 3 days of a prior ed evaluation, and they are admitted up to five times more frequently than others. we evaluated the effect of a street outreach rapid response team (sorrt) on the health care utilization of a homeless population. a nonmedical outreach staff responds to the ed and intensely case manages the patient: arranges primary care follow-up, social services, temporary housing opportunities, and drug/ alcohol rehabilitation services. objectives: we hypothesized that this program would decrease the ed visits and hospital admissions of this cohort of patients. methods: before and after study at an urban teaching hospital from june, 2010-december, 2011 in indianapolis, indiana. upon identification of homeless status, sorrt was immediately notified. eligibility for sorrt enrollment is determined by housing and urban development homeless criteria and the outreach staff attempted to enter all such identified patients into the program. the patients' health care utilization was evaluated in the 6 months prior to program entry as compared to the 6 months after enrollment by prospectively collecting data and a retrospective medical record query for any unreported visits. since the data were highly skewed, we used the nonparametric signed rank test to test for paired differences between periods. results: 22 patients met criteria but two refused participation. the 20-patient cohort had 388 total ed visits (175 pre and 213 post) with a mean of 8.8 (sd 10.1) and median of 6.5 (range 1-44) ed visits in 6 months pre-sorrt as compared to a mean of 10.7 (sd 19.5) and median of 5.0 (0-90) in 6 months post-sorrt (p = 0.815). there were 28 total inpatient admissions pre-intervention and 27 post-intervention, with a mean of 1.4 (sd 2.0) and median of 0.5 (0.7) per patient in the pre-intervention period as compared to 1.4 (sd 1.9) and 1.0 (0-6) in the post-intervention period (p = 0.654). in the pre-sorrt period 50.0% had at least one inpatient admission as compared to 55.0% post-sorrt (p = 1.00). there were no differences in icu days or overall length of stay between the two periods. conclusion: an aggressive case management program beginning immediately with homeless status recognition in the ed has not demonstrated success in decreasing utilization in our population. methods: this was a secondary analysis of a prospective randomized trial that included consenting patients discharged with outpatient antibiotics from an urban county ed with an annual census of 100,000. patients unable to receive text messages or voice-mails were excluded. health literacy was assessed using a validated health literacy assessment, the newest vital sign (nvs). patients were randomized to a discharge instruction modality: 1) standard care, typed and verbal medication and case-specific instructions; 2) standard care plus text-messaged instructions sent to the patient's cell phone; or 3) standard care plus voice-mailed instructions sent to the patient's cell. patients were called at 30 days to determine preference for instruction delivery modality. preference for discharge instruction modality was analyzed using z-tests for proportions. results: 758 patients were included (55% female, median age 30, range 5 months to 71 years); 98 were excluded. 23% had an nvs score of 0-1, 31% 2-3, and 46% 4-6. among the 51.1% of participants reached at 30 days, 26% preferred a modality other than written. there was a difference in the proportion of patients who preferred discharge instructions in written plus another modality (see table) . with the exception of written plus another modality, patient preference was similar across all nvs score groups. conclusion: in this sample of urban ed patients, more than one in four patients prefer non-traditional (text message, voice-mail) modalities of discharge instruction delivery to standard care (written) modality alone. additional research is needed to evaluate the effect of instructional modality on accessibility and patient compliance. figure) . conclusion: cumulative saps ii scoring fails to predict mortality in ohca. the risk scores assigned to age, gcs, and hco 3 independently predict mortality and combined are good mortality predictors. these findings suggest that an alternative severity of illness score should be used in post-cardiac arrest patients. future studies should determine optimal risk scores of saps ii variables in a larger cohort of ohca. objectives: to determine the extent to which cpp recovers to pre-pause levels with 20 seconds of cpr after a 10-second interruption in chest compressions for ecg rhythm analysis. methods: this was a secondary analysis of prospectively collected data from an iacuc-approved protocol. fortytwo yorkshire swine (weighing 25-30 kg) were instrumented under anesthesia. vf was electrically induced. after 12 minutes of untreated vf, cpr was initiated and a standard dose of epinephrine (sde) (0.01 mg/kg) was given. after 2.5 minutes of cpr to circulate the vasopressor, compressions were interrupted for 10 seconds to analyze the ecg rhythm. this was immediately followed by 20 seconds of cpr to restore cpp before the first rs was delivered. if the rs failed, cpr resumed and additional vasopressors (sde, and vasopressin 0.57 mg/kg) were given and the sequence repeated. the cpp was defined as aortic diastolic pressure minus right atrial diastolic pressure. the cpp values were extracted at three time points: immediately after the 2.5 minutes of cpr, following the 10-second pause, and immediately before defibrillation for the first two rs attempts in each animal. eighty-three sets of measurements were logged from 42 animals. descriptive statistics were used to analyze the data. in most cities, the proportion of patients who achieve prehospital return of spontaneous circulation (rosc) is less than 10%. the association between time of day and ohca outcomes in the prehospital setting is unknown. objectives: we sought to determine whether rates of prehospital rosc varied by time of day. we hypothesized that night ohcas would exhibit lower rates of rosc. methods: we performed a retrospective review of cardiac arrest data from a large, urban ems system. included were all ohcas occurring in individuals >18 years of age from 1/1/2008 to 12/31/2010. excluded were traumatic arrests and cases where resuscitation measures were not performed. day was defined as 7:00 am-6:59 pm, while night was 7:00 pm-6:59 am. we examined the association between time of day and paramedic-perceived prehospital rosc in unadjusted and adjusted analyses. variables included age, sex, race, presenting rhythm, aed application by a bystander or first responder, defibrillation, and bystander cpr performance. analyses were performed using chisquare tests and logistic regression. objectives: determine whether a smei helps to improve physician compliance with ihi bundle and reduce patient mortality in ed patients with s&s. methods: we conducted a pre-smei retrospective review of four months of ed patients with s&s to determine baseline pre-smei physician compliance and patient mortality. we designed and completed a smei attended by 25 of 28 ed attending physicians and 28 of 30 ed resuscitation residents. finally, we conducted a twenty-month post-smei prospective study of ongoing physician compliance and patient mortality in ed patients with s&s. results: in the four month pre-smei retrospective review, we identified 23 patients with s&s, with a 61% physician overall compliance and mortality rate of 30%. the average ed physician smei multiple-choice pre-test score was 74%, and showed a significant improvement in the post-test score of 94% (p = 0.0003). additionally, 87% of ed physicians were able to describe three new clinical pearls learned and 85% agreed that the smei would improve compliance. in the twenty months of the post-smei prospective study, we identified 144 patients with s&s, with a 75% physician overall compliance, and mortality rate of 21%. relative physician compliance improved 23% (p = 0.0001) and relative patient mortality was reduced by 32% (p < 0.0001) when comparing pre-and post-smei data. conclusion: our data suggest that a smei improves overall physician compliance with the six hour goals of the ihi bundle and reduces patient mortality in ed patients with s&s. conclusion: using a population-level, longitudinal, and multi-state analysis, the rate of return visits within 3 days is higher than previously reported, with nearly 1 in 12 returning back to the ed. we also provide the first estimation of health care costs for ed revisits. background: the ability of patients to accurately determine their level of urgency is important in planning strategies that divert away from eds. in fact, an understanding of patient self-triage abilities is needed to inform health policies targeting how and where patients access acute care services within the health care system. objectives: to determine the accuracy of a patient's self-assessment of urgency compared against triage nurses. methods: setting: ed patients are assigned a score by trained nurses according to the canadian emergency department triage and acuity scale (ctas). we present a cross-sectional survey of a random patient sample from 12 urban/regional eds conducted during the winters of 2007 and 2009. this previously validated questionnaire, based on the british healthcare commission survey, was distributed according to a modified dillman protocol. exclusion criteria consisted of: age 0-15 years, left prior to being seen/treated, died during ed visit, no contact information, presented with a privacy-sensitive case. alberta health services provided linked non-survey administrative data. results: 21,639 surveys distributed with a response rate of 46%. patients rated health problems as life-threatening (6%), possibly life-threatening (22%), urgent (30%), somewhat urgent (37%), or not urgent (5%). triage nurses assigned the same patients ctas scores of i (<1%), ii (20%), iii (45%), iv (29%) or v (5%). patients self-rated their condition as 3 or 4 points less urgent than the assigned ctas score (<1% of the time), 2 points less urgent (5%), 1 point less urgent (25%), exactly as urgent (38%), 1 point more urgent (24%), 2 points more urgent (7%), or 3 or 4 points more urgent (1%, respectively). among ctas i or ii patients, 54% described their problem as life-threatening/possibly life-threatening, 26% as urgent (risk of permanent damage), 18% as urgent (needed to be seen that day), and 2% as not urgent (wanted to be but did not need to be seen that day). conclusion: the majority of ed patients are generally able to accurately assess the acuity of their problem. encouraging patients with low-urgency conditions to self-triage to lower-acuity sources of care may relieve stress on eds. however, physicians and patients must be aware that a small minority of patients are unable to self-triage safely. when the tourniquet was released, blood spurted from the injured artery as hydrostatic pressure decayed. pressure and flow were recorded in three animals (see table) . the concept was proof-tested in a single fresh frozen human cadaver with perfusion through the femoral artery and hemorrhage from the popliteal artery. the results were qualitatively and quantitatively similar to the swine carcass model. conclusion: a perfused swine carcass can simulate exsanguinating hemorrhage for training purposes and serves as a prototype for a fresh-frozen human cadaver model. additional research and development are required before the model can be widely applied. background: in the pediatric emergency department (ped), clinicians must work together to provide safe and effective care. crisis resource management (crm) principles have been used to improve team performance in high-risk clinical settings, while simulation allows practice and feedback of these behaviors. objectives: to develop a multidisciplinary educational program in a ped using simulation-enhanced teamwork training to standardize communication and behaviors and identify latent safety threats. methods: over 6 months a workgroup of physicians and nurses with experience in team training and simulation developed an educational program for clinical staff of a tertiary ped. goals included: create a didactic curriculum to teach the principles of crm, incorporate principles of crm into simulation-enhanced team training in-situ and center-based exercises, and utilize assessment instruments to evaluate for teamwork, completion of critical actions, and presence of latent safety threats during in-situ sim resuscitations. results: during phase i, 130 clinicians, divided into teams, participated in 90-minute pre-training assessments of pals-based in-situ simulations. in phase ii, staff participated in a 6-hour curriculum reviewing key crm concepts, including team training exercises utilizing simulation and expert debriefing. in phase iii, staff participated in post-training 90 minute teamwork and clinical skills assessments in the ped. in all phases, critical action checklists (cac) were tabulated by simulation educators. in-situ simulations were recorded for later review using the assessment tools. after each simulation, educators facilitated discussion of perceptions of teamwork and identification of systems issues and latent hazards. overall, 54 in-situ simulations were conducted capturing 97% of the physicians and 84% of the nurses. cac data were collected by an observer and compared to video recordings. over 20 significant systems issues, latent hazards, and knowledge deficits were identified. all components of the program were rated highly by 90% of the staff. conclusion: a workgroup of pem, simulation, and team training experts developed a multidisciplinary team training program that used in-situ and centerbased simulation and a refined crm curriculum. unique features of this program include its multidisciplinary focus, the development of a variety of assessment tools, and use of in-situ simulation for evaluation of systems issues and latent hazards. this program was tested in a ped and findings will be used to refine care and develop a sustainment program while addressing issues identified. objectives: our hypothesis is that participants trained on high-fidelity mannequins will perform better than participants trained on low-fidelity mannequins on both the acls written exam and in performance of critical actions during megacode testing. the study was performed in the context of an acls initial provider course for new pgy1 residents at the penn medicine clinical simulation center and involved three training arms: 1) low fidelity (low-fi): torso-rhythm generator; 2) mid-fidelity (mid-fi): laerdal simmanò turned off; and 3) high-fidelity (high-fi): laerdal simmanò turned on. training in each arm of the study followed standard aha protocol. educational outcomes were evaluated by written scores on the acls written examination and expert rater reviews of acls megacode videos performed by trainees during the course. a sample of 54 subjects were randomized to one of the three training arms: low-fi (n = 18), mid-fi (n = 18), or high-fi (n = 18). results: statistical significance across the groups was determined using analysis-of-variance (anova). the three groups had similar written pre-test scores [low-fi 0.4 (0.1), mid-fi 0.5 (0.1), and high-fi 0.4 (0. 2)] and written post-test scores [low-fi 0.9 (0.1), mid-fi 0.9 (0.1), and high-fi 0.8 (0.1)]. similarly, test improvement was not significantly different. after completion of the course, high-fi subjects were more likely to report they felt comfortable in their simulator environment (p = 0.005). low-fi subjects were less likely to perceive a benefit in acls training from high-fi technology (p < 0.001). acls instructors were not rated significantly different by the subjects using the debriefing assessment for simulation in healthcareª (dash) student version except for element 6, where the high-fi group subjects reported lower scores (6.1 vs 6.6 and 6.7 in the other groups, p = 0.046). objectives: we sought to determine if stress associated with the performance of a complex procedural task can be affected by level of medical training. heart rate variability (hrv) is used as a measure of autonomic balance, and therefore an indicator of the level of stress. methods: twenty-one medical students and emergency medicine residents were enrolled. participants performed airway procedures on an airway management trainer. hrv data were collected using a continuous heart rate variability monitoring system. participant hrv was monitored at baseline, during the unassisted first attempt at endotracheal intubation, during supervised practice, and then during a simulated respiratory failure clinical scenario. standard deviation of beat to beat variability (sdnn), very low frequency (vlf), total power (tp), and low frequency (lf) was analyzed to determine the effect of practice and level of training on the level of stress. a cohen's d test was used to determine differences between study groups. results: sdnn data showed that second-year residents were less stressed during all stages than were fourthyear medical students (avg d = 1.12). vlf data showed third-year residents exhibited less sympathetic activity than did first-year residents (avg d = )0.68). the opportunity to practice resulted in less stress for all participants. tp data showed that residents had a greater degree of control over their autonomic nervous system (ans) than did medical students (avg d = 0.85). lf data showed that subjects were more engaged in the task at hand as the level of training increased indicating autonomic balance (avg d = 0.80). conclusion: our hrv data show that stress associated with the performance of a complex procedural task is reduced by increased training. hrv may provide a quantitative measure of physiologic stress during the learning process and thus serve as a marker of when a subject is adequately trained to perform a particular task. objectives: we seek to examine whether intubation during cpr can be done as efficiently as intubation without ongoing cpr. the hypothesis is that the predictable movement of an automated chest compression device will make intubation easier than the random movement from manual cpr. methods: the project was an experimental controlled trial and took place in the emergency department at a tertiary referral center in peoria, illinois. emergency medicine residents, attendings, paramedics, and other acls trained staff were eligible for participation. in randomized order, each participant attempted intubation on a mannequin with no cpr ongoing, during cpr with a human compressor, and during cpr with an automatic chest compression device (physio control lucas 2). participants could use whichever style laryngoscope they felt most comfortable with and they were timed during the three attempts. success was determined after each attempt. results: there were 43 participants in the trial. the success rate in the control group and the automated cpr group were both 88% (38/43) and the success rate in the manual cpr group was 74% (32/43). the differences in success rates were not statistically significant (p = 0.99 and p = 0.83). the automated cpr group had the fastest average time (13.6 sec; p = 0.019). the mean times for intubation with manual cpr and no cpr were not statistically different (17.1 sec, 18.1 sec; p = 0.606). conclusion: the success rate of tracheal intubation with ongoing chest compression was the same as the success rate of intubation without cpr. although intubation with automatic chest compression was faster than during other scenarios, all methods were close to the 10 second timeframe recommended by acls. based on these findings, it may not always be necessary to hold cpr to place a definitive airway; however, further studies will be needed. background: after acute myocardial infarction, vascular remodeling in the peri-infarct area is essential to provide adequate perfusion, prevent additional myocyte loss, and aid in the repair process. we have previously shown that endogenous fibroblast growth factor 2 (fgf2) is essential to the recovery of contractile function and limitation of infarct size after cardiac ischemia-reperfusion (ir) injury. the role of fgf2 in vascular remodeling in this setting is currently unknown. objectives: determine the role of endogenous fgf2 in vascular remodeling in a clinically relevant, closed-chest model of acute myocardial infarction. methods: mice with a targeted ablation of the fgf2 gene (fgf2 knockout) and wild type controls were subjected to a closed-chest model of regional cardiac ir injury. in this model, mice were subjected to 90 minutes of occlusion of the left anterior descending artery followed by reperfusion for either 1 or 7 days. immunofluorescence was performed on multiple histological sections from these hearts to visualize capillaries (endothelium, anti-cd31 antibody), larger vessels (venules and arterioles, antismooth muscle actin antibody), and nuclei (dapi). digital images were captured, and multiple images from each heart were measured for vessel density and vessel size. results: sham-treated fgf2 knockout and wild type mice show no differences in capillary or vessel density suggesting no defect in vessel formation in the absence of endogenous fgf2. when subjected to closed-chest regional cardiac ir injury, fgf2 knockout hearts had normal capillary and vessel number and size in the peri-infarct area after 1 day of reperfusion compared to wild type controls. however, after 7 days, fgf2 knockout hearts showed significantly decreased capillary and vessel number and increased vessel size compared to wild type controls (p < 0.05). conclusion: these data show the necessity of endogenous fgf2 in vascular remodeling in the peri-infarct zone in a clinically relevant animal model of acute myocardial infarction. these findings may suggest a potential role for modulation of fgf2 signaling as a therapeutic intervention to optimize vascular remodeling in the repair process after myocardial infarction. the diagnosis of aortic dissections by ed physicians is rare scott m. alter, barnet eskin, john r. allegra morristown medical center, morristown, nj background: aortic dissection is a rare event. the most common symptom of dissection is chest pain, but chest pain is a frequent emergency department (ed) chief complaint and other diseases that cause chest pain, such as acute coronary syndrome and pulmonary embolism, occur much more frequently. furthermore, 20% of dissections are without chest pain and 6% are painless. for all these reasons, diagnosing dissection can be difficult for the ed physician. we wished to quantify the magnitude of this problem in a large ed database. objectives: our goal was to determine the number of patients diagnosed by ed physicians with aortic dissections compared to total ed patients and to the total number of patients with a chest pain diagnosis. methods: design: retrospective cohort. setting: 33 suburban, urban, and rural new york and new jersey eds with annual visits between 8,000 and 75,000. participants: consecutive patients seen by ed physicians from january 1, 1996 through december 31, 2010. observations: we identified aortic dissections using icd-9 codes and chest pain diagnoses by examining all icd-9 codes used over the period of the study and selecting those with a non-traumatic chest pain diagnosis. we then calculated the number of total ed patients and chest pain patients for every aortic dissection diagnosed by emergency physicians. we determined 95% confidence intervals (cis). results: from a database of 9.5 million ed visits, we identified 782 (0.0082%) aortic dissections, or one for every 12,200 (95% ci 11,400 to 13,100) visits. the mean age of aortic dissection patients was 58 ± 19 years and 57% were female. of the total visits there were 763,000 (8%) with a chest pain diagnosis. thus there is one aortic dissection diagnosis for every 980 (95% ci 910 to 1,050) chest pain diagnoses. conclusion: the diagnosis of aortic dissections by ed physicians is rare. an ed physician seeing 3,000 to 4,000 patients a year would diagnose an aortic dissection approximately once every 3 to 4 years. an aortic dissection would be diagnosed once for approximately every 1,000 ed chest pain patients. patients were excluded if they suffered a cardiac arrest, were transferred from another hospital, or if the ccl was activated for an inpatient or from ems in the field. fp ccl activation was defined as 1) a patient for whom activation was cancelled in the ed and ruled out for mi or 2) a patient who went to catheterization but no culprit vessel was identified and mi was excluded. ecgs for fp patients were classified using standard criteria. demographic data, cardiac biomarkers, and all relevant time intervals were collected according to an on-going quality assurance protocol. results: a total of 506 ccl activations were reviewed, with 68% male, average age 57, and 59% black. there were 210 (42%) true stemis and 86 (17%) fp activations. there were no significant differences between the fp patients who did and did not have catheterization. for those fp patients who had a catheterization (13%), ''door to page'' and ''door to lab'' times were significantly longer than the stemi patients (see table) , but there was substantial overlap. there was no difference in sex or age, but fp patients were more likely to be black (p = 0.02). a total of 82 fp patients had ecgs available for review; findings included anterior elevation with convex (21%) or concave (13%) elevation, st elevation from prior anterior (10%) or inferior (11%) mi, pericarditis (16%), presumed new lbbb (15%), early repolarization (5%), and other (9%). conclusion: false ccl activation occurred in a minority of patients, most of whom had ecg findings warranting emergent catheterization. the rate of false ccl activation appears acceptable. background: atrial fibrillation (af) is the most common cardiac arrhythmia treated in the ed, leading to high rates of hospitalization and resource utilization. dedicated atrial fibrillation clinics offer the possibility of reducing the admission burden for af patients presenting to the ed. while the referral base for these af clinics is growing, it is unclear to what extent these clinics contribute to reducing the number of ed visits and hospitalizations related to af. objectives: to compare the number of ed visits and hospitalizations among discharged ed patients with a primary diagnosis of af who followed up with an af clinic and those who did not. methods: a retrospective cohort study and medical records review including three major tertiary centres in calgary, canada. a sample of 600 patients was taken representing 200 patients referred to the af clinic from the calgary zone eds and compared to 400 matched control ed patients who were referred to other providers for follow-up. the controls were matched for age and sex. inclusion criteria included patients over 18 years of age, discharged during the index visit, and seen by the af clinic between january 1, 2009 and october 25, 2010. exclusion criteria included non-residents and patients hospitalized during the index visit. the number of cardiovascular-related ed visits and hospitalizations was measured. all data are categorical, and were compared using chi-square tests. results: patients in the control and af clinic cohorts were similar for all baseline characteristics except for a higher proportion of first episode patients in the intervention arm. in the six months following the index ed visit, 55 study group patients (27.5%) visited an ed on 95 occasions, and 12 (6%) were hospitalized on 16 occasions. of the control group, 122 patients (30.5%) visited an ed on 193 occasions, and 44 (11%) were hospitalized on 55 occasions. using a chi-square test we found no significant difference in ed visits (p = 0.5063) or hospitalizations (p = 0.0664) between the control and af clinic cohorts. conclusion: based on our results, referral from the ed to an af clinic is not associated with a significant reduction in subsequent cardiovascular related ed visits and hospitalizations. due to the possibility of residual confounding, randomized trials should be performed to evaluate the efficacy of af clinics. reported an income of less than $10,000. there were no significant associations between sex, race, marital status, education level, income, insurance status, and subsequent 30-and-90 day readmission rates. hla score was not found to be significantly related to readmission rates. the mean hla score was 18.9 (sd = 7.87), equivalent to less than 6th grade literacy, meaning these patients may not be able to read prescription labels. for each unit increase in hfkt score, the odds of being readmitted within 30 days decreased by 0.219 (p < 0.001) and for 31-90 days decreased by 0.440 (p < 0.001). for each unit increase in scbs score, the odds of being readmitted within 90 days decreased by 0.949 (p = 0.038). conclusion: health care literacy in our patient population is not associated with readmission, likely related to the low literacy rate of our study population. better hf knowledge and self-care behaviors are associated with lower readmission rates. greater emphasis should be placed on patient education and self-care behaviors regarding hf as a mechanism to decrease readmission rates. comparison of door to balloon times in patients presenting directly or transferred to a regional heart center with stemi jennifer ehlers, adam v. wurstle, luis gruberg, adam j. singer stony brook university, stony brook, ny background: based on the evidence, a door-to-balloon-time (dtbt) of less than 90 minutes is recommended by the aha/acc for patients with stemi. in many regions, patients with stemi are transferred to a regional heart center for percutaneous coronary intervention (pci). objectives: we compared dtbt for patients presenting directly to a regional heart center with those for patients transferred from other regional hospitals. we hypothesized that dtbt would be significantly longer for transferred patients. methods: study design-retrospective medical record review. setting-academic ed at a regional heart center with an annual census of 80,000 that includes a catchment area of 12 hospitals up to 50 miles away. patients-patients with acute stemi identified on ed 12-lead ecg. measures-demographic and clinical data including time from triage to ecg, from ecg to activation of regional catheterization lab, and from initial triage to pci (dtbt , and door to intravascular balloon deployment (d2b). methods: the study was performed in an inner-city academic ed between 1/1/07 and 12/31/10. every patient for whom ed activation of our stemi system occurred was included. all times data from a pre-existing quality assurance database were collected prospectively. patient language was determined retrospectively by chart review. results: there were 132 patients between 1/1/07 and 12/31/10. 21 patients (16%) were deemed too sick or unable to provide history and were excluded, leaving 111 patients for analysis. 85 (77%) spoke english and 26 (23%) did not. in the non-english group, chinese was the most common language, in 22 (20%) background: syncope is a common, potentially highrisk ed presentation. hospitalization for syncope, although common, is rarely of benefit. no populationbased study has examined disparities in regional admission practices for syncope care in the ed. moreover, there are no population-based studies reporting prognostic factors for 7-and 30-day readmission of syncope. objectives: 1) to identify factors associated with admission as well as prognostic factors for 7-and 30-day readmission to these hospitals; 2) to evaluate variability in syncope admission practices across different sizes and types of hospitals. methods: design -multi-center retrospective cohort study using ed administrative data from 101 albertan eds. participants/subjects -patients >17 years of age with syncope (icd10: r55) as a primary or secondary diagnosis from 2007 to june 2011. readmission was defined as return visits to the ed or admission <7 days or 7-30 days after the index visit (including against medical advice and left without being seen during the index visit). outcomes -factors associated with hospital admission at index presentation, and readmission following ed discharge, adjusted using multivariable logistic regression. results: overall, 44521 syncope visits occurred over 4 years. increased age, increased length of stay (los), performance of cxr, transport by ground ambulance, and treatment at a low-volume hospital (non-teaching or non-large urban) were independently associated with index hospitalization. these same factors, as well as hospital admission itself, were associated with 7-day readmission. additionally, increased age, increased los, performance of a head ct, treatment at a low-volume hospital, hospital admission, and female sex were independently associated with 7-30 day readmission. arrival by ground ambulance was associated with a decreased likelihood of both 7-and 7-30 day readmission. conclusion: our data identify variations in practice as well as factors associated with hospitalization and readmission for syncope. the disparity in admission and readmission rates between centers may highlight a gap in quality of care or reflect inappropriate use of resources. further research to compare patient out-comes and quality of patient care among urban and non-urban centers is needed. background: change in dyspnea severity (ds) is a frequently used outcome measure in trials of acute heart failure (ahf). however, there is limited information concerning its validity. objectives: to assess the predictive validity of change in dyspnea severity. methods: this was a secondary analysis of a prospective observational study of a convenience sample of ahf patients presenting with dyspnea to the ed of an academic tertiary referral center with a mixed urban/ suburban catchment area. patients were enrolled weekdays, june through december 2006. patients assessed their ds using a 10-cm visual analog scale at three times: the start of ed treatment (baseline) as well as at 1 and 4 hours after starting ed treatment. the difference between baseline and 1 hour was the 1-hour ds change. the difference between baseline and 4 hours was the 4-hour ds change. two clinical outcome measures were obtained: 1) the number of days hospitalized or dead within 30 days of the index visit (30-day outcome), and 2) the number of days hospitalized or dead within 90 days of the index visit (90-day outcome). results: data on 86 patients were analyzed. the median 30-day outcome variable was 6 days with an interquartile range (iqr) of 3 to 16. the median 90-day outcome variable was 10 days (iqr 4 to 27.5). the median 1-hour ds change was 2.6 cm (iqr 0.3 to 6.7). the median 4-hour ds change was 4.9 cm (iqr 2.2 to 8.2). the 30-day and 90-day mortality rates were 9% and 13% respectively. the spearman rank correlations and 95% confidence intervals are presented in the table below. conclusion: while the point estimates for the correlations were below 0.5, the 95% ci for two of the correlations extended above 0.5. these pilot data support change in ds as a valid outcome measure for ahf when measured over 4 hours. a larger prospective study is needed to obtain a more accurate point estimate of the correlations. background: the majority of volume-quality research has focused on surgical outcomes in the inpatient setting; very few studies have examined the effect of emergency department (ed) case volume on patient outcomes. objectives: to determine whether ed case volume of acute heart failure (ahf) is associated with short-term patient outcomes. methods: we analyzed the 2008 nationwide emergency department sample (neds) and nationwide inpatient sample (nis), the largest, all-payer, ed and inpatient databases in the us. ed visits for ahf were identified with a principal diagnosis of icd-9-cm code 428.xx. eds were categorized into quartiles by ed case volume of ahf. the outcome measures were early inpatient mortality (within the first 2 days of admission), overall inpatient mortality, and hospital length of stay (los). results: there were an estimated 946,000 visits for ahf from approximately 4,700 eds in 2008; 80% were hospitalized. of these, the overall inpatient mortality rate was 3.2%, and the median hospital los was 4 days. early inpatient mortality was lower in the highest-volume eds, compared with the lowest-volume eds (0.8% vs. 2.1%; p < 0.001). similar patterns were observed for overall inpatient mortality (3.0% vs. 4.1%; p < 0.001). in a multivariable analysis adjusting for 37 patient and hospital characteristics, early inpatient mortality remained lower in patients admitted through the highest-volume eds (adjusted odds ratios [or], 0.70; 95% confidence interval [ci], 0.52-0.96), as compared with the lowest-volume eds. there was a trend towards lower overall inpatient mortality in the highest-volume eds; however, this was not statistically significant (adjusted or, 0.92; 95%ci, 0.75-1.14). by contrast, using the nis data including various sources of admissions, a higher case volume of inpatient ahf patients predicted lower overall inpatient mortality (adjusted or, 0.51; 95%ci, 0.40-0.65). the hospital los in patients admitted through the highest-volume eds was slightly longer (adjusted difference, 0.7 day; 95%ci, 0.2-1.2), compared with the lowest-volume eds. conclusion: ed patients who are hospitalized for ahf have an approximately 30% reduced early inpatient mortality if they were admitted from an ed that handles a large volume of ahf cases. the ''practice-makesperfect'' concept may hold in emergency management of ahf. emergency department disposition and charges for heart failure: regional variability alan b. storrow, cathy a. jenkins, sean p. collins, karen p. miller, candace mcnaughton, naftilan allen, benjamin s. heavrin vanderbilt university, nashville, tn background: high inpatient admission rates for ed patients with acute heart failure are felt partially responsible for the large economic burden of this most costly cardiovascular problem. objectives: we examined regional variability in ed disposition decisions and regional variability in total dollars spent on ed services for admitted patients with primary heart failure. methods: the 2007 nationwide emergency department sample (neds) was used to perform a retrospective, cohort analysis of patients with heart failure (icd-9 code of 428.x) listed as the primary ed diagnosis. demographics and disposition percentages (with se) were calculated for the overall sample and by region: northeast, south, midwest, and west. to account for the sample design and to obtain national and regional estimates, a weighted analysis was conducted. results: there were 941,754 weighted ed visits with heart failure listed as the primary diagnosis. overall, over eighty percent were admitted (see table) . fifty-two percent of these patients were female; mean age was 72.7 years (se 0.20). hospitalization rates were higher in the northeast (89.1%) and south (81.2%) than in the midwest (76.0%) and west (74.8%). total monies spent on ed services were highest in the south ($69,078,042) followed by the northeast ($18,233,807), west ($6,360,315) and midwest ($5,899,481) . conclusion: this large retrospective ed cohort suggests a very high national admission rate with significant regional variation in both disposition decisions as well as total monies spent on ed services for patients with a primary diagnosis of heart failure. examining these estimates and variations further may provide strategies to reduce the economic burden of heart failure. background: workplace violence in health care settings is a frequent occurrence. gunfire in hospitals is of particular concern. however, information regarding such workplace violence is limited. accordingly, we characterized u.s. hospital-based shootings from 2000-2010. objectives: to determine extent of hospital-based shootings in the u.s. and involvement of emergency departments. methods: using lexisnexis, google, netscape, pub-med, and sciencedirect, we searched reports for acute care hospital shooting events from january 2000 through december 2010, and those with at least one injured victim were analyzed. results: we identified 140 hospital-related shootings (86 inside the hospital, 54 on hospital grounds), in 39 states, with 216 victims, of whom 98 were perpetrators. in comparison to external shootings, shootings within the hospital have not increased over time (see figure) . perpetrators were from all age groups, including the elderly. most of the events involved a determined shooter: grudge (26%), suicide (19%), ''euthanizing'' an ill relative (15%), and prisoner escape (12%). ambient societal violence (8%) and mentally unstable patients (4%) were comparatively infrequent. the most common injured was the perpetrator (45%). hospital employees comprised only 21% of victims; physician (3%) and nurse (5%) victims were relatively infrequent. the emergency department was the most common site (29%), followed by patient rooms (20%) and the parking lot (20%). in 13% of shootings within hospitals, the weapon was a security officer's gun grabbed by the perpetrator. ''grudge'' motive was the only factor determinative of hospital staff victims (or = 4.34, 95% ci 1.85-10.17). conclusion: although hospital-based shootings are relatively rare, emergency departments are the most likely site. the unpredictable nature of this type of event represents a significant challenge to hospital security and deterrence practices, as most perpetrators proved determined, and many hospital shootings occur outside the building. impact of emergency physician board certification on patient perceptions of ed care quality albert g. sledge iv 1 , carl a. germann 1 , tania d. strout 1 , john southall 2 1 maine medical center, portland, me; 2 mercy hospital, portland, me background: the hospital value-based purchasing program mandated by the affordable care act is the latest example of how patients' perceptions of care will affect the future practice environment of all physicians. the type of training of medical providers in the emergency department (ed) is one possible factor affecting patient perceptions of care. a unique situation in a maine community ed led to the rapid transition from non-emergency medicine (em) residency trained physicians to all em residency trained and american board of emergency medicine (abem) certified providers. objectives: the purpose of this study was to evaluate the effect of the implementation of an all em-trained, abem-certified physician staff on patient perceptions of the quality of care they received in the ed. methods: we retrospectively evaluated press ganey data from surveys returned by patients receiving treatment in a single, rural ed. survey items addressed patient's perceptions of physician courtesy, time spent listening, concern for patient comfort, and informativeness. additional items evaluated overall perceptions of care and the likelihood that the respondent would recommend the ed to another. data were compared for the three years prior to and following implementation of the all trained, certified staff. we used the independent samples t-test to compare mean responses during the two time periods. bonferroni's correction was applied to adjust for multiple comparisons. results: during the study period, 3,039 patients provided surveys for analysis: 1,666 during the pre-certification phase and 1,373 during the post-certification phase. across all six survey items, mean responses increased following transition to the board-certified staff. these improvements were noted to be statistically significant in each case: courtesy p < 0.001, time listening p < 0.001, concern for comfort p < 0.001, informativeness p < 0.001, overall perception of care p < 0.001, and likelihood to recommend p < 0.001. conclusion: data from this community ed suggest that transition from a non-residency trained, abem certified staff to a fully trained and certified model has important implications for patient's perceptions of the care they receive. we observed significant improvement in rating scores provided by patients across all physicianoriented and general ed measures. background: transfer of care from the ed to the inpatient floor is a critical transition when miscommunication places patients at risk. the optimal form and content of handoff between providers has not been defined. in july 2011, ed-to-floor signout for all admissions to the medicine and cardiology floors was changed at our urban, academic, tertiary care hospital. previously, signout was via an unstructured telephone conversation between ed resident and admitting housestaff. the new signout utilizes a web-based ed patient tracking system and includes: 1) a templated description of ed course is completed by the ed resident; 2) when a bed is assigned, an automated page is sent to the admitting housestaff; 3) ed clinical information, including imaging, labs, medications, and nursing interventions (figure) is reviewed by admitting housestaff; 4) if housestaff has specific questions about ed care, a telephone conversation between the ed resident and housestaff occurs; 5) if there are no specific questions, it is indicated electronically and the patient is transferred to the floor. objectives: to describe the effects on patient safety (floor-to-icu transfer in 24 hours) and ed throughput (ed length of stay (los) and time from bed assignment to ed departure) resulting from a change to an electronic, discussion-optional handoff system. conclusion: transition to a system in which signout of admitted patients is accomplished by accepting housestaff review of ed clinical information supplemented by verbal discussion when needed resulted in no significant change in rate of floor-to-icu transfer or ed los and reduced time from bed assignment to ed departure. background: emergency physicians may be biased against patients presenting with nonspecific complaints or those requiring more extensive work-ups. this may result in patients being seen less quickly than those with more straightforward presentations, despite equal triage scores or potential for more dangerous conditions. objectives: the goal of our study was to ascertain which patients, if any, were seen more quickly in the ed based on chief complaint. methods: a retrospective report was generated from the emr for all moderate acuity (esi 3) adult patients who visited the ed from january 2005 through december 2010 at a large urban teaching hospital. the most common complaints were: abdominal pain, alcohol intoxication, back pain, chest pain, cough, dyspnea, dizziness, fall, fever, flank pain, headache, infection, pain (nonspecific), psychiatric evaluation, ''sent by md,'' vaginal bleeding, vomiting, and weakness. non-parametric independent sample tests assessed median time to be seen (ttbs) by a physician for each complaint. differences in the ttbs between genders and based on age were also calculated. chi-square testing compared percentages of patients in the ed per hour to assess for differences in the distribution of arrival times. results: we obtained data from 116,194 patients. patients with a chief complaint of weakness and dizziness waited the longest with a median time of 35 minutes and patients with flank pain waited the shortest with 24 minutes (p < 0.0001) ( figure 1 ). overall, males waited 30 minutes and females waited 32 minutes (p < 0.0001). stratifying by gender and age, younger females between the ages of 18-50 waited significantly longer times when presenting with a chief complaint of abdominal pain (p < 0.0001), chest pain (p < 0.05), or flank pain (p < 0.0001) as compared to males in the same age group ( figure 2 ). there was no difference in the distribution of arrival times for these complaints. conclusion: while the absolute time differences are not large, there is a significant bias toward seeing young male patients more quickly than women or older males despite the lower likelihood of dangerous conditions. triage systems should perhaps take age and gender better into account. patients might benefit from efforts to educate em physicians on the delays and potential quality issues associated with this bias in an attempt to move toward more egalitarian patient selection. background: detailed analysis of emergency department (ed) event data identified the time from completion of emergency physician evaluation (doc done) to the time patients leave the ed as a significant contributor to ed length of stay (los) and boarding at our institution. process flow mapping identified the time from doc done to the time inpatient beds were ordered (bo) as an interval amendable to specific process improvements. objectives: the purpose of this study was to evaluate the effect of ed holding orders for stable adult 3.6 (3.0 -4.1) 7.8 (6.9 -8.7) 15.2 (12.8 -17.6) 4.9 (2.8 -7.0) 17.3 (12.9 -21.7) 6.5 (4.5 -8.5) inpatient medicine (aim) patients on: a) the time to bo and b) ed los. methods: a prospective, observational design was used to evaluate the study questions. data regarding the time to bo and los outcomes were collected before and after implementation of the ed holding orders program. the intervention targeted stable aim patients being admitted to hospitalist, internal medicine, and family medicine services. ed holding orders were placed following the admission discussion with the accepting service and special attention was paid to proper bed type, completion of the emergent work-up and the expected immediate course of the patient's hospital stay. holding orders were of limited duration and expired 4 hours after arrival to the inpatient unit. results: during the 6-month study period, 7321 patients were eligible for the ed holding orders intervention; 6664 (91.0%) were cared for using the standard adult medicine order set and 657 (9.0%) received the intervention. the median time from doc done to bo was significantly shorter for patients in the ed holding orders group, 41 min (iqr 19, 88) vs. 95 min (iqr 53, 154) for the standard adult medicine group, p < 0.001. similarly, the median ed los was significantly shorter for those in the ed holding orders group, 413 min (iqr 331, 540) vs. 456 min (iqr 346, 581) for the standard adult medicine group, p < 0.001. no lapses in patient care were reported in the intervention group. conclusion: in this cohort of ed patients being admitted to an aim service, placing ed holding orders rather than waiting for a traditional inpatient team evaluation and set of admission orders significantly reduced the time from the completion of the ed workup to placement of a bo. as a result, ed los was also significantly shortened. while overall utilization of the intervention was low, it improved with each month. emergency department interruptions in the age of electronic health records matthew albrecht, john shabosky, jonathan de la cruz southern illinois university school of medicine, springfield, il background: interruptions of clinical care in the emergency department (ed) have been correlated with increased medical errors and decreased patient satisfaction. studies have also shown that most interruptions happen during physician documentation. with the advent of the electronic health record and computerized documentation, ed physicians now spend much of their clinical time in front of computers and are more susceptible to interruptions. voice recognition dictation adjuncts to computerized charting boast increased provider efficiency; however, little is known about how data input of computerized documentation affects physician interruptions. objectives: we present here observational interruptions data comparing two separate ed sites, one that uses computerized charting by conventional techniques and one assisted by voice recognition dictation technology. methods: a prospective observational quality initiative was conducted at two teaching hospital eds located less than 1 mile from each other. one site primarily uses conventional computerized charting while the other uses voice recognition dictation computerized charting. four trained observers followed ed physicians for 180 minutes during shifts. the tasks each ed physician performed were noted and logged in 30 second intervals. tasks listed were selected from a predetermined standardized list presented at observer training. tasks were also noted as either completed or placed in queue after a change in task occurred. a total of 4140 minutes were logged. interruptions were noted when a change in task occurred with the previous task being placed in queue. data were then compared between sites. results: ed physicians averaged 5.33 interruptions/ hour with conventional computerized charting compared to 3.47 interruptions/hour with assisted voice recognition dictation (p = 0.0165). conclusion: computerized charting assisted with voice recognition dictation significantly decreased total per hour interruptions when compared to conventional techniques. charting with voice recognition dictation has the potential to decrease interruptions in the ed allowing for more efficient workflow and improved patient care. background: using robot assistants in health care is an emerging strategy to improve efficiency and quality of care while optimizing the use of human work hours. robot prototypes capable of performing vital signs and assisting with ed triage are under development. however, ed users' attitudes toward robot assistants are not well studied. understanding of these attitudes is essential to design user-friendly robots and to prepare eds for the implementation of robot assistants. objectives: to evaluate the attitudes of ed patients and their accompanying family and friends toward the potential use of robot assistants in the ed. methods: we surveyed a convenience sample of adult ed patients and their accompanying adult family members and friends at a single, university-affiliated ed, 9/ 26/11-10/27/11. the survey consisted of eight items from the negative attitudes towards robots scale (normura et al.) modified to address robot use in the ed. response options included a 5-point likert scale. a summary score was calculated by summing the responses for all 8 items, with a potential range of 8 (completely negative attitude) to 40 (completely positive attitude). research assistants gave the written surveys to subjects during their ed visit. internal consistency was assessed using cronbach's alpha. bivariate analyses were performed to evaluate the association between the summary score and the following variables: participant type (patient or visitor), sex, race, time of day, and day of week. results: of 121 potential subjects approached, 113 (93%) completed the survey. participants were 37% patients, 63% family members or friends, 62% women, 79% white, and had a median age of 45.5 years (iqr 18-84). cronbach's alpha was 0.94. the mean summary score was 22.2 (sd = 0.87), indicating subjects were between ''occasionally'' and ''sometimes'' comfortable with the idea of ed robot assistants (see table) . men were more positive toward robot use than women (summary score: 24.6 vs 20.8; p = 0.033). no differences in the summary score were detected based on participant type, race, time of day, or day of week. conclusion: ed users reported significant apprehension about the potential use of robot assistants in the ed. future research is needed to explore how robot designs and strategies to implement ed robots can help alleviate this apprehension. background: emergency department cardioversion (edc) of recent-onset atrial fibrillation or flutter (af) patients is an increasingly common management approach to this arrhythmia. patients who qualify for edc generally have few co-morbidities and are often discharged directly from the ed. this results in a shift towards a sicker population of patients admitted to the hospital with this diagnosis. objectives: to determine whether hospital charges and length of stay (los) profiles are affected by emergency department discharge of af patients. methods: patients receiving treatment at an urban teaching community hospital with a primary diagnosis of atrial fibrillation or flutter were identified through the hospital's billing data base. information collected on each patient included date of service, patient status, length of stay, and total charges. patient status was categorized as inpatient (admitted to the hospital), observation (transferred from the ed to an inpatient bed but placed in an observation status), or ed (discharged directly from the ed). the hospital billing system automatically defaults to a length of stay of 0 for observation patients. ed patients were assigned a length of stay of 0. total hospital charges and mean los were determined for two different models: a standard model (sm) in which patients discharged from the ed were excluded from hospital statistics, and an inclusive model (im) in which discharged ed patients were included in the hospital statistics. statistical analysis was through anova. results: a total of 317 patients were evaluated for af over an 18-month period. of these, 197 (62%) were admitted, 22 (7%) were placed in observation status, and 98 (31%) were discharged from the ed. hospital charges and los in days are summarized in the table. all differences were statistically significant at (p < 0.001). conclusion: emergency department management can lead to a population of af patients discharged directly from the ed. exclusion of these patients from hospital statistics skews performance profiles effectively punishing institutions for progressive care. background: recent health care reform has placed an emphasis on the electronic health record (ehr). with the advent of the ehr it is common to see ed providers spending more time in front of computers documenting and away from patients. finding strategies to decrease provider interaction with computers and increase time with patients may lead to improved patient outcomes and satisfaction. computerized charting adjuncts, such as voice recognition software, have been marketed as ways to improve provider efficiency and patient contact. objectives: we present here observational data comparing two separate ed sites, one where computerized charting is done by conventional techniques and one that is assisted with voice recognition dictation, and their effects on physican charting and patient contact. methods: a prospective observational quality initiative was conducted at two teaching hospitals located less than 1 mile from each other. one site primarily uses conventional computerized charting while the other uses voice recognition dictation. four trained quality assistants observed ed physicians for 180 minutes during shifts. the tasks each physician performed were noted and logged in 30 second intervals. tasks listed were identified from a predetermined standardized list presented at observer training. a total of 4140 minutes were logged. time allocated to charting and that allocated to direct patient care were then compared between sites. results: ed physicians spent 28.6% of their time charting using conventional techniques vs 25.7% using voice recognition dictation (p = 0.4349). time allocated to direct patient care was found to be 22.8% with conventional charting vs 25.1% using dictation (p = 4887). in total, ed physicians using conventional charting techniques spent 668/2340 minutes charting. ed physicians using voice recognition dictation spent 333/1800 minutes dictating and an additional 129.5/1800 minutes reviewing or correcting their dictations. the use of voice recognition assisted dictation rather than conventional techniques did not significantly change the amount of time physicians spent charting or with direct patient care. although voice recognition dictation decreased initial input time of documenting data, a considerable amount of time was required to review and correct these dictations. objectives: for our primary objective, we studied whether emergency department triage temperatures detected fever adequately when compared to a rectal temperature. as secondary objectives, we examined the temperature differences when a rectal temperature was taken within an hour of non-invasive temperature, temperature site (oral, axillary, temporal), and also examined the patients that were initially afebrile but were found to be febrile by rectal temperature. methods: we performed an electronic chart review at our inner city, academic emergency department with an annual census of 110,000 patients. we identified all patients over the age of 18 who received a non-invasive triage temperature and a subsequent rectal temperature while in the ed from january 2002 through february 2011. specific data elements included many aspects of the patient's medical record (e.g. subject demographics, temperature, and source). we analyzed our data with standard descriptive statistics, t-tests for continuous variables, and pearson chi-square tests for proportions. results: a total of 27,130 patients met our inclusion criteria. the mean difference in temperatures between the initial temperature and the rectal temperature was 1.3°f, with 25.9% having higher rectal temperatures ‡2°f, and 5.0% having higher rectal temperatures ‡4°f. the mean temperature difference among the 10,313 patients who an initial noninvasive temperature and a rectal temperature within one hour was 1.4°f. the mean difference among patients that received oral, axillary, and temporal temperatures was 1.2°f, 1.8°f, and 1.2°f respectively. approximately one in five patients (18.1%) were initially afebrile and found to be febrile by rectal temperature, with an average temperature difference of 2.5°f. these patients had a higher rate of admission, and were more likely to be admitted to the intensive care unit. conclusion: there are significant differences between rectal temperatures and non-invasive triage temperatures in this emergency department cohort. in almost one in five patients, fever was missed by triage temperature. background: pediatric emergency department (ped) overcrowding has become a national crisis, and has resulted in delays in treatment, and patients leaving without being seen. increased wait times have also been associated with decreased patient satisfaction. optimizing ped throughput is one means by which to handle the increased demands for services. various strategies have been proposed to increase efficiency and reduce length of stay (los). objectives: to measure the effect of direct bedding, bedside registration, and patient pooling on ped wait times, length of stay, and patient satisfaction. methods: data were extracted from a computerized ed tracking system in an urban tertiary care ped. comparisons were made between metrics for 2010 (23,681 patients) and the 3 months following process change (6,195 patients). during 2010, patients were triaged by one or two nurses, registered, and then sent either to a 14-bed ped or a physically separate 5-bed fast-track unit, where they were seen by a physician. following process change, patients were brought directly to a bed in the 14-bed ped, triaged and registered, then seen by a physician. the fast-track unit was only utilized to accommodate patient surges. results: anticipating improved efficiencies, attending physician coverage was decreased by 9%. after instituting process changes, improvements were noted immediately. although daily patient volume increased by 3%, median time to be seen by a physician decreased by 20%. additionally, median los for discharged patients decreased by 15%, and median time until the decisionto-admit decreased by 10%. press-ganey satisfaction scores during this time increased by greater than 5 mean score points, which was reported to be a statistically significant increase. conclusion: direct bedding, bedside registration, and patient pooling were simple to implement process changes. these changes resulted in more efficient ped throughput, as evidenced by decreased times to be seen by a physician, los for discharged patients, and time until decision-to-admit. additionally, patient satisfaction scores improved, despite decreased attending physician coverage and a 30% decrease in room utilization. ) . during period 1, the ou was managed by the internal medicine department and staffed by primary care physicians and physician assistants. during periods 2 and 3, the ou was managed and staffed by em physicians. data collected included ou patient volume, length of stay (los) for discharged and admitted patients, admission rates, and 30-day readmission rates for discharged patients. cost data collected included direct, indirect, and total cost per patient encounter. data were compared using chi-square and anova analysis followed by multiple pairwise comparisons using the bonferroni method of p-value adjustment. results: see table. the ou patient volume and percent of ed volume was greater in period 3 compared to periods 1 and 2. length of stay, admission rates, 30-day readmission rates, and costs were greater in period 1 compared to periods 2 and 3. conclusion: em physicians provide more cost-effective care for patients in this large ou compared to non-em physicians, resulting in shorter los for admitted and discharged patients, greater rates of patients discharged, and less 30-day readmission rates for discharged patients. this is not affected by an increase in ou volume and shows a trend towards improvement. background: emergency department (ed) crowding continues to be a problem, and new intake models may represent part of the solution. however, little data exist on the sustainability and long-term effects of physician triage and screening on standard ed performance metrics, as most studies are short-term. objectives: we examined the hypothesis that a physician screening program (start) sustainably improves standard ed performance metrics including patient length of stay (los) and patients who left without completing assessment (lwca). we also investigated the number of patients treated and dispositioned by start without using a monitored bed and the median patient door-to-room time. methods: design and setting: this study is a retrospective before-and-after analysis of start in a level i tertiary care urban academic medical center with approximately 90,000 annual patient visits. all adult patients from december 2006 until november 2010 are included, though only a subset was seen in start. start began at our institution in december 2007. observations: our outcome measures were length of stay for ed patients, lwca rates, patients treated and dispositioned by start without using a monitored bed, and door-to-room time. statistics: simple descriptive statistics were used. p-values for los were calculated with wilcoxon test and p-value for lwca was calculated with chi-square. results: table 2 shows median length of stay for ed patients was reduced by 56 minutes/patient (p-value <0.0001) when comparing the most recent year to the year before start. patients who lwca were reduced from 4.8% to 2.9% (p-value <0.0001) during the same time period. we also found that in the first half-year of start, 18% of patients screened in the ed were treated and dispositioned without using a monitored bed and by the end of year 3, this number had grown to 29%. median door-to-room time decreased from 18.4 minutes to 9.9 minutes over the same period of time. conclusion: a start system can provide sustained improvements in ed performance metrics, including a significant reduction in ed los, lwca rate, and doorto-room time. additionally, start can decrease the need for monitored ed beds and thus increase ed capacity. . labs were obtained in 98%, ct in 37%, us in 30%, and consultation in 23%. 18% of the cohort was admitted to the hospital. the most commonly utilized source of translation was a layman (35%). a professional translator was used in 9% and translation service (language line, marty) in 30%. the examiner was fluent in the patient's language in 11%. both the patient and examiner were able to maintain basic communication in 11%. there were 47 patients in the professional/ fluent translation group and 44 patients in the lay translation group. there was no difference in ed los between groups 288 vs 304 min; p = 0.6. there was no difference in the frequency of lab tests, computerized tomography, ultrasound, consultations, or hospital admission. frequencies did not differ by sex or age. conclusion: translation method was not associated with a difference in overall ed los, ancillary test use, or specialist consultation in spanish-speaking patients presenting to the ed for abdominal pain. emergency department patients on warfarin -how often is the visit due to the medication? jim killeen, edward castillo, theodore chan, gary vilke ucsd medical center, san diego, ca background: warfarin has important therapeutic value for many patients, but has been associated with signi-ficant bleeding complications, hypersensitivity reactions, and drug-drug interactions, which can result in patients seeking care in the emergency department (ed). objectives: to determine how often ed patients on warfarin present for care as a result of the medication itself. methods: a multi-center prospective survey study in two academic eds over 6 months. patients who presented to the ed taking warfarin were identified, and ed providers were prospectively queried at the time of disposition regarding whether the visit was the result of a complication or side effect associated with warfarin. data were also collected on patient demographics, chief complaint, triage acuity, vital signs, disposition, ed evaluation time, and length of stay (los). patients identified with a warfarin-related cause for their ed visit were compared with those who were not. statistical analysis was performed using descriptive statistics. results: during the study period, 31,500 patients were cared for by ed staff, of whom 594 were identified as taking warfarin as part of their medication regimen. of these, providers identified 54.7% (325 patients) who presented with a warfarin-related complication as their primary reason for the ed visit. 56.9% (338) each 100 hours of daily boarding is associated with a drop of 1.3 raw score points in both pg metrics. these seemingly small drops in raw scores translate into major changes in rankings on press ganey national percentile scales (a difference of as much as 10 percentile points). our institution commonly has hundreds of hours of daily boarding. it is possible that patient-level measurements of boarding impact would show stronger correlation with individual satisfaction scores, as opposed to the daily aggregate measures we describe here. our research suggests that reducing the burden of boarding on eds will improve patient satisfaction. background: prolonged emergency department (ed) boarding is a key contributor to ed crowding. the effect of output interventions (moving boarders out of the ed into an intermediate area prior to admission or adding additional capacity to an observation unit) has not been well studied. objectives: we studied the effect of a combined observation-transition (ot) unit, consisting of observation beds and an interim holding area for boarding ed patients, on the length of stay (los) for admitted patients, as well as secondary outcomes such as los for discharged patients, and left without being seen rates. methods: we conducted a retrospective review (12 months pre-, 12 months post-design) of an ot unit at an urban teaching ed with 59,000 annual visits (study ed). we compared outcomes to a nearby communitybased ed with 38,000 annual visits in the same health system (control ed) where no capacity interventions were performed. the ot had 17 beds, full monitoring capacity, and was staffed 24 hours per day. the number of beds allocated to transition and observation patients fluctuated throughout the course of the intervention, based on patient demands. all analyses were conducted at the level of the ed-day. wilcoxon rank-sum and analysis of covariance tests were used for comparisons; continuous variables were summarized with medians. results: in unadjusted analyses, median daily los of admitted patients at the study ed was 31 minutes lower in the 12 months after the ot opened, 6.98 to 6.47 hours (p < 0.0001). control site daily los for admitted patients increased 26 minutes from 4.52 to 4.95 hours (p < 0.0001). results were similar after adjusting for other covariates (day of week, ed volume, and triage level). los of discharged patients at study ed decreased by 14 minutes, from 4.1 hours to 3.8 hours (p < 0.001), while the control ed saw no significant changes in discharged patient los (2.6 hours to 2.7 hours, p = 0.06). left without being seen rates did not decrease at either site. conclusion: opening an ot unit was associated with a 30-minute reduction in average daily ed los for admitted patients and discharged patients in the study ed. given the large expense of opening an ot, future studies should compare capacity-dependent (e.g., ot) vs. capacity-independent (e.g, organizational) interventions to reduce ed crowding. fran balamuth, katie hayes, cynthia mollen, monika goyal children's hospital of philadelphia, philadelphia, pa background: lower abdominal pain and genitourinary problems are common chief complaints in adolescent females presenting to emergency departments. pelvic inflammatory disease (pid) is a potentially severe complication of lower genital tract infections, which involves inflammation of the female upper genital tract secondary to ascending stis. pid has been associated with severe sequelae including infertility, ectopic pregnancy, and chronic pelvic pain. we describe the prevalence and microbial patterns of pid in a cohort of adolescent females presenting to an urban emergency department with abdominal or genitourinary complaints. objectives: to describe the prevalence and microbial patterns of pid in a cohort of adolescent patients presenting to an ed with lower abdominal or genitourinary complaints. methods: this is a secondary analysis of a prospective study of females ages 14-19 years presenting to a pediatric ed with lower abdominal or genitourinary complaints. diagnosis of pid was per 2006 cdc guidelines. patients underwent chlamydia trachomatis (ct) and neisseria gonorrhea (gc) testing via urine aptima combo 2 assay and trichomonas vaginalis (tv) testing using the vaginal osom trichomonas rapid test. descriptive statistics were performed using stata 11.0. results: the prevalence of pid in this cohort of 328 patients was 19.5% (95% ci 15.2%, 23.8%), 37.5% (95% ci 25.3%, 49.7%) of whom had positive sexually transmitted infection (sti) testing: 25% (95% ci 14.1%, 35.9%) with ct, 7.8% (95% ci 1.1, 14.6%) with gc, and 12.5% (95% ci 4.2%, 20.8%) with tv. 84.4% (95% ci 75.2, 93.5%) of patients diagnosed with pid received antibiotics consistent with cdc recommendations. patients with lower abdominal pain as their chief complaint were more likely to have pid than patients with genitourinary complaints (or 3.3, 95% ci 1.7, 6.4). conclusion: a substantial number of adolescent females presenting to the emergency department with lower abdominal pain were diagnosed with pid, with microbial patterns similar to those previously reported in largely adult, outpatient samples. furthermore, appropriate treatment for pid was observed in the majority of patients diagnosed with pid. impact background: in resource-poor settings, maternal health care facilities are often underutilized, contributing to high maternal mortality. the effect of ultrasound in these settings on patients, health care providers, and communities is poorly understood. objectives: the purpose of this study was to assess the effect of the introduction of maternal ultrasound in a population not previously exposed to this intervention. methods: an ngo-led program trained nurses at four remote clinics outside koutiala, mali, who performed 8,339 maternal ultrasound scans over three years. our researchers conducted an independent assessment of this program, which involved log book review, sonographer skill assessment, referral follow-up, semi-structured interviews of clinic staff and patients, and focus groups of community members in surrounding villages. analyses included the effect of ultrasound on clinic function, job satisfaction, community utilization of prenatal care and maternity services, alterations in clinical decision making, sonographer skill, and referral frequency. we used qrs nvivo9 to organize qualitative findings, code data, and identify emergent themes, and graphpad software (la jolla, ca) and microsoft excel to tabulate quantitative findings results: -findings that triggered changes in clinical practice were noted in 10.1% of ultrasounds, with a 3.5% referral rate to comprehensive maternity care facilities. -skill retention and job satisfaction for ultrasound providers was high. -the number of patients coming for antenatal care increased, after introduction of ultrasound, in an area where the birth rate has been decreasing. -over time, women traveled from farther distances to access ultrasound and participate in antenatal care. -very high acceptance among staff, patients and community members. -ultrasound was perceived as most useful for finding fetal position, sex, due date, and well-being. -improved confidence in diagnosis and treatment plan for all cohorts. -improved compliance with referral recommendations. -no evidence of gender selection motivation for ultrasound use. conclusion: use of maternal ultrasound in rural and resource-limited settings draws women to an initial antenatal care visit, increases referral, and improves job satisfaction among health care workers. methods: a retrospective database analysis was conducted using the electronic medical record from a single, large academic hospital. ed patients who received a billing diagnosis of ''nausea and vomiting of pregnancy'' or ''hyperemesis gravidarum'' between 1/1/10 and 12/31/10 were selected. a manual chart review was conducted with demographic and treatment variables collected. statistical significance was determined using multiple regression analysis for a primary outcome of return visit to the emergency department for nausea and vomiting of pregnancy. results: 113 patients were identified. the mean age was 27.1 years (sd±5.25), mean gravidity 2.90 (sd±1.94), and mean gestational age 8.78 weeks (sd±3.21). the average length of ed evaluation was 730 min (sd±513). of the 113 patients, 38 (33.6%) had a return ed visit for nausea and vomiting of pregnancy, 17 (15%) were admitted to the hospital, and 49 (43%) were admitted to the ed observation protocol. multiple regression analysis showed that the presence of medical co-morbidity (p = 0.039), patient gravditity (p = 0.016), gestational age (p = 0.038), and admission to the hospital (p = 0.004) had small but significant effects on the primary outcome (return visits to the emergency department). no other variables were found to be predictive of return visits to the ed including admission to the ed observation unit or factors classically thought to be associated with severe forms of nausea and vomiting in pregnancy including ketonuria, electrolyte abnormalities, or vital sign abnormalities. conclusion: nausea and vomiting in pregnancy has a high rate of return ed visits that can be predicted by young patient age, low patient gravidity, early gestational age, and the presence of other comorbidities. these patients may benefit from obstetric consultation and/or optimization of symptom management after discharge in order to prevent recurrent utilization of the ed. prevalence conclusion: there is a high prevalence of ht in adult sa victims. although our study design and data do not allow us to make any inferences regarding causation, this first report of ht ed prevalence suggests the opportunity to clarify this relationship and the potential opportunity to intervene. background: sexually transmitted infections (sti) are a significant public health problem. because of the risks associated with stis including pid, ectopic pregnancy, and infertility the cdc recommends aggressive treatment with antibiotics in any patient with a suspected sti. objectives: to determine the rates of positive gonorrhea and chlamydia (g/c) screening and rates of empiric antibiotic use among patients of an urban academic ed with >55,000 visits in boston, ma. methods: a retrospective study of all patients who had g/c cultures in the ed over 12 months. chi-square was used in data analysis. sensitivity and specificity were also calculated. results: a positive rate of 9/712 (1.2%) was seen for gonorrhea and 26/714 (3.6%) for chlamydia. females had positive rates of 2/602 (0.3%) and 17/603 (2.8%) respectively. males had higher rates of 7/110 (6.4%) (p =< 0.001) and 9/111 (8.1%) (p = 0.006). 284 patients with g/c sent received an alternative diagnosis, the most common being uti (63), ovarian pathology (35), vaginal bleeding (34), and vaginal candidiasis (33); 4 were excluded. this left 426 without definitive diagnosis. of these, 24.2% (87/360) of females were treated empirically with antibiotics for g/c, and a greater percentage of males (66%, 45/66) were treated empirically (p < 0.001). of those empirically treated, 109/132 (82.6%) had negative cultures. meanwhile 9/32 (28.1%) who ultimately had positive cultures were not treated with antibiotics during their ed stay. sensitivity of the provider to predict presence of disease based on decision to give empiric antibiotics was 71.9 (ci 53.0-85.6). specificity was 72.3 (ci 67.6-76.6). conclusion: most patients screened in our ed for g/c did not have positive cultures and 82.6% of those treated empirically were found not to have g/c. while early treatment is important to prevent complications, there are risks associated with antibiotic use such as allergic reaction, c difficile infection, and development of antibiotic resistance. our results suggest that at our institution we may be over-treating for g/c. furthermore, despite high rates of treatment, 28% of patients who ultimately had positive cultures did not receive antibiotics during their ed stay. further research into predictive factors or development of a clinical decision rule may be useful to help determine which patients are best treated empirically with antibiotics for presumed g/c. background: air travel may be associated with unmeasured neurophysiological changes in an injured brain that may affect post-concussion recovery. no study has compared the effect of commercial airtravel on concussion injuries despite rather obvious decreased oxygen tension and increased dehydration effect on acute mtbi. objectives: to determine if air travel within 4-6 hours of concussion is associated with increased recovery time in professional football and hockey players. methods: prospective cohort study of all active-roster national football league and national hockey league players during the 2010-2011 seasons. internet website review of league sties for injury identification of concussive injury and when player returned to play solely for mtbi. team schedules and flight times were also confirmed to include only players who flew immediately following game (within 4-6 hr). multiple injuries were excluded as were players who had injury around all-star break for nhl and scheduled off week in nfl. results: during the 2010-2011 nfl and nhl seasons, 122 (7.2%) and 101 (13.0%) players experienced a concussion (percent of total players), in the respective leagues. of these, 68 nfl players (57%) and 39 nhl players (39%) flew within 6 hours of the incident injury. the mean distance flown was shorter for nfl (850 miles, sd 576 vs. nhl 1060, sd 579) miles and all were in a pressurized cabin. the mean number of games missed for nfl and nhl players who traveled by air immediately after concussion was increased by 29% and 24% (respectively) than for those who did not travel by air nfl: 3.8 (sd 2.2) vs. 2.6 games (sd 1.8) and nhl: 16.2 games (sd 22.0) vs.12.4 (sd 18.6); p < 0.03. conclusion: this is an initial report of an increased rate of recovery in terms of more games missed, for professional athletes flying commercial airlines post-mtbi compared to those that do not subject their recently injured brains to pressurized airflight. the obvious changes of decreased oxygen tension with altitude equivalent of 7,500 feet, decreased humidity with increased dehydration, and duress of travel accompanying pressurized airline cabins all likely increase the concussion penumbra in acute mtbi. early air travel post concussion should be further evaluated and likely postponed 48-72 hr. until initial symptoms subside. background: previous studies have shown better in-hospital stroke time targets for those who arrive by ambulance compared to other modes of transport. however, regional studies report that less than half of stroke patients arrive by ambulance. objectives: our objectives were to describe the proportion of stroke patients who arrive by ambulance nationwide, and to examine regional differences and factors associated with the mode of transport to the emergency department (ed). methods: this is a cross-sectional study of all patients with a primary discharge diagnosis of stroke based on previously validated icd-9 codes abstracted from the national hospital ambulatory medical care survey for 2007-2009. we excluded subjects <18 years of age and those with missing data. the study related survey variables included patient demographics, community characteristics, mode of transport to the hospital, and hospital characteristics. results: 566 patients met inclusion criteria, representing 2,153,234 patient records nationally. of these, 50.4% arrived by ambulance. after adjustment for potential confounders, patients residing in the west and south had lower odds of arriving by ambulance for stroke when compared to northeast (southern region, or 0.45, 95% ci 0.26-0.76, western region, or 0.45, 95% ci 0.25-0.84, midwest region, or 0.56, 95% ci 0.31-1.01). compared to the medicare population, privately insured and self insured had lower odds of arriving by ambulance (or for private insurance 0.48, 95% ci 0.28-0.84 and or for self payers 0.36, 95% ci 0.14-0.93). age, sex, race, urban or rural location of ed, or safety net status were not independently associated with ambulance use. conclusion: patients with stroke arrive by ambulance more frequently in the northeast than in other regions of the us. identifying reasons for this regional difference may be useful in improving ambulance utilization and overall stroke care nationwide. objectives: we sought to determine whether there was a difference in type of stroke presentation based upon race. we further sought to determine whether there is an increase in hemorrhagic strokes among asian patients with limited english proficiency. methods: we performed a retrospective chart review of all stroke patients age 18 and older for 1 year of patients that were diagnosed with cerebral vascular accident (cva) or intracranial hemorrhage (ich). we collected data on patient demographics, and past medical history. we then stratified patients according to race (white, black, latino, asian, and other). we classified strokes as ischemic, intracranial hemorrhage (ich), subarachnoid hemorrhage (sah), subdural hemorrhage (sdh), and other (e.g., bleeding into metatstatic lesions). we used only the index visit. we present the data percentages, medians and interquartile ranges (iqr). we tested the association of the outcome of intracranial hemorrhage against demographic and clinical variables using chi-square and kruskal-wallis tests. we performed a logistic regression model to determine factors related to presentation with an intracranial hemorrhage (ich background: the practice of obtaining laboratory studies and routine ct scan of the brain on every child with a seizure has been called into question in the patient who is alert, interactive, and back to functional baseline. there is still no standard practice for the management of non-febrile seizure patients in the pediatric emergency department (ped). objectives: we sought to determine the proportion of patients in whom clinically significant laboratory studies and ct scans of the brain were obtained in children who presented to the ped with a first or recurrent non-febrile seizure. we hypothesize that the majority of these children do not have clinically significant laboratory or imaging studies. if clinically significant values were found, the history given would warrant further laboratory and imaging assessment despite seizure alone. methods: we performed a retrospective chart review of 93 patients with first-time or recurrent non-febrile seizures at an urban, academic ped between july 2007 to june 2011. exclusion criteria included children who presented to the ped with a fever and age less than 2 months. we looked at specific values that included a complete blood count, basic metabolic panel, and liver function tests, and if the child was on antiepileptics along with a level for a known seizure disorder, and ct scan. abnormal laboratory and ct scan findings were classified as clinically significant or not. results: the median age of our study population is 4 years with male to female ratio of 1.7. 70% of patients had a generalized tonic-clonic seizure. laboratory studies and ct scans were obtained in 87% and 35% of patients, respectively. five patients had clinically significant abnormal labs; however, one had esrd, one developed urosepsis, one had eclampsia, and two others had hyponatremia, which was secondary to diluted formula and trileptal toxicity. three children had an abnormal head ct: two had a vp shunt and one had a chromosomal abnormality with developmental delay. conclusion: the majority of the children analyzed did not have clinically significant laboratory or imaging studies in the setting of a first or recurrent non-febrile seizure. of those with clinically significant results, the patient's history suggested a possible etiology for their seizure presentation and further workup was indicated. background: in patients with a negative ct scan for suspected subarachnoid hemorrhage (sah), ct angiography (cta) has emerged as a controversial alternative diagnostic strategy in place of lumbar puncture (lp). objectives: to determine the diagnostic accuracy for sah and aneurysm of lp alone, cta alone, and lp followed by cta if the lp is positive. methods: we developed a decision and bayesian analysis to evaluate 1) lp, 2) cta, and 3) lp followed by cta if the lp is positive. data were obtained from the literature. the model considers probability of sah (15%), aneurysm (85% if sah), sensitivity and specificity of ct (92.9% and 100% overall), of lp (based on rbc and xanthochromia), and of cta, traumatic tap and its influence on sah detection. analyses considered all patients and those presenting at less than 6 hours or greater than 6 hours from symptom onset by varying the sensitivity and specificity of ct and cta. results: using the reported ranges of ct scan sensitivity and the specificity, the revised likelihood of sah following a negative ct ranged from 0.5-3.7%, and the likelihood of aneurysm ranged from 2.3-5.4%. following any of the diagnostic strategies, the likelihood of missing sah ranged from 0-0.7%. either lp strategy diagnosed 99.8% of sahs versus 83-84% with cta alone because cta only detected sah in the presence of an aneurysm. false positive sah with lp ranged from 8.5-8.8% due to traumatic taps and with cta ranged from 0.2-6.0% due to aneurysms without sah. the positive predictive value for sah ranged from 5.7-30% with lp and from 7.9-63% with cta. for patients presenting within 6 hours of symptom onset, the revised likelihood of sah following a negative ct became 0.53%, and the likelihood of aneurysm ranged from 2.3-2.7%. following any of the diagnostic strategies, the likelihood of missing sah ranged from 0.01-0.095%. either lp strategy diagnosed 99.8% of sah versus 83-84% with cta alone. false positive sah with lp was 8.8% and with cta ranged from 0.2-5.1%. the positive predictive value for sah was 5.7% with lp and from 7.9-63% with cta. cta following a positive lp diagnosed 8.5-24% of aneurysms. conclusion: lp strategies are more sensitive for detecting sah but less specific than cta because of traumatic taps, leading to lower predictive value positives for sah with lp than with cta. either diagnostic strategy results in a low likelihood of missing sah, particularly within 6 hours of symptom onset. background: recent studies support perfusion imaging as a prognostic tool in ischemic stroke, but little data exist regarding its utility in transient ischemic attack (tia). ct perfusion (ctp), which is more available and less costly to perform than mri, has not been well studied. objectives: to characterize ctp findings in tia patients, and identify imaging predictors of outcome. methods: this retrospective cohort study evaluated tia patients at a single ed over 15 months, who had ctp at initial evaluation. a neurologist blinded to ctp findings collected demographic and clinical data. ctp images were analyzed by a neuroradiologist blinded to clinical information. ctp maps were described as qualitatively normal, increased, or decreased in mean transit time (mtt), cerebral blood volume (cbv), and cerebral blood flow (cbf). quantitative analysis involved measurements of average mtt (seconds), cbv (cc/100 g) and cbf (cc/[100g x min]) in standardized regions of interest within each vascular distribution. these were compared with values in the other hemisphere for relative measures of mtt difference, cbv ratio, and cbffratio. mtt difference of ‡2 seconds, rcbv as £0.60, and rcbf as £0.48 were defined as abnormal based on prior studies. clinical outcomes including stroke, tia, or hospitalization during follow-up were determined up to one year following the index event. dichotomous variables were compared using fisher's exact test. logistic regression was used to evaluate the association of ctp abnormalities with outcome in tia patients. results: of 99 patients with validated tia, 53 had ctp done. mean age was 72 ± 12 years, 55% were women, and 64% were caucasian. mean abcd 2 score was 4.7 ± 2.1, and 69% had an abcd 2 ‡ 4. prolonged mtt was the most common abnormality (19, 36%), and 5 (9.4%) had decreased cbv in the same distribution. on quantitative analysis, 23 (43%) had a significant abnormality. four patients (7.5%) had prolonged mtt and decreased cbv in the same territory, while 17 (32%) had mismatched abnormalities. when tested in a multivariate model, no significant associations between mismatch abnormalities on ctp and new stroke, tia, or hospitalizations were observed. conclusion: ctp abnormalities are common in tia patients. although no association between these abnormalities and clinical outcomes was observed in this small study, this needs to be studied further. objectives: we hypothesized that pre-thrombolytic anti-hypertensive treatment (aht) may prolong door to treatment time (dtt). methods: secondary data analysis of consecutive tpatreated patients at 24 randomly selected michigan community hospitals in the instinct trial. dtt among stroke patients who received pre-thrombolytic aht were compared to those who did not receive pre-thrombolytic aht. we then calculated a propensity score for the probability of receiving pre-thrombolytic aht using a logistic regression model with covariates including demographics, stroke risk factors, antiplatelet or beta blocker as home medication, stroke severity (nihss), onset to door time, admission glucose, pretreatment systolic and diastolic blood pressure, ems usage, and location at time of stroke. a paired t-test was then performed to compare the dtt between the propensity-matched groups. a separate generalized estimating equations (gee) approach was also used to estimate the differences between patients receiving pre-thrombolytic aht and those who did not while accounting for within-hospital clustering. results: a total of 557 patients were included in instinct; however, onset, arrival, or treatment times were not able to be determined in 23, leaving 534 patients for this analysis. the unmatched cohort consisted of 95 stroke patients who received pre-thrombolytic aht and 439 stroke patients who did not receive aht from 2007-2010 (table) . in the unmatched cohort, patients who received pre-thrombolytic aht had a longer dtt (mean increase 9 minutes; 95% confidence interval (ci) 2-16 minutes) than patients who did not receive pre-thrombolytic aht. after propensity matching (table) , patients who received pre-thrombolytic aht had a longer dtt (mean increase 10.4 minutes, 95% ci 1.9-18.8) than patients who did not receive pre-thrombolytic aht. this effect persisted and its magnitude was not altered by accounting for clustering within hospitals. conclusion: pre-thrombolytic aht is associated with modest delays in dtt. this represents a feasible target for physician educational interventions and quality improvement initiatives. further research evaluating optimum hypertension management pre-thrombolytic treatment is warranted. post-pds, 7% had only pre-pds, and 9% had both. the most common pds included failure to treat post-treatment hypertension (131, 24%), antiplatelet agent within 24 hours of treatment (61, 11%), pre-treatment blood pressure over 185/110 (39, 7%), anticoagulant agent within 24 hours of treatment (31, 6%), and treatment outside the time window (29, 5%). symptomatic intracranial hemorrhage (sich) was observed in 7.3% of patients with pds and 6.5% of patients without any pd. in-hospital case fatality was 12% with and 10% without a pd. in the fully adjusted model, older age was significantly associated with pre-pds (table) . when post-pds were evaluated with adjustment for pre-pds, age was not associated with pds; however, pre-pds were associated with post-pds. conclusion: older age was associated with increased odds of pre-pds in michigan community hospitals. pre-pds were associated with post-pds. sich and in-hospital case fatality were not associated with pds; however, the low number of such events limited our ability to detect a difference. ct background: mri has become the gold standard for the detection of cerebral ischemia and is a component of multiple imaging enhanced clinical risk prediction rules for the short-term risk of stroke in patients with transient ischemic attack (tia). however, it is not always available in the emergency department (ed) and is often contraindicated. leukoaraiosis (la) is a radiographic term for white matter ischemic changes, and has recently been shown to be independently predictive of disabling stroke. although it is easily detected by both ct and mri, their comparative ability is unknown. objectives: we sought to determine whether leukoaraiosis, when combined with evidence of acute or old infarction as detected by ct, achieved similar sensitivity to mri in patients presenting to the ed with tia. methods: we conducted a retrospective review of consecutive patients diagnosed with tia between june 2009 and july 2011 that underwent both ct and mri as part of routine care within 1 calendar day of presentation to a single, academic ed. ct and mr images were reviewed by a single emergency physician who was blinded to the mr images at the time of ct interpretation. la was graded using the van sweiten scale (vss), a validated grading scale applicable to both ct and mri. anterior and posterior regions were graded independently from 0 to 2. results: 361 patients were diagnosed with tia during the study period. of these, 194 had both ct and mri background: helping others is often a rewarding experience but can also come with a ''cost of caring'' also known as compassion fatigue (cf). cf can be defined as the emotional and physical toll suffered by those helping others in distress. it is affected by three major components: compassion satisfaction (cs), burnout (bo), and traumatic experiences (te). previous literature has recognized an increase in bo related to work hours and stress among resident physicians. objectives: to assess the state of cf among residents with regard to differences in specialty training, hours worked, number of overnights, and demands of child care. we aim to measure associations with the three components of cf (cs, bo, and te). methods: we used the previously validated survey, proqol 5. the survey was sent to the residents after approval from the irb and the program directors. results: a total of 193 responses were received (40% of the 478 surveyed). five were excluded due to incomplete questionnaires. we found that residents who worked more hours per week had significantly higher bo levels (median 25 vs 21, p = 0.038) and higher te (22 vs 19, p = 0.048) than those working less hours. there was no difference in cs (42 vs 40, p = 0.73). eighteen percent of the residents worked a majority of the night shifts. these residents had higher levels of bo background: emergency department (ed) billing includes both facility and professional fees. an algorithm derived from the medical provider's chart generates the latter fee. many private hospitals encourage appropriate documentation by financially incentivizing providers. academic hospitals sometimes lag in this initiative, possibly resulting in less than optimal charting. past attempts to teach proper documentation using our electronic medical record (emr) were difficult in our urban, academic ed of 80 providers (approximately 25 attending physicians, 36 residents, and 20 physician assistants). objectives: we created a tutorial to teach documentation of ed charts, modified the emr to encourage appropriate documentation, and provided feedback from the coding department. this was combined with an incentive structure shared equally amongst all attendings based on increased collections. we hypothesized this instructional intervention would lead to more appropriate billing, improve chart content, decrease medical liability, and increase educational value of charting process. methods: documentation recommendations, divided into two-month phases of 2-3 proposals, were administered to all ed providers by e-mails, lectures, and reminders during sign-out rounds. charts were reviewed by coders who provided individual feedback if specific phase recommendations were not followed. our endpoints included change in total rvu, rvus/ patient, e/m level distribution, and subjective quality of chart improvement. we did not examine effects on procedure codes or facility fees. results: our base average rvu/patient in our ed from 1/1/11-6/30/11 was 2.615 with monthly variability of approximately 2%. implementation of phase one increased average rvu/patient within two weeks to 2.73 (4.4% increase from baseline, p < 0.05). the second aggregate phase implemented 8 weeks later increased average rvu/patient to 3.04 (16.4% increase from baseline, p < 0.05). conclusion: using our teaching methods, chart reviews focused on 2-3 recommendations at a time, and emr adjustments, we were able to better reflect the complexity of care that we deliver every day in our medical charts. future phases will focus on appropriate documentation for procedures, critical care, fast track, and pediatric patients, as well as examining correlations between increase in rvus with charge capture. identifying mentoring ''best practices'' for medical school faculty julie l. welch, teresita bellido, cherri d. hobgood background: mentoring has been identified as an essential component for career success and satisfaction in academic medicine. many institutions and departments struggle with providing both basic and transformative mentoring for their faculty. objectives: we sought to identify and understand the essential practices of successful mentoring programs. methods: multidisciplinary institutional stakeholders in the school of medicine including tenured professors, deans, and faculty acknowledged as successful mentors were identified and participated in focused interviews between mar-nov 2011. the major area of inquiry involved their experiences with mentoring relationships, practices, and structure within the school, department, or division. focused interview data were transcribed and grounded theory analysis was performed. additional data collected by a 2009 institutional mentoring taskforce were examined. key elements and themes were identified and organized for final review. results: results identified the mentoring practices for three categories: 1) general themes for all faculty, 2) specific practices for faculty groups: basic science researchers, clinician researchers, clinician educators, and 3) national examples. additional mentoring strategies that failed were identified. the general themes were quite universal among faculty groups. these included: clarify the best type of mentoring for the mentee, allow the mentee to choose the mentor, establish a panel of mentors with complementary skills, schedule regular meetings, establish a clear mentoring plan with expectations and goals, offer training and resources for both the mentor and mentee at institutional and departmental levels, ensure ongoing mentoring evaluation, create a mechanism to identify and reward mentoring. national practice examples offered critical recommendations to address multi-generational attitudes and faculty diversity in terms of gender, race, and culture. conclusion: mentoring strategies can be identified to serve a diverse faculty in academic medicine. interventions to improve mentoring practices should be targeted at the level of the institution, department, and individual faculty members. it is imperative to adopt results such as these to design effective mentoring programs to enhance the success of emergency medicine faculty seeking robust academic careers. background: women comprise half of the talent pool from which the specialty of emergency medicine draws future leaders, researchers, and educators and yet only 5% of full professors in us emergency medicine are female. both research and interventions are aimed at reducing the gender gap, however, it will take decades for the benefits to be realized which creates a methodological challenge in assessing system's change. current techniques to measure disparities are insensitive to systems change as they are limited to percentages and trends over time. objectives: to determine if the use of relative rate index (rri) better predicts which stage in the system women are not advancing in the academic pipeline than traditional metrics. methods: rri is a method of analysis that assesses the percent of sub-populations in each stage relative to their representation in the stage directly prior. thus, there is a better notion of the advancement given the availability to advance. rri also standardizes data for ease of interpretation. this study was conducted on the total population of academic professors in all departments at yale school of medicine during the academic year of 2010-2011. data were obtained from the yale university provost's office. results: n = 1305. there were a total of 402 full, 429 associate, and 484 assistant professors. males comprised 78%, 59%, and 54% respectively. rri for the department of emergency medicine (dem) is 0.67, 1.93, and 0.78, for full, associate, and assistant professors, respectively while the percentages were 44%, 60%, and 33% respectively. conclusion: relying solely on percentages masks improvements to the system. women are most represented at the associate professor level in dem, highlighting the importance of systems change evidence. specifically, twice as many women are promoted to associate professor rank given the number who exists as assistant professors. within 5 years, the dem should have an equal system as the numbers of associate professors have dramatically increased and will be eligible to promote to full professor. additionally, dem has a better record of retaining and promoting women than other yale departments of medicine at both associate and full professor ranks. objectives: we examine the payer mixes of community non-rehabilitation eds in metropolitan areas by region to identify the proportion of academic and nonacademic eds that could be considered safety net eds. we hypothesize that the proportion of safety net academic eds is greater than that for non-academic eds and is increasing over time. methods: this is an ecological study examining us ed visits from 2006 through 2008. data were obtained from the nationwide emergency department sample (neds). we grouped each ed visit according to the unique hospital-based ed identifier, thus creating a payer mix for each ed. we define a ''safety net ed'' as any ed where the payer mix satisfied any one of the following three conditions: 1) >30% of all ed visits are medicaid patients; 2) >30% of all ed visits are self-pay patients; or 3) >40% of all ed visits are either medicaid or self-pay patients. neds tags each ed with a hospital-based variable to delineate metropolitan/non-metropolitan locations and academic affiliation. we chose to examine a subpopulation of eds tagged as either academic metropolitan or non-academic metropolitan, because the teaching status of non-metropolitan hospitals was not provided. we then measured the proportion of eds that met safety net criteria by academic status and region. results: we examined 2,821, 2,793, and 2,844 weighted metro eds in years 2006-2008, respectively. table 1 presents safety net proportions. the proportions of academic safety net eds increased across the study period. widespread regional variability in safety net proportions existed across all years. the proportions of safety net eds were highest in the south and lowest in the northeast and midwest. table 2 describes these findings for 2008. conclusion: these data suggest that the proportion of safety-net academic eds may be greater than that of non-academic eds, is increasing over time, and is objectives: to examine the effect of ma health reform implementation on ed and hospital utilization before and after health reform, using an approach that relies on differential changes in insurance rates across different areas of the state in order to make causal inferences as to the effect of health reform on ed visits and hospitalizations. our hypothesis was that health care reform (i.e. reducing rates of uninsurance) would result in increased rates of ed use and hospitalizations. methods: we used a novel difference-in-differences approach, with geographic variation (at the zip code level) in the percentage uninsured as our method of identifying changes resulting from health reform, to determine the specific effect of massachusetts' health care reform on ed utilization and hospitalizations. using administrative data available from the massachusetts division of health care finance and policy acute hospital case mix databases, we compared a one-year period before health reform with an identical period after reform. we fit linear regression models at the area-quarter level to estimate the effect of health reform and the changing uninsurance rate (defined as self-pay only) on ed visits and hospitalizations. results: there were 2,562,330 ed visits and 777,357 hospitalizations pre-reform and 2,713,726 ed visits and 787,700 hospitalizations post-reform. the rate of uninsurance decreased from 6.2% to 3.7% in the ed group and from 1.3% to 0.6% in the hospitalization group. a reduction in the rate of the uninsured was associated with a small but statistically significant increase in ed utilization (p = 0.03) and no change in hospitalizations (p = 0.13). conclusion: we find that increasing levels of insurance coverage in massachusetts were associated with small but statistically significant increases in ed visits, but no differences in rates of hospitalizations. these results should aid in planning for anticipated changes that might result from the implementation of health reform nationally. with high levels of co-morbidity when untreated in adolescents. despite broad cdc screening recommendations, many youth do not receive testing when indicated. the pediatric emergency department (ped) is a venue with a high volume of patients potentially in need of sti testing, but assessing risk in the ped is difficult given constraints on time and privacy. we hypothesized that patients visiting a ped would find an audio-enhanced computer-assisted self-interview (acasi) program to establish sti risk easy to use, and would report a preference for the acasi over other methods of disclosing this information. objectives: to assess acceptability, ease of use, and comfort level of an acasi designed to assess adolescents' risk for stis in the ped. methods: we developed a branch-logic questionnaire and acasi system to determine whether patients aged 15-21 visiting the ped need sti testing, regardless of chief complaint. we obtained consent from participants and guardians. patients completed the acasi in private on a laptop. they read a one-page computer introduction describing study details and completed the acasi. patients rated use of the acasi upon completion using five-point likert scales. results: 2030 eligible patients visited the ped during the study period. we approached 873 (43%) and enrolled and analyzed data for 460/873 (53%). the median time to read the introduction and complete the acasi was 8.2 minutes (interquartile range 6.4-11.5 minutes). 90.7% of patients rated the acasi ''very easy'' or ''easy'' to use, 90.6% rated the wording as ''very easy'' or ''easy'' to understand, 60% rated the acasi ''very short'' or ''short'', 60.3% rated the audio as ''very helpful'' or ''helpful,'' 82.9% were ''very comfortable'' or ''comfortable'' with the system confidentiality, and 71.2% said they would prefer a computer interface over in-person interviews or written surveys for collection of this type of information. conclusion: patients rated the computer interface of the acasi as easy and comfortable to use. a median of 8.2 minutes was needed to obtain meaningful clinical information. the acasi is a promising approach to enhance the collection of sensitive information in the ped. the participants were randomized to one of three conditions, bi delivered by a computer (cbi), bi delivered by a therapist assisted by a computer (tbi), or control, and completed 3, 6, and 12 month follow-up. in addition to content on alcohol misuse and peer violence, adolescents reporting dating violence received a tailored module on dating violence. the main outcome for this analysis was frequency of moderate and severe dating victimization and aggression at the baseline assessment and 3, 6, and 12 months post ed visit. results: among eligible adolescents, 55% (n = 397) reported dating violence and were included in these analyses. compared to controls, after controlling for baseline dating victimization, participants in the cbi showed reductions in moderate dating victimization at 3 months (or 0.7; ci 0.51-0.99; p < 0.05, effect size 0.12) and 6 months (or 0.56; ci 0.38-0.83; p < 0.01, effect size 0.18); models examining interaction effects were significant for the cbi on moderate dating victimization at 3 and 6 months. significant interaction effects were found for the tbi on moderate dating victimization at 6 and 12 months and severe dating victimization at 3 months. the computer-based intervention shows promise for delivering content that decreases moderate dating victimization over 6 months. the therapist bi is promising for decreasing moderate dating victimization over 12 months and severe dating victimization over 3 months. ed-based bis delivered on a computer addressing multiple risk behaviors could have important public health effects. figure 1 . the 21-only ordinance was associated with a significant reduction of ar visits. this ordinance was also associated with reduction in underage ar visits, ui student visits, and public intoxication bookings. these data suggest that other cities should consider similar ordinances to prevent unwanted consequences of alcohol. background: prehospital providers perform tracheal intubation in the prehospital environment, and failed attempts are of concern due to the danger of hypoxia and hypotension. some question the appropriateness of intubation in this setting due to the morbidity risk associated with intubation in the field. thus it is important to gain an understanding of the factors that predict the success of prehospital intubation attempts to inform this discussion. objectives: to determine the factors that affect success rates on first attempt of paramedic intubations in a rapid sequence intubation (rsi) capable critical care transport service. methods: we conducted a multivariate logistic analysis on a prospectively collected database of airway management from an air and land critical care transport service that provides scene responses and interfacility transport in the province of ontario. background: motor vehicle collisions (mvcs) are one of the most common types of trauma for which people seek ed care. the vast majority of these patients are discharged home after evaluation. acute psychological distress after trauma causes great suffering and is a known predictor of posttraumatic stress disorder (ptsd) development. however, the incidence and predictors of psychological distress among patients discharged to home from the ed after mvcs have not been reported. objectives: to examine the incidence and predictors of acute psychological distress among individuals seen in the ed after mvcs and discharged to home. methods: we analyzed data from a prospective observational study of adults 18-64 years of age presenting to one of eight ed study sites after mvc between 02/ 2009 and 10/2011. english-speaking patients who were alert and oriented, stable, and without injuries requiring hospital admission were enrolled. patient interview included assessment of patient sociodemographic and psychological characteristics and mvc characteristics. level of psychological distress in the ed was assessed using the 13-item peritraumatic distress inventory (pdi). pdi scores >23 are associated with increased risk of ptsd and were used to define substantial psychological distress. descriptive statistics and logistic regression were performed using stata ic 11.0 (statacorp lp, college station, texas). results: 9339 mvc patients were screened, 1584 were eligible, and 949 were enrolled. 361/949 (38%) participants had substantial psychological distress. after adjusting for crash severity (severity of vehicle damage, vehicle speed), substantial patient distress was predicted by sociodemographic factors, pre-mvc depressive symptoms, and arriving to the ed on a backboard (table) . conclusion: substantial psychological distress is common among individuals discharged from the ed after mvcs and is predicted by patient characteristics separate from mvc severity. a better under standing of the frequency and predictors of substantial psychological distress is an important first step in identifying these patients and developing effective interventions to reduce severe distress in the aftermath of trauma. such interventions have the potential to reduce both immediate patient suffering and the development of persistent psychological sequelae. figure) the predictive characteristics of pets, pesi, and spesi for 30-day mortality in emperor, including auc, negative predictive value, sensitivity, and specificity were calculated. results: the 646 of 1438 patients (44.9%; 95% ci 42.3%-47.5%) classified as pets low had 30-day mortality of 0.5% (95% ci 0.1-1.5%), versus 10.2% (95% ci 8.0%-12.4%) in the pets high group, statistically similar to pesi and spesi. pets is significantly more specific for mortality than the spesi (47.0% v 37.6%; p < 0.0001), classifying far more patients as low-risk while maintaining a sensitivity of 96% (95% ci 88.3%-99.0%), not significantly different from spesi or pesi (p > 0.05). conclusion: with four variables, pets in this derivation cohort is as sensitive for 30-day mortality as the more complicated pesi and spesi, with significantly greater specificity than the spesi for mortality, placing 25% more patients in the low-risk group. external validation is necessary. nicole seleno, jody vogel, michael liao, emily hopkins, richard byyny, ernest moore, craig gravitz, jason haukoos denver health medical center, denver, co background: the sequential organ failure assessment (sofa) score, base excess, and lactate have been shown to be associated with mortality in critically ill trauma patients. the denver emergency department (ed) trauma organ failure (tof) score was recently derived and internally validated to predict multiple organ failure in trauma patients. the relationship between the denver tof score and mortality has not been assessed or compared to other conventional measures of mortality in trauma. objectives: to compare the prognostic accuracies of the denver ed tof score, ed sofa score, and ed base excess and lactate for mortality in a large heterogeneous trauma population. methods: a secondary analysis of data from the denver health trauma registry, a prospectively collected database. consecutive adult trauma patients from 2005 through 2008 were included in the study. data collected included demographics, injury characteristics, prehospital care characteristics, response to injury characteristics, ed diagnostic evaluation and interventions, and in-hospital mortality. the values of the four clinically relevant measures (denver ed tof score, ed sofa score, ed base excess, and ed lactate) were determined within four hours of patient arrival, and prognostic accuracies for in-hospital mortality for the four measures were evaluated with receiver operating characteristic (roc) curves. multiple imputation was used for missing values. results: of the 4,355 patients, the median age was 37 (iqr 26-51) years, median injury severity score was 9 (iqr 4-16), and 81% had blunt mechanisms. thirty-eight percent (1,670 patients) were admitted to the icu with a median icu length of stay of 2.5 (iqr 1-8) days, and 3% (138 patients) died. in the non-survivors, the median values for the four measures were ed sofa 5.0 (iqr 0.0-8.0); denver ed tof 4.0 (iqr 4.0-5.0); ed base excess 7.0 (iqr 8.0-19.0) meq/l; and ed lactate 6.5 (iqr 4.5-11.8) mmol/l. the areas under the roc curves for these measures are demonstrated in the figure. conclusion: the denver ed tof score more accurately predicts in-hospital mortality in trauma patients as compared to the ed sofa score, ed base excess, or ed lactate. the denver ed tof score may help identify patients early who are at risk for mortality, allowing for targeted resuscitation and secondary triage to improve outcomes in these critically ill patients. the background: both animal and human studies suggest that early initiation of therapeutic hypothermia (th) and rapid cooling improve outcomes after cardiac arrest. objectives: the objective was to determine if administration of cold iv fluids in a prehospital setting decreased time-to-target-temperature (tt) with secondary analysis of effects on mortality and neurological outcome. methods: patients resuscitated after out-of-hospital cardiac arrest (oohca) who received an in-hospital post cardiac arrest bundle including th were prospectively enrolled into a quality assurance database from november 2007 to november 2011. on april 1, 2009 a protocol for intra-arrest prehospital cooling with 4°c normal saline on patients experiencing oohca was initiated. we retrospectively compared tt for those receiving prehospital cold fluids and those not receiving cold fluids. tt was defined as 34°c measured via foley thermistor. secondary outcomes included mortality, good neurological outcome defined as cerebral performance category (cpc) score of 1 or 2 at discharge, and effects of pre-rosc cooling. results: there were 132 patients who were included in this analysis with 80 patients receiving prehospital cold iv fluids and 52 who did not. initially, 63% of patients were in vf/vt and 36% asystole/pea. patients receiving prehospital cooling did not have a significant improvement in tt (256 minutes vs 271 minutes, p = 0.64). survival to discharge and good neurologic outcome were not associated with prehospital cooling (54% vs 50%, p = 0.67) and cpc of 1 or 2 in 49% vs 44%, (p = 0.61). initiating cold fluids prior to rosc showed both a nonsignificant decrease in survival (48% vs 56%, p = 0.35) and increase in poor neurologic outcomes (42% vs 50%, p = 0.39). 77% of patients received £ 1l of cooled ivf prior to hospital arrival. patients receiving prehospital cold ivf had a longer time from arrest to hospital arrival (44 vs 34 min, p =< 0.001) in addition to a prolonged rosc to hospital time (20 vs 12 min, p = 0.005). conclusion: at our urban hospital, patients achieving rosc following oohca did not demonstrate faster tt or outcome improvement with prehospital cooling compared to cooling initiated immediately upon ed arrival. further research is needed to assess the utility of prehospital cooling. assessment background: an estimated 10% of emergency department (ed) patients 65 years of age and older have delirium, which is associated with short-and long-term risk of morbidity and mortality. early recognition could result in improved outcomes, but the reliability of delirium recognition in the continuum of emergency care is unknown. objectives: we tested whether delirium can be reliably detected during emergency care of elderly patients by measuring the agreement between prehospital providers, ed physicians, and trained research assistants using the confusion assessment method for the icu (cam-icu) to identify the presence of delirium. our hypothesis was that both ed physicians and prehospital providers would have poor ability to detect elements of delirium in an unstructured setting. methods: prehospital providers and ed physicians completed identical questionnaires regarding their clinical encounter with a convenience sample of elderly (age >65 years) patients who presented via ambulance to two urban, teaching eds over a three-month period. respondents noted the presence or absence of (1) an acute change in mental status, (2) inattention, (3) disorganized thinking, and (4) altered level of consciousness (using the richmond agitation sedation scale). these four components comprise the operational definition of delirium. a research assistant trained in the cam-icu rated each component for the same patients using a standard procedure. we calculated inter-rater reliability (kappa) between prehospital providers, ed physicians, and research assistants for each component. objectives: this study aimed to assess the association between age and ems use while controlling for potential confounders. we hypothesized that this association use would persist after controlling for confounders. methods: a cross-sectional survey study was conducted at an academic medical center's ed. an interview-based survey was administered and included questions regarding demographic and clinical characteristics, mode of ed arrival, health care use, and the perceived illness severity. age was modeled as an ordinal variable (<60, 60-79, and ‡ 80 years). bivariate analyses were used to identify potential confounders and effect measure modifiers and a multivariable logistic regression model was constructed. odds ratios were calculated as measures of effect. results: a total of 1092 subjects were enrolled and had usable data for all covariates, 465 (43%) of whom arrived via ems. the median age of the sample was 60 years and 52% were female. there was a statistically significant linear trend in the proportion of subjects who arrived via ems by age (p < 0.0001). compared to adults aged less than 60 years, the unadjusted odds ratio associating age and ems use was 1.41 (95% ci: background: we previously derived a clinical decision rule (cdr) for chest radiography (cxr) in patients with chest pain and possible acute coronary syndrome (acs) consisting of the absence of three predictors: history of congestive heart failure, history of smoking, and abnormalities on lung auscultation. objectives: to prospectively validate and refine a cdr for cxr in an independent patient population. methods: we prospectively enrolled patients over 24 years of age with a primary complaint of chest pain and possible acs from september 2009 to january 2010 at a tertiary care ed with 73,000 annual patient visits. physicians completed standardized data collection forms before ordering chest radiographs and were thus blinded to cxr findings at the time of data collection. two investigators, blinded to the predictor variables, independently classified cxrs as ''normal,'' ''abnormal not requiring intervention,'' and ''abnormal requiring intervention'' (e.g, heart failure, infiltrates) based on review of the radiology report and the medical record. analyses included descriptive statistics, inter-rater reliability assessment (kappa), and recursive partitioning. results: of 1159 visits for possible acs, mean age (sd) was 60.3 (15.6) and 51% were female. twenty-four percent had a history of acute myocardial infarction, 10% congestive heart failure, and 11% atrial fibrillation. seventy-one (6.1%, 95% ci 4.9-7.7) patients had a radiographic abnormality requiring intervention. ing the likelihood of coronary artery disease (cad) could reduce the need for stress testing or coronary imaging. acyl-coa:cholesterol acyltransferase-2 (acat2) activity has been shown in monkey and murine models to correlate with atherosclerosis. objectives: to determine if a novel cardiac biomarker consisting of plasma cholesteryl ester levels (ce) typically derived from the activity of acat2 is predictive of cad in a clinical model. methods: a single center prospective observational cohort design enrolled a convenience sample of subjects from a tertiary care center with symptoms of acute coronary syndrome undergoing coronary ct angiography or invasive angiography. plasma samples were analyzed for ce composition with mass spectrometry. the primary endpoint was any cad determined at angiography. multivariable logistic regression analyses were used to estimate the relationship between the sum of the plasma concentrations from cholesteryl palmitoleate (16:1) and cholesteryl oleate (18:1) (defined as acat2-ce) and the presence of cad. the added value of acat2-ce to the model was analyzed comparing the c-statistics and integrated discrimination improvement (idi). results: the study cohort was comprised of 113 participants enrolled over 24 months with a mean age 49 (±11.7) years, 59% with cad at angiography. the median plasma concentration of acat2-ce was 938 lm (758, 1099) in patients with cad and 824 lm (683, 998) in patients without cad (p = 0.03) (figure) . when considered with age, sex, and the number of conventional cad risk factors, acat2-ce were associated with a 6.5% increased odds of having cad per 10 lm increase in concentration. the addition of acat2-ce significantly improved the c-statistic (0.89 vs 0.95, p = 0.0035) and idi (0.15, p < 0.001) compared to the reduced model. in the subgroup of low-risk observation unit patients, the ce model had superior discrimination compared to the diamond forrester classification (idi 0.403, p < 0.001). conclusion: plasma levels of acat2-ce, considered in a clinical model, have strong potential to predict a patient's likelihood of having cad. in turn, this could reduce the need for cardiac imaging after the exclusion of mi. further study of acat2-ce as biomarkers in patients with suspected acs is needed. background: outpatient studies have demonstrated a correlation between carotid intima-media thickness (cimt) on ultrasound and coronary artery disease (cad). there are no known published studies that investigate the role of cimt in the ed using cardiac ct or percutaneous cardiac intervention (pci) as a gold standard. objectives: we hypothesized that cimt can predict cardiovascular events and serve as a noninvasive tool in the ed. methods: this was a prospective study of adult patients who presented to the ed and required evaluation for chest pain. the study location was an urban ed with a census of 120,000 annual visits and 24-hour cardiac catheterization. patients who did not have ct or pci or had carotid surgery were excluded from the study. ultrasound cimt measurements of right and left common carotid arteries were taken with a 10mhz linear transducer (zonare, mountain view, ca). anterior, medial, and posterior views of the near and far wall were obtained (12 cimt scores total). images were analyzed by carotid analyzer 5 (mailing imaging application llc, coralville, iowa). patients were classified into two groups based on the results from ct or pci. a subject was classified as having significant cad if there was over 70% occlusion or multi-vessel disease. results: ninety of 102 patients were included in the study; 55.7% were males. mean age was 56.6 ± 13 years. there were 34 (37.8%) subjects with significant cad and 56 (62.2%) with non-significant cad. the mean of all 12 cimt measurements was significantly higher in the cad group than in the non-cad group (0.60 ± 0.20 vs. 0.35 ± 0.23; p < 0.00001). a logistic regression analysis was carried out with significant cad as the event of interest and the following explanatory variables in the model: objectives: to determine the diagnostic yield of routine testing in-hospital or following ed discharge among patients presenting to an ed following syncope. methods: a prospective, observational, cohort study of consecutive ed patients ‡18 years old presenting with syncope was conducted. the four most commonly utilized tests (echocardiography, telemetry, ambulatory electrocardiography monitoring, and cardiac markers) were studied. interobserver agreement as to whether tests results determined the etiology of the syncope was measured using kappa (k) values. results: of 570 patients with syncope, 150 (26%) had echocardiography with 33 (6%) demonstrating a likely etiology of the syncopal event such as critical valvular disease or significantly depressed left ventricular function (k = 0.78). on hospitalization, 349 (61%) patients were placed on telemetry, 19 (3%) of these had worrisome dysrhythmias (k = 0.66). 317 (55%) patients had troponin levels drawn of whom 19 (3%) had positive results (k = 1); 56 (10%) patients were discharged with monitoring with significant findings in only 2 (0.4%) patients (k = 0.65). overall, 73 (8%, 95% ci 7-10%) studies were diagnostic. conclusion: although routine testing is prevalent in ed patients with syncope, the diagnostic yield is relatively low. nevertheless, some testing, particularly echocardiography, may yield critical findings in some cases. current efforts to reduce the cost of medical care by eliminating non-diagnostic medical testing and increasing emphasis on practicing evidence-based medicine argue for more discriminate testing when evaluating syncope. (originally submitted as a ''late-breaker.'') unusual fatigue was reported by 70.7% (severe 29.7%) and insomnia by 47.8% (severe 21.0%). these findings have led to risk management recommendations to consider these symptoms as predictive of acute coronary syndromes (acs) among women visiting the ed. objectives: to document the prevalence of these symptoms among all women visiting an ed. to analyze the potential effect of using these symptoms in the ed diagnostic process for acs. methods: a survey on fatigue and insomnia symptoms was administered to a convenience sample of all adult women visiting an urban academic ed (all arrival modes, acuity levels, all complaints). a sensitivity analysis was performed using published data and expert opinion for inputs. results: we approached 548 women, with 379 enrollments. see table. the top box shows prevalences of prodromal symptoms among all adult female ed patients. the bottom box shows outputs from sensitivity analysis on the diagnostic effect of initiating an acs workup for all female ed patients reporting prodromal symptoms. conclusion: prodromal symptoms of acs are highly prevalent among all adult women visiting the ed in this study. this likely limits their utility in ed settings. while screening or admitting women with prodromal symptoms in the ed would probably increase sensitivity, that increase would be accompanied by a dramatic reduction in specificity. such a reduction in specificity would translate to admitting, observing, or working up somewhere between 29% and 61% of all women visiting the ed, which is prohibitive in terms of personal costs, risks of hospitalization, and financial costs. while these symptoms may or may not have utility in other settings such as primary care, their prevalence, and the implied lack of specificity for acs suggest they will not be clinically useful in the ed. length methods: we examined a cohort of low-risk chest pain patients evaluated in an ed-based ou using prospective and retrospective ou registry data elements. cox proportional hazard modeling was performed to assess the effect of testing modality (stress testing vs. ccta) on the los in the cdu. as ccta is not available on weekends, only subjects presenting on weekdays were included. cox models were stratified on time of patient presentation to the ed, based on four hour blocks beginning at midnight. the primary independent variable was first test modality, either stress imaging (exercise echo, dobutamine echo, stress mri) or ccta. age, sex, and race were included as covariates. the proportional hazards assumption was tested using scaled schoenfield residuals, and the models were graphically examined for outliers and overly influential covariate patterns. test selection was a time varying covariate in the 8am strata, and therefore the interaction with ln (los) was included as a correction term. after correction for multiple comparisons, an alpha of 0.01 was held to be significant. results: over the study period, 841 subjects (of 1,070 in the registry) presented on non-weekend days. the median los was 18.5 hours (iqr 12.4-23.3 hours), 57% were white, and 61% were female. the table shows the number of subjects in each time strata, the number tested, and the number undergoing stress testing vs. ccta. after adjusting all models for age, race, and sex, the hazard ratio (hr) for los is as shown. only those patients presenting between 8am and noon noted a significant improvement in los with ccta use (p < 0.0001). objectives: determine the validity of a managementfocused em osce as a measure of clinical skills by determining the correlation between osce scores and faculty assessment of student performance in the ed. methods: medical students in a fourth year em clerkship were enrolled in the study. on the final day of the clerkship students participated in a five-station em osce. student performance on the osce was evaluated using a task-based evaluation system with 3-4 critical management tasks per case. task performance was evaluated using a three-point system: performed correctly/timely (2), performed incorrectly/late (1), or not performed (0). descriptive anchors were used for performance criteria. communication skills were also graded on a three-point scale. student performance in the ed was based on traditional faculty assessment using our core-competency evaluation instrument. a pearson correlation coefficient was calculated for the relationship between osce score and ed performance score. case item analysis included determination of difficulty and discrimination. the acgme also requires that trainees are evaluated on these 6ccs during their residency. trainee evaluation in the 6ccs are frequently on a subjective rating scale. one of the recognized problems with a subjective scale is the rating stringency of the rater, commonly known as the hawk-dove effect. this has been seen in standardized clinical exam scoring. recent data have shown that score variance can be related to evaluator performance with a negative correlation. higher-scoring physicians were more likely to be a stringent or hawk type rater on the same evaluation. it is unclear if this pattern also occurs in the subjective ratings that are commonly used in assessments of the 6ccs. objectives: comparison of attending physician scores on the acgme 6ccs with attending ratings of residents for a negative correlation or hawk-dove effect. methods: residents are routinely evaluated on the 6ccs with a 1-9 numerical rating scale as part of their training. the evaluation database was retrospectively reviewed. residents anonymously scored attending physicians on the 6ccs with a cross-sectional survey that utilized the same rating scale, anchors, and prompts as the resident evaluations. average scores for and by each attending were calculated and a pearson correlation calculated by core competency and overall. results: in this irb-approved study, a total of 43 attending physicians were scored on the 6ccs with 447 evaluations by residents. attendings evaluated 162 residents with a total of 1,678 evaluations completed over a 5-year period. attending mode score was 9 ranging from 2 to 9; resident scores had a mode of 8 with a range of 1 to 9. there was no correlation between the rated performance of the attendings overall or in each 6ccs and the scores they gave (p = 0.065-0.861). conclusion: hawk-dove effects can be seen in some scoring systems and has the potential to affect trainee evaluation on the acgme core competencies. however, a negative correlation to support a hawk-dove scoring pattern was not found in em resident evaluations by attending physicians. this study is limited by being a single center study and utilizing grouped data to preserve resident anonymity. background: all acgme-accredited residency programs are required to provide competency-based education and evaluation. graduating residents must demonstrate competency in six key areas. multiple studies have outlined strategies for evaluating competency, but data regarding residents' self-assessments of these competencies as they progress through training and beyond is scarce. objectives: using data from longitudinal surveys by the american board of emergency medicine, the primary objective of this study was to evaluate if resident self-assessments of performance in required competencies improve over the course of graduate medical training and in the years following. additionally, resident self-assessment of competency in academic medicine was also analyzed. methods: this is a secondary data analysis of data gathered from two rounds of the abem longitudinal study of emergency medicine residents (1996-98 and 2001-03) and three rounds of the abem longitudinal study of emergency physicians (1999, 2004, 2009 ). in both surveys, physicians were asked to rate a list of 18 items in response to the question, ''what is your current level of competence in each of the following aspects of work in em?'' the rated items were grouped according to the acgme required competencies of patient care, medical knowledge, practice-based learning and improvement, interpersonal and communication skills, and system-based practice. an additional category for academic medicine was also added. results: rankings improved in all categories during residency training. rankings in three of the six categories improved from the weak end of the scale to the strong end of the scale. there is a consistent decline in rankings one year after graduation from residency. the greatest drop is in medical knowledge. mean self-ranking in academic medicine competency is uniformly the lowest ranked category for each year. conclusion: while self-assessment is of uncertain value as an objective assessment, these increasing rankings suggest that emergency medicine residency programs are successful at improving residents' confidence in the required areas. residents do not feel as confident about academic medicine as they do about the acgme required competencies. the uniform decline in rankings the first year after residency is an area worthy of further inquiry. screening medical student rotators from outside institutions improves overall rotation performance shaneen doctor, troy madsen, susan stroud, megan l. fix university of utah, salt lake city, ut background: emergency medicine is a rapidly growing field. many student rotations are limited in their ability to accommodate all students and must limit the number of students they allow per rotation. we hypothesize that pre-screening visiting student rotators will improve overall student performance. objectives: to assess the effect of applicant screening on overall rotation grade and mean end of shift card scores. methods: we initiated a medical student screening process for all visiting students applying to our 4-week elective em rotation starting in 2008. this consisted of reviewing board scores and requiring a letter of intent. students from our home institution were not screened. all end-of-shift evaluation cards and final rotation grades (honors, high pass, pass, fail) from 2004 to 2011 were analyzed. we identified two cohorts: home students (control) and visiting students. we compared pre-intervention (2004) (2005) (2006) (2007) (2008) and postintervention (2008-2011) scores and grades. end of shift performance scores are recorded using a fivepoint scale that assesses indicators such as fund of knowledge, judgment, and follow-through to disposition. mean ranks were compared and p-values were calculated using the armitage test of trend and confirmed using t-tests. results: we identified 162 visiting students (91 pre, 81 post) and 160 home students (90 pre, 80 post). 12 (13.2%) visiting students achieved honors pre-intervention while 31 (38.3%) achieved honors post-intervention (p = 0.000093). no significant difference was seen in home student grades: 28 (31.1%) received honors pre-2008 and 17 (21.3%) received honors post-2008 conclusion: we found that implementation of a screening process for visiting medical students improved overall rotation scores and grades as compared to home students who did not receive screening. screening rotating students may improve the overall quality of applicants and thereby the residency program. background: there are many descriptions in the literature of computer-assisted instruction in medical education, but few studies that compare them to traditional teaching methods. objectives: we sought to compare the suturing skills and confidence of students receiving video preparation before a suturing workshop versus a traditional instructional lecture. methods: 88 first and second year medical students were randomized into two groups. the control group was given a lecture followed by 40 minutes of suturing time. the video group was provided with an online suturing video at home, no lecture, and given 40 minutes of suturing time during the workshop. both groups were asked to rate their confidence before and after the workshop, and their belief in the workshop's effectiveness. each student was also videotaped suturing a pig's foot after the workshop and graded on a previously validated 16-point suturing checklist. 83 videos were scored. results: there was no significant difference between the test scores of the lecture group (m = 11.21, sd = 3.17, n = 42) and the video group (m = 11.27, sd = 2.53, n = 41) using the two-sample independent ttest for equal variances (t(81) = )0.09, p = 0.93). there was a statistically significant difference in the proportion of students scoring correctly for only one point: ''curvature of needle followed'': 25/42 in the lecture group and 35/41 in the video group (chi = 6.92, df = 1, p = 0.008). students in the video group were found to be 2.45 times more likely to have a neutral or favorable feeling of suturing confidence before the workshop (p = 0.067, ci 0.94-6.4) using a proportional odds model. no association was detected between group assignment and level of suturing confidence after the workshop (p = 0.475). there was also no association detected between group assignment and opinion of the suturing workshop (p = 0.681) using a logistic regression odds model. among those students who indicated a lack of confidence before training, there was no detected association (p = 0.967) between group assignment and having an improved confidence using a logistic regression odds model. conclusion: students in the video group and students in the control group achieved similar levels of suturing skill and confidence, and equal belief in the workshop's effectiveness. this study suggests that video instruction could be a reasonable substitute for lectures in procedural education. background: accurate interpretation of the ecg in the emergency department is not only clinically important but also critical to assess medical knowledge competency. with limitations to expansion of formal didactics, educational technology offers an innovative approach to improve the quality of medical education. objectives: the aim of this study was to assess an online multimedia-based ecg training module evaluating st elevation myocardial infarction (stemi) identification among medical students. methods: a convenience sample of fifty-two medical students on their em rotations at an academic medical center with an em residency program was evaluated in a before-after fashion during a 6-month period. one cardiologist and two ed attending physicians independently validated a standardized exam of ten ecgs: four were normal ecgs, three were classic stemis, and three were subtle stemis. the gold standard for diagnosis was confirmed acute coronary thrombus during cardiac catheterization. after evaluating the 10 ecgs, students completed a pre-intervention test wherein they were asked to identify patients who required emergent cardiac catheterization based on the presence or absence of st segment elevation on ecg. students then completed an online interactive multimedia module containing 13 minutes of stemi training based on american heart association/american college of cardiology guidelines on stemi. medical students were asked to complete a post-test of the 10 ecgs after watching online multimedia. objectives: our objective was to quantify the number of pre-verbal pediatric head cts performed at our community hospital that could have been avoided by utilizing the pecarn criteria. methods: we conducted a standardized chart review of all children under the age of 2 who presented to our community hospital and received a head ct between jan 1st, 2010 and dec 31st, 2010. following recommended guidelines for conducting a chart review, we: 1) utilized four blinded chart reviewers, 2) provided specific training, 3) created a standardized data extraction tool, and 4) held periodic meetings to evaluate coding discrepancies. our primary outcome measure was the number of patients who were pecarn negative and received a head ct at our institution. our secondary outcome was to reevaluate the sensitivity and specificity of the pecarn criteria to detect citbi in our cohort. data were analyzed using descriptive statistics and 95% confidence intervals were calculated around proportions using the modified wald method. results: a total of 138 patients under the age of 2 received a head ct at our institution during the study period. 23 patients were excluded from the final analysis because their head cts were not for trauma. the prevalence of a citbi in our cohort was 2.6% (95% ci 0.6%-7.7%) ( (dti) measures disruption of axonal integrity on the basis of anisotropic diffusion properties. findings on dti may relate to the injury, as well as the severity of postconcussion syndrome (pcs) following mtbi. objectives: to examine acute anisotropic diffusion properties based on dti in youth with mtbi relative to orthopedic controls and to examine associations between white matter (wm) integrity and pcs symptoms. methods: interim analysis of a prospective casecontrol cohort involving 12 youth ages 11-16 years with mtbi and 10 orthopedic controls requiring extremity radiographs. data collected in ed included demographics, clinical information, and pcs symptoms measured by the postconcussion symptom scale. within 72 hours of injury, symptoms were re-assessed and a 61-direction, diffusion weighted, spin-echo imaging scan was performed on a 3t philips scanner. dti images were analyzed using tract-based spatial statistics. fractional anisotropy (fa), mean diffusivity (md), axial diffusivity (ad), and radial diffusivity were measured. results: there were no group demographic differences between mtbi cases and controls. presenting symptoms within the mtbi group included gcs = 15 83%, loss of consciousness 33%, amnesia 33%, post-traumatic seizure 8%, headache 83%, vomiting 33%, dizziness 42%, and confusion 42%. pcs symptoms were greater in mtbi cases than in the controls at ed visit (30.1 ± 17.0 vs. 15.5 ± 16.8, p < 0.06) and at the time of scan (19.1 ± 12.9 vs. 5.7 ± 6.5, p < 0.01). the mtbi group displayed decreased fa in cerebellum and increased md and ad in the cerebral wm relative to controls (uncorrected p < 0.05). increased fa in cerebral wm was also observed in mtbi patients but the group difference was not significant. pcs symptoms at the time of the scan were positively correlated with fa and inversely correlated with rd in extensive cerebral wm areas (p < 0.05, uncorrected). in addition, pcs symptoms in mtbi patients were also found to be inversely correlated with md, ad, and rd in cerebellum (p < 0.05). conclusion: dti detected axonal damage in youth with mtbi which correlated with pcs symptoms. dti performed acutely after injury may augment detection of injury and help prediction of those with worse outcomes. background: sports-related concussion among professional, collegiate, and more recently high school athletes has received much attention from the media and medical community. to our knowledge, there is a paucity of research in regard to sports-related concussion in younger athletes. objectives: the aim of this study was to evaluate parental knowledge of concussion in young children who participate in recreational tackle football. methods: parents/legal guardians of children aged 5-15 years enrolled in recreational tackle football were asked to complete an anonymous questionnaire based on the cdc's heads up: concussion in youth sports quiz. parents were asked about their level of agreement in regard to statements that represent definition, symptoms, and treatment of concussion. results: a total of 310 out of 369 parents voluntarily completed the questionnaire (84% response rate). parent and child demographics are listed in table 1 . ninety four percent of parents believed their child had never suffered a concussion. however, when asked to agree or disagree with statements addressing various aspects of concussion, only 13% (n = 41) could correctly identify all seven statements. most did not identify that a concussion is considered a mild traumatic brain injury and can be achieved from something other than a direct blow to the head. race, sex, and zip code had no significant association with correctly answering statements. education (0.24; p < 0.01) and number of years the child played (0.11; p < 0.05) had a small effect. fifty-three percent of parents reported someone had discussed the definition of concussion with them and 58% the symptoms of concussion. see table 2 for source of information to parents. no parent was able to classify all symptoms listed as correctly related or not related to concussion. however, identification of correct concussion definitions correlated with identification of correct symptoms (0.25; p < 0.05). conclusion: while most parents had received some education regarding concussion from a health care provider, important misconceptions remain among parents of young athletes regarding the definition, symptoms, and treatment of concussion. this study highlights the need for health care providers to increase educational efforts among parents of young athletes in regard to concussion. figure 1 ). 2/2 (100%) of patients with baseline liver dysfunction were 25(oh)d deficient and 5/6 (83%) of deaths were patients who had insufficient levels of 25(oh)d. there was an inverse association between 25(oh)d level and tnf-a (p = 0.03; figure 2 ) and il-6 (p = 0.04). background: fever is common in the emergency department (ed), and 90% of those diagnosed with severe sepsis present with fever. despite data suggesting that fever plays an important role in immunity, human data conflict on the effect of antipyretics on clinical outcomes in critically ill adults. objectives: to determine the effect of ed antipyretic administration on 28-day in-hospital mortality in patients with severe sepsis. methods: single-center, retrospective observational cohort study of 171 febrile severe sepsis patients presenting to an urban academic 90,000-visit ed between june 2005 and june 2010. all ed patients meeting the following criteria were included: age ‡ 18, temperature ‡ 38.3°c, suspected infection, and either systolic blood pressure £ 90 mmhg after a 30 ml/kg fluid bolus or lactate of ‡ 4. patients were excluded for a history of cirrhosis or acetaminophen allergy. antipyretics were defined as acetaminophen, ibuprofen, or ketorolac. results: one hundred-thirty five (78.9%) patients were treated with an antipyretic medication (89.4% acetaminophen). intubated patients were less likely to receive antipyretic therapy (51.9% vs. 84.0%, p < 0.01), but the groups were otherwise well matched. patients requiring ed intubation (n = 27) had much higher in-hospital mortality (51.9% vs. 7.6%, p < 0.01). patients given an antipyretic in the ed had lower mortality (11.9% vs. 25.0%, p < 0.05). when multivariable logistic regression was used to account for apache-ii, intubation status, and fever magnitude, antipyretic therapy was not associated with mortality (adjusted or 0.97, 0.31-3.06, p = 0.96). conclusion: although patients treated with antipyretic therapy had lower 28-day in-hospital mortality, antipyretic therapy was not independently associated with mortality in multivariable regression analysis. these findings are hypothesis-generating for future clinical trials, as the role of fever control has been largely unexplored in severe sepsis (grant ul1 rr024992, nih-ncrr). , and caval index )0.09 ± 0.14 (ci )0.14, )0.05) and all were statistically significant. the groups receiving 10 ml/kg and 30 ml/kg had statistically significant changes in caval index; however the 30 ml/kg group had no significant change in mean ivc diameter. one-way anova differences between the means of all groups were not statistically different. conclusion: overall, there were statistically significant differences in mean ivc-us measurements before and after fluid loading, but not between groups. fasting asymptomatic subjects had a wide inter-subject variation in both baseline ivc-us measurements and fluid-related changes. the wide differences within our 30 ml/kg group may limit conclusions regarding proportionality. there were significant differences in performance on ed measures by ownership (p < 0.0001) and region (p = 0.0002). scores on ed process measures were highest at for-profit hospitals (27% above average) and hospitals in the south (5% above average), and lowest at public hospitals (16% below average) and hospitals in the northeast (8% below average). conclusion: there was considerable variation in performance on the ed measures included in the vbp program by hospital ownership and region. ed directors may come under increasing pressure to improve scores in order to reduce potential financial losses under the program. our data provide early information on the types of hospitals with the greatest opportunity for improvement. methods: design/setting -an independent agency mandated by the government collected and analyzed ed patient experience data using a comprehensive, validated multidimensional instrument and a random periodic sampling methodology of all ed patients. a prospective pre-post experimental study design was employed in the eight community and tertiary care hospitals most affected by crowding. two 5.5 month study periods were evaluated (pre: 28/06-12/12/2010; post: 13/12/2010-29/ 05/2011). outcomes -the primary outcome was patient perception of wait times and crowding reported as a composite mean score (0-100) from six survey items with higher scores representing better ratings. the overall rating of care by ed patients (composite score) and other dimensions of care were collected as secondary outcomes. all outcomes were compared using chi-square and two-tailed student's t-tests. results: a total of 3774 surveys were completed in both the pre-ocp and post-ocp study periods representing a response rate of 45%. we compared in-patient mortality from ami for patients who lived in a community with either 2.5 miles or 5 miles of a closure but did not need to travel farther to the nearest ed with those who did not. we used patient-level data from the california office of statewide health and planning development (oshpd) database patient discharge data, and locations of patient residence and hospitals were geo-coded to determine any changes in distance to the nearest ed. we applied a generalized linear mixed effects model framework to estimate a patient's likelihood to die in the hospital of ami as a function of being affected by a neighborhood closure event. results background: fragmentation of care has been recognized as a problem in the us health care system. however, little is known about ed utilization after hospitalization, a potential marker of poor outpatient care coordination after discharge, particularly for common inpatient-based procedures. objectives: to determine the frequency and variability in ed visits after common inpatient procedures, how often they result in readmission, and related payments. methods: using national medicare data for 2005-2007, we examined ed visits within 30 days of hospital discharge after six common inpatient procedures: percutaneous coronary intervention, coronary artery bypass grafting (cabg), elective abdominal aortic aneurysm repair, back surgery, hip fracture repair, and colectomy. we categorized hospitals into risk-adjusted quintiles based on the frequency of ed visits after the index hospitalization. we report visits by primary diagnosis icd-9 codes and rates of readmission. we also assessed payments related to these ed visits. results: overall, the highest quintile of hospitals had 30-day ed visit rates that ranged from a low of 17.8% with an associated 7.3% readmission rate (back surgery) to a high of 27.8% with an associated 13.6% readmission rate (cabg). the most variability was more than 3-fold and found among patients undergoing colectomy in which the worst-performing hospitals saw 24.1% of their patients experienced an ed visit within 30 days while the best-performing hospitals saw 7.4%. average total payments for the 30-day window from initial discharge across all surgical cohorts varied from $18,912 for patients discharged without subsequent ed visit; $20,061for those experiencing an ed visit(s); $38,762 for those readmitted through the ed; and $33,632 for those readmitted from another source. if all patients who did not require readmission also did not incur an ed visit within the 30-day window, this would represent a potential cost savings of $125 million. conclusion: among elderly medicare recipients there was significant variability between hospitals for 30-day ed visits after six common inpatient procedures. the ed visit may be a marker of poor care coordination in the immediate discharge period. this presents an opportunity to improve post-procedure outpatient care coordination which may save costs related to preventable ed visits and subsequent readmissions. objectives: we sought to assess the effect of pharmacist medication review on ed patient care, in particular time from physician order to medication administration for the patient (order-to-med time). methods: we conducted a multi-center, before-after study in two eds (urban academic teaching hospital and suburban community hospital, combined census of 61,000) after implementation of the electronic prospective pharmacy review system (prs). the system allowed a pharmacist to review all ed medication orders electronically at the time of physician order and either approve or alter the order. we studied a 5-month time period before implementation of the system (pre-prs, 7/1/10-11/30/11) and after implementation (post-prs, 7/ 1/11-11/30/11). we collected data on all ed medication orders including dose, route, class, pharmacist review action, time of physician order, and time of medication administration. differences in order-to-medication between the pre-and post-prs study periods were compared using a results: ed metrics that were significantly associated with lbtcs varied across ed patient-volume categories (table) . for eds seeing less than 20k patients annually, the percentage of ems arrivals admitted to the hospital and ed square footage were both weakly associated with lbtcs (p = 0.09). for eds seeing at least 20k-39k patients, median ed length of stay (los), percent of patients admitted to hospital through the ed, percent of ems arrivals admitted to hospital, and percent of pediatric patients were all positively associated, while percent of patients admitted to the hospital was negatively associated with lbtcs. for eds seeing 40k-59k, median los and percent of x-rays performed were positively associated, while percent of ekgs performed was negatively associated with lbtcs. for eds seeing 60k-79k, percent of patients admitted to the hospital through the ed was negatively associated and percent of ekgs performed was positively associated with lbtcs. for eds with volume greater than 80k, none of the selected variables were associated with lbtc. conclusion: ed factors that help explain high lbtc rates differ depending on the size of an ed. interventions attempting to improve lbtc rates by modifying ed structure or process will need to consider baseline ed volume as a potential moderating influence. objectives: our study sought to compare bacterial growth of samples taken from surfaces after use of a common approved quat compound and a virtually non-toxic, commercially available solution containing elemental silver (0.02%), hydrogen peroxide (15%), and peroxyacetic acid (20%) (shp) in a working ed. we hypothesized that, based on controlled laboratory data available, shp compound would be more effective on surfaces in an active urban ed. methods: we cleaned and then sampled three types of surfaces in the ed (suture cart, wooden railing, and the floor) during midday hours one minute after application of tap water, quat, and shp and then again at 24 hours without additional cleaning. conventional environmental surface surveillance rodac media plates were used for growth assessment. images of bacterial growth were quantified at 24 and 48 hours. standard cleaning procedures by hospital staff were maintained per usual. results: shp was superior to control and quat one minute after application on all three surfaces. quat and water had 10x and 40x more bacterial growth than the surface cleaned with shp, respectively. 24 hours later, the shp area produced fewer colonies sampled from the wooden railing: 4x more bacteria for quat, and 5x for water when compared to shp. 24h cultures from the cart and floor had confluent growth and could not be quantified. conclusion: shp outperforms quat in sterilizing surfaces after one minute application. shp may be a superior agent as a non-toxic, non-corrosive, and effective agent for surfaces in the demanding ed setting. further studies should examine sporidical and virucidal properties in a similar environment. objectives: evaluate the effect on patient satisfaction of increasing waiting room times and physician evaluation times. methods: emergency department flow metrics were collected on a daily basis as well as average daily patient satisfaction scores. the data were from july 2010 through february 2011, in a 44,000 census urban hospital. the data were divided into equal intervals. the arrival to room time was divided by 15 minute intervals up to 135 minutes with the last group being greater than 136 minutes. the physician evaluation times were divided into 20 minute intervals, up to 110, the last group greater than 111 with 46 days in the group. data were analyzed using means and standard deviations, and well as anova for comparison between groups. results: the overall satisfaction score for the outpatient emergency visit was higher when the patient was in a room within 15 minutes of arrival (88.4, std deviation 5.9), analysis of variation between the groups had a p = 0.13, for the means of each interval (see table 1 ). the total satisfaction with the visit as well as satisfaction with the provider dropped when the evaluation extended over 110 minutes, but was not statistically significant on anova analysis (see table 2 for means). conclusion: once a patient's time in the waiting room extends beyond 15 minutes, you have lost a significant opportunity for patient satisfaction; once they have been in the waiting room for over 120 minutes, you are also much more likely to receive a poor score. physician evaluation time scores are much more consistent but as longer evaluation times occurred beyond total of 110 minutes we started to see a trend downward in the satisfaction score. results: in all three eds, pain medication rates (both in ed and rx) varied significantly by clinical factors including location of pain, discharge diagnosis, pain level, and acuity. we observed little to no variation in pain medication rates by patient factors such as age, sex, race, insurance, or prior ed visits. the table displays key pain management practices by site and provider. after adjusting for patient and clinical characteristics, significant differences in pain medication rates remained by provider and site (see figure) . conclusion: within this health system, the approach to pain management by both providers and sites is not standardized. investigation of the potential effect of this variability on patient outcomes is warranted. results: all measures showed significant differences, p < 0.01. average pts/h decreased post-cpoe and did not recover post transitional period, 1.92 ± 0.13 vs 1.75 ± 0.11, p < 0.05. rvu/h also decreased post-cpoe and did not recover post transitional period, 5.23 ± 0.37 vs 4.79 ± 0.32 and 4.82 ± 0.33, p < 0.05. charges/h also decreased after cpoe implementation and did not recover after system optimization. there was a sustained significant decrease in charges/h of 4.5% ± 6.5% post cpoe and 3.6% ± 6.4% post optimization, p < 0.05. sub-group analysis for each provider group was also evaluated and showed variability for different providers. conclusion: there was a significant decrease in all productivity metrics four months after the implementation of cpoe. the system did undergo optimization initiated by providers with customization for ease and speed of use. however, productivity measurements did not recover after these changes were implemented. these data show that with the implementation of a cpoe system there is a decrease in productivity that continues even after a transition period and system customization. background: procedural competency is a key component of emergency medicine residency training. residents are required to log procedures to document quantity of procedures and identify potential weaknesses in their training. as emergency medicine evolves, it is likely that the type and number of procedures change over time. also, exposure to certain rare procedures in residency is not guaranteed. objectives: we seek to delineate trends in type and volume of core em procedures over a decade of emergency medicine residents graduating from an accredited four-year training program. methods: deidentified procedure logs from 2003-2011 were analyzed to assess trends in type and quantity of procedures. procedure logs were self-reported by individual residents on a continuous basis during training onto a computer program. average numbers of procedures per resident in each graduating class were noted. statistical analysis was performed using spss and includes a simple linear regression to evaluate for significant changes in number of procedures over time and an independent samples two-tailed t-test of procedures performed before and after the required resident duty hours change. results: a total of 112 procedure logs were analyzed and the frequency of 29 different procedures was evaluated. a significant increase was seen in one procedure, the venous cutdown. significant decreases were seen in 12 procedures including key procedures such as central venous catheters, tube thoracostomy, and procedural sedation. the frequency of five high-stakes/ resuscitative procedures, including thoracotomy and cricothyroidotomy, remained steady but very low (<4 per resident over 4 years). of the remaining 11 procedures, 8 showed a trend toward decreased frequency, while only 5 increased. conclusion: over the past 9 years, em residents in our program have recorded significantly fewer opportunities to perform most procedures. certain procedures in our emergency medicine training program have remained stable but uncommon over the course of nearly a decade. to ensure competency in uncommon procedures, innovative ways to expose residents to these potentially life saving skills must be considered. these may include practice on high-fidelity simulators, increased exposure to procedures on patients during residency (possibly on off-service rotations), or practice in cadaver and animal labs. objectives: to study the effectiveness of a unique educational intervention using didactic and hands-on training in usgpiv. we hypothesized that senior medical students would improve performance and confidence with usgpiv after the simulation training. methods: fourth year medical students were enrolled in an experimental, prospective, before and after study conducted at a university medical school simulation center. baseline skills in participant's usgpiv on simulation vascular phantoms were graded by ultrasound expert faculty using standardized checklists. the primary outcome was time to cannulation, and secondary outcomes were ability to successfully cannulate, number of needle attempts, and needle-tip visualization. subjects then observed a 15-minute presentation on correct performance of usgpiv followed by a 30-minute hands-on practical session using the vascular simulators with a 1:4 to 1:6 ultrasound instructor to student ratio. an expert blinded to the participant's initial performance graded post-educational intervention usgpiv ability. pre-and post-intervention surveys were obtained to evaluate usgpiv confidence, previous experience with ultrasound, peripheral iv access, usg-piv, and satisfaction with the educational format. objectives: this study examines the grade distribution of resident evaluations when the identity of the evaluator was anonymous as compared to when the identity of the evaluator was known to the resident. we hypothesize that there will be no change in the grades assigned to residents. methods: we retrospectively reviewed all faculty evaluations of residents and grades assigned from july 1, 2008 through november 15, 2011. prior to july 1, 2010 the identity of the faculty evaluators was anonymous, while after this date, the identity of the faculty evaluators was made known to the residents. throughout this time period, residents were graded on a five-point scale. each resident evaluation included grades in the six acgme core competencies as well as in select other abilities. specific abilities evaluated varied over the dates analyzed. evaluations of residents were assigned to two groups, based on whether the evaluator was anonymous or made known to the resident. grades were compared between the two groups. results: a total of 10,760 grades were assigned in the anonymous group, with an average grade of 3.90 (95ci 3.88, 3.91). a total of 7,122 grades were assigned in the known group with an average grade of 3.77 (95ci 3.75, 3.79). specific attention was paid to assignment of unsatisfactory grades (1 or 2 on the five-point scale). the anonymous group assigned 355 grades in this category, comprising 3.3% of all grades assigned. the known group assigned 100 grades in this category, comprising 1.4% of all grades assigned. unsatisfactory grades were assigned by the anonymous group 1.9% (95ci 1.5, 2.3) more often. additionally, 5.8% (95ci 3.8, 6.8) fewer exceptional grades (4 or 5 on the five-point scale) were assigned by the anonymous group. conclusion: the average grade assigned was closer to average (3 on a five-point scale) when the identity of the evaluator was made known to the residents. additionally, fewer unsatisfactory and exceptional grades were assigned in this group. this decrease of both unsatisfactory and exceptional grades may make it more difficult for program directors to effectively identify struggling and strong residents respectively. testing to improve knowledge retention from traditional didactic presentations: a pilot study david saloum, amish aghera, brian gillett maimonides medical center, brooklyn, ny background: the acgme requires an average of at least 5 hours of planned educational experiences each week for em residents, which traditionally consists of formal lecture based instruction. however, retention by adult learners is limited when presented material in a lecture format. more effective methods such as small group sessions, simulation, and other active learning modalities are time-and resource-intensive and therefore not practical as a primary method of instruction. thus, the traditional lecture format remains heavily relied upon. efficient strategies to improve the effectiveness of lectures are needed. testing utilized as a learning tool to force immediate recall of lecture material is an example of such a strategy. objectives: to evaluate the effect of immediate postlecture short answer quizzes on em residents' retention of lecture content. methods: in this prospective randomized controlled study, em residents from a community based 3-year training program were randomized into two groups. block randomization provided a similar distribution of postgraduate year training levels and performance on both us-mle and in-training examinations between the two groups. each group received two identical 50-minute lectures on ecg interpretation and aortic disease. one group of residents completed a five-question short answer quiz immediately following each lecture (n = 13), while the other group received the lectures without subsequent quizzes (n = 16). the quizzes were not scored or reviewed with the residents. two weeks later, retention was assessed by testing both groups with a 20-question multiple choice test (mct) derived in equal part from each lecture. mean and median test results were then compared between groups. statistical significance was determined using a paired t-test of median test scores from each group. results: residents who received immediate post-lecture quizzes demonstrated significantly higher mct scores (mean = 57%, median 58%, n = 10) compared to those receiving lectures alone (mean = 48%, median = 50%, n = 15); p = 0.023. conclusion: short answer testing immediately after a traditional didactic lecture improves knowledge retention at a 2-week interval. limitations of the study are that it is a single center study and long term retention was not assessed. background: the task of educating the next generation of physicians is steadily becoming more difficult with the inherent obstacles that exist for faculty educators and the work hour restrictions that students must adhere to. the obstacles make developing curricula that not only cover important topics but also do so in a fashion that helps support and reinforce the clinical experiences very difficult. several areas of medical education are using more asynchronous techniques and self-directed online educational modules to overcome these obstacles. objectives: the aim of this study was to demonstrate that educational information pertaining to core pediatric emergency medicine topics could be as effectively disseminated to medical students via self-directed online educational modules as it could through traditional didactic lectures. methods: this was a prospective study conducted from august 1, 2010 through december 31, 2010. students participating in the emergency medicine rotation at carolinas medical center were enrolled and received education in a total of eight core concepts. the students were divided into two groups which changed on a monthly basis. group 1 was taught four concepts via self-directed online modules and four traditional didactic lectures. group 2 was taught the same core concepts, but in opposite fashion to group 1. each student was given a pre-test, post-test, and survey at the conclusion of the rotation. results: a total of 28 students participated in the study. students, regardless of which group assigned, performed similarly on the pre-test, with no statistical difference among scores. when looking at the summative total scores between online and traditional didactic lectures, there was a trend towards significance for more improvement among those taught online. the student's assessment of the online modules showed that the majority either felt neutral or preferred the online method. the majority thought the depth and length of the modules were perfect. most students thought having access to the online modules was valuable and all but one stated that they would use them again. conclusion: this study demonstrates that self-directed, online educational modules are able to convey important concepts in emergency medicine similar to traditional didactics. it is an effective learning technique that offers several advantages to both the educator and student. background: critical access hospitals (cah) provide crucial emergency care to rural populations that would otherwise be without ready access to health care. data show that many cah do not meet standard adult quality metrics. adults treated at cah often have inferior outcomes to comparable patients cared for at other community-based emergency departments (eds). similar data do not exist for pediatric patients. objectives: as part of a pilot project to improve pediatric emergency care at cah, we sought to determine whether these institutions stock the equipment and medications necessary to treat any ill or injured child who presents to the ed. methods: five north carolina cah volunteered to participate in an intensive educational program targeting pediatric emergency care. at the initial site visit to each hospital, an investigator, in conjunction with the ed nurse manager, completed a 109-item checklist of commonly required ed equipment and medications based on the 2009 acep ''guidelines for care of children in the emergency department''. the list was categorized into monitoring and respiratory equipment, vascular access supplies, fracture and trauma management devices, and specialized kits. if available, adult and pediatric sizes were listed. only hospitals stocking appropriate pediatric sizes of an item were counted as having that item. the pharmaceutical supply list included antibiotics, antidotes, antiemetics, antiepileptics, intubation and respiratory medications, iv fluids, and miscellaneous drugs not otherwise categorized. results: overall, the hospitals reported having 91% of the items listed (range 87-96%). the two greatest deficiencies were fracture devices (range 33-66%), with no hospital stocking infant-sized cervical collars, and antidotes, with no hospital stocking pralidoxime, 1/5 hospitals stocking fomepizole, and 2/5 hospitals stocking pyridoxine and methylene blue. only one of the five institutions had access to prostaglandin e. the hospitals stated cost and rarity of use as the reason for not stocking these medications. conclusion: the ability of cah to care for pediatric patients does not appear to be hampered by a lack of equipment. ready access to infrequently used, but potentially lifesaving, medications is a concern. tertiary care centers preparing to accept these patients should be aware of these potential limitations as transport decisions are made. background: while incision and drainage (i&d) alone has been the mainstay of management of uncomplicated abscesses for decades, some advocate for adjunct antibiotic use, arguing that available trials are underpowered and that antibiotics reduce treatment failures and recurrence. objectives: to investigate the role of antibiotics in addition to i&d in reducing treatment failure as compared to management with i&d alone. methods: we performed a search using medline, embase, web of knowledge, and google scholar databases (with a medical librarian) to include trials and observational studies analyzing the effect of antibiotics in human subjects with skin and soft-tissue abscesses. two investigators independently reviewed all the records. we performed three overlapping meta-analy-ses: 1. only randomized trials comparing antibiotics to placebo on improvement of the abscess during standard follow-up. 2. trials and observational studies comparing appropriate antibiotics to placebo, no antibiotics, or inappropriate antibiotics (as gauged by wound culture) on improvement during standard follow-up. 3. only trials, but broadened outcome to include recurrence or new lesions during a longer follow-up period as treatment failure. we report pooled risk ratios (rr) using a fixed-effects model for our point estimates with shore-adjusted 95% confidence intervals (ci). results: we screened 1,937 records, of which 12 studies fit inclusion criteria, 9 of which were meta-analyzed (5 trials, 4 observational studies) because they reported results that could be pooled. of the 9 studies, 5 enrolled subjects from the ed, 2 from a soft-tissue infection clinic, and 2 from a general hospital without definition of enrollment site. five studies enrolled primarily adults, 3 pediatrics, and 1 without specification of ages. after pooling results for all randomized trials only, the rr = 1.03 (95% ci: 0.97-1.08). exposure being ''appropriate'' antibiotics (using trials and observational studies) resulted in a pooled rr = 1.01 (95% ci: 0.98-1.03). when we broadened our treatment failure criteria to include recurrence or new lesions at longer lengths of follow-up (trials only), we noted a rr = 1.05 (95% ci: 0.97-1.15). conclusion: based on available literature pooled for this analysis, there is no evidence to suggest any benefit from antibiotics in addition to i&d in the treatment of skin and soft tissue abscesses. (originally submitted as a ''late-breaker.'') primary objectives: to compare wound healing and recurrence rates after primary vs. secondary closure of drained abscesses. we hypothesized the percentage of drained ed abscesses that would be completely healed at 7 days would be higher after primary closure. methods: this randomized clinical trial was undertaken in two academic emergency departments. immunocompetent adult patients with simple, localized cutaneous abscesses were randomly assigned to i & d followed by primary or secondary closure. randomization was balanced by center, with an allocation sequence based on a block size of four, generated by a computer random number generator. the primary outcome was percentage of healed wounds seven days after drainage. a sample of 50 patients had 80% power to detect an absolute difference of 40% in healing rates assuming a baseline rate of 25%. all analyses were by intention to treat. results: twenty-seven patients were allocated to primary and 29 to secondary closure, of whom 23 and 27, respectively, were followed to study completion. healing rates at seven days were similar between the primary and secondary closure groups ( we compared 100 consecutive patients each scanned on the 64 or 320 slice ccta in 2010-2011. measures and outcomes-data were prospectively collected using standardized data collection forms required prior to performing ccta. the main outcomes were cumulative radiation doses and volumes of intravenous contrast. data analysis-groups compared with t-, mann whitney u, and chi-square tests. results: the mean age of patients imaged with the 64 and 320 scanners were 49 (sd 10) vs. 51 (13) (p = 0.27). male:female ratios were also similar (57:43 vs. 51:49 respectively, p = 0.40). both mean (p < 0.001) and median (p = 0.006) effective radiation dose were significantly lower with the 320 (6.8 and 6 msv) vs. the 64-slice scanner (12.2 and 10 msv) respectively. prospective gating was successful in 100% of the 320 scans and only in 38% of the 64 scans (p < 0.001). mean iv contrast volumes were also lower for the 320 vs. the 64-slice scanner (74 ± 10 vs. 96 ± 12 ml; p < 0.001). the % non-diagnostic scans was similarly low in both scanners (3% each). there were no differences in use of beta-blockers or nitrates. conclusion: when compared with the 64-slice scanner, the 320-slice scanner reduces the effective radiation doses and iv contrast volumes in ed patients with cp undergoing ccta. need for beta-blockers and nitrates was similar and both scanners achieved excellent diagnostic image quality. background: a few studies have demonstrated that bedside ultrasound measurement of inferior vena cava to aorta (ivc-to-ao) ratio is associated with the level of dehydration in pediatric patients and a proposed cutoff of 0.8 has been suggested, below which a patient is considered dehydrated. objectives: we sought to externally validate the ability of ivc-to-ao ratio to discriminate dehydration and the proposed cutoff of 0.8 in an urban pediatric emergency department (ed). methods: this was a prospective observational study at an urban pediatric ed. we included patients aged 3 to 60 months with clinical suspicion of dehydration by the ed physician and an equal number of control patients with no clinical suspicion of dehydration. we excluded children who were hemodynamically unstable, had chronic malnutrition or failure to thrive, open abdominal wounds, or were unable to provide patient or parental consent. a validated clinical dehydration score (cds) (range 0 to 8) was used to measure initial dehydration status. an experienced sonographer blinded to the cds and not involved in the patient's care measured the ivc-to-ao ratio on the patient prior to any hydration. cds was collapsed into a binary outcome of no dehydration or any level of dehydration (1 or higher). the ability of ivc-to-ao ratio to discriminate dehydration was assessed using area under the receiver operating characteristic curve (auc) and the sensitivity and specificity of ivc-to-ao ratio was calculated for three cutoffs (0.6, 0.8, 1.0). calculation of auc was repeated after adjusting for age and sex. results: 92 patients were enrolled, 39 (42%) of whom had a cds of 1 or higher. median age was 28 (interquartile range 16-39) months, and 53 (58%) were female. the ivcto-ao ratio showed an unadjusted auc of 0.66 (95% ci 0.54-0.77) and adjusted auc of 0.67 (95% ci 0.56-0.79). for a cutoff of 0.6 sensitivity was 26% (95% ci 13%-42%) and specificity 92% (95% ci 82%-98%); for a cutoff of 0.8 sensitivity was 51% (95% ci 35%-68%) and specificity 74% (95% ci 60%-85%); for a cutoff of 1.0 sensitivity was 79% (95% ci 64%-91%) and specificity 40% (95% ci 26%-54%). conclusion: the ability of the ivc-to-ao ratio to discriminate dehydration in young pediatric ed patients was modest and the cutoff of 0.8 was neither sensitive nor specific. background: while early cardiac computed tomographic angiography (ccta) could be more effective to manage emergency department (ed) patients with acute chest pain and intermediate (>4%) risk of acute coronary syndrome (acs) than current management strategies, it also could result in increased testing, cost, and radiation exposure. objectives: the purpose of the study was to determine whether incorporation of ccta early in the ed evaluation process leads to more efficient management and earlier discharge than usual care in patients with acute chest pain at intermediate risk for acs. methods: randomized comparative effectiveness trial enrolling patients between 40-75 years of age without known cad, presenting to the ed with chest pain but without ischemic ecg changes or elevated initial troponin and require further risk stratification for decision making, at nine us sites. patients are being randomized to either ccta as the first diagnostic test or to usual care, which could include no testing or functional testing such as exercise ecg, stress spect, and stress echo following serial biomarkers. test results were provided to physicians but management in neither arm was driven by a study protocol. data on time, diagnostic testing, and cost of index hospitalization, and the following 28 days are being collected. the primary endpoint is length of hospital stay (los). the trial is powered to allow for detection of a difference in los of 10.1 hours between competing strategies with 95% power assuming that 70% of projected los values are true. secondary endpoints are cumulative radiation exposure, and cost of competing strategies. tertiary endpoints are institutional, caregiver, and patient characteristics associated with primary and secondary outcomes. rate of missed acs within 28 days is the safety endpoint. results: as of november 21st, 2011, 880 of 1000 patients have been enrolled (mean age: 54 ± 8, 46.5% female, acs rate 7.55%). the anticipated completion of the last patient visit is 02/28/12 and the database will be locked in early march 2012. we will present the results of the primary, secondary, and some tertiary endpoints for the entire cohort. conclusion: romicat ii will provide rigorous data on whether incorporation of ccta early in the ed evaluation process leads to more efficient management and triage than usual care in patients with acute chest pain at intermediate risk for acs. (originally submitted as a ''late-breaker.'') meta background: many studies have documented higher rates of advanced radiography utilization across u.s. emergency departments (eds) in recent years, with an associated decrease in diagnostic yield (positive tests / total tests). provider-to-provider variability in diagnostic yield has not been well studied, nor have the factors that may explain these differences in clinical practice. objectives: we assessed the physician-level predictors of diagnostic yield using advanced radiography to diagnose pulmonary embolus (pe) in the ed, including demographics and d-dimer ordering rates. methods: we conducted a retrospective chart review of all ed patients who had a ct chest or v/q scan ordered to rule out pe from 1/06 to 12/09 in four hospitals in the medstar health system. attending physicians were included in the study if they had ordered 50 or more scans over the study period. the result of each ct and vq scan was recorded as positive, negative, or indeterminate, and the identity of the ordering physician was also recorded. data on provider sex, residency type (em or other), and year of residency completion were collected. each provider's positive diagnostic yield was calculated, and logistic regression analysis was done to assess correlation between positive scans and provider characteristics. results: during the study period, 15,015 scans (13,571 cts and 1,443 v/qs) were ordered by 93 providers. the physicians were an average of 9.7 years from residency, 36% were female, and 98% were em-trained. diagnostic yield varied significantly among physicians (p < 0.001), and ranged from 0% to 18%. the median diagnostic yield was 5.9% (iqr 3.8%-7.8%). the use of d-dimer by provider also varied significantly from 4% to 48% (p < 0.001). the odds of a positive test were significantly lower among providers less than 10 years out of residency graduation (or 0.80, ci 0.68-0.95) after controlling for provider sex, type of residency training, d-dimer use, and total number of scans ordered. conclusion: we found significant provider variability in diagnostic yield for pe and use of d-dimer in this study population, with 25% of providers having diagnostic yield less than or equal to 3.8%. providers who were more recently graduated from residency appear to have a lower diagnostic yield, suggesting a more conservative approach in this group. background: the literature reports that anticoagulation increases the risk of mortality in patients presenting to emergency departments (ed) with head trauma (ht). it has been suggested that such patients should be treated in a protocolized fashion, including ct within 15 minutes, and anticipatory preparation of ffp before ct results are available. there are significant logistical and financial implications associated with implementation of such a protocol. objectives: our primary objective was to determine the effect of anticoagulant therapy on the risk of intracranial hemorrhage (ich) in elderly patients presenting to our urban community hospital following bunt head injury. methods: this was a retrospective chart review study of ht patients >60 years of age presenting to our ed over a 6-month period. charts reviewed were identified using our electronic medical record via chief complaints and icd-9 codes and cross referencing with written ct logs. research assistants underwent review of at least 25% of their contributing data to validate reliability. we collected information regarding use of warfarin, clopidogrel, and aspirin and ct findings of ich. using univariate logistic regression, we calculated odds ratios (or) for ich with 95% ci. results: we identified 363 elderly ht patients. the mean age of our population was 72, 34 (8.3%) admitted to using anticoagulant therapy, and 23% were on antiplatelet drugs. 14 (3.8%) of the cohort had icb, 3 patients required neurosurgical intervention, and 1 had transfusion of blood products. of the non-anticoagulated patients, 12 (3.6%) were found to have ich, half of those (6) , and mir-223) were measured using real-time quantitative pcr from serum drawn at enrollment. il-6, il-10, and tnf-a were measured using a bio-plex suspension system. baseline characteristics, il-6, il-10, tnf-a and micrornas were compared using one way anova or fisher exact test, as appropriate. correlations between mirnas and sofa scores, il-6, il-10, and tnf-a were determined using spearman's rank. a logistic regression model was constructed using in-hospital mortality as the dependent variable and mirnas as the independent variables of interest. bonferroni adjustments were made for multiple comparisons. results: of 93 patients, 24 were controls, 29 had sepsis, and 40 had septic shock. we found no difference in serum mir-146a or mir-223 between cohorts, and found no association between these micrornas and either inflammatory markers or sofa score. mir-150 demonstrated a significant correlation with sofa score (q = 0.31, p = 0.01), il-10 (q = 0.37, p = 0.001), but not il-6 or tnf-a (p = 0.046, p = 0.59). logistic regression demonstrated mir-150 to be associated with mortality, even after adjusting for sofa score (p = 0.003). conclusion: mir-146a or mir-223 failed to demonstrate any diagnostic or prognostic ability in this cohort. mir-150 was associated with inflammation, increasing severity of illness, and mortality, and may represent a novel prognostic marker for diagnosis and prognosis of sepsis. objectives: to examine the association between emergency physician recognition of sirs and sepsis and subsequent treatment of septic patients. methods: a retrospective cohort study of all-age patient medical records with positive blood cultures drawn in the emergency department from 11/2008-1/ 2009 at a level i trauma center. patient parameters were reviewed including vital signs, mental status, imaging, and laboratory data. criteria for sirs, sepsis, severe sepsis, and septic shock were applied according to established guidelines for pediatrics and adults. these data were compared to physician differential diagnosis documentation. the mann-whitney test was used to compare time to antibiotic administration and total volume of fluid resuscitation between two groups of patients: those with recognized sepsis and those with unrecognized sepsis. results: sirs criteria were present in 233/338 reviewed cases. sepsis criteria were identified in 215/338 cases and considered in the differential diagnosis in 121/215 septic patients. severe sepsis was present in 89/338 cases and septic shock was present in 42/338 cases. the sepsis 6-hour resuscitation bundle was completed in the emergency department in 16 cases of severe sepsis or septic shock. 121 patients who met sepsis criteria and were recognized by the ed physician had a median time to antibiotics of 150 minutes (iqr: 89-282) and a median ivf of 1500 ml (iqr: 500-3000). the 94 patients who met sepsis criteria but went unrecognized in the documentation had a median time to antibiotics of 225 minutes (iqr: 135-355) and median volume of fluid resuscitation of 1000 ml (iqr: . median time to antibiotics and median volume of fluid resuscitation differed significantly between recognized and unrecognized septic patients (p = 0.003 and p = 0.002, respectively). conclusion: emergency physicians correctly identify and treat infection in most cases, but frequently do not document sirs and sepsis. lack of documentation of sepsis in the differential diagnosis is associated with increased time to antibiotic delivery and a smaller total volume of fluid administration, which may explain poor sepsis bundle compliance in the emergency department. background: severe sepsis is a common clinical syndrome with substantial human and financial impact. in 1992 the first consensus definition of sepsis was published. subsequent epidemiologic estimates were collected using administrative data, but ongoing discrepancies in the definition of severe sepsis led to large differences in estimates. objectives: we seek to describe the variations in incidence and mortality of severe sepsis in the us using four methods of database abstraction. methods: using a nationally representative sample, four previously published methods (angus, martin, dombrovskiy, wang) were used to gather cases of severe sepsis over a 6-year period (2004) (2005) (2006) (2007) (2008) (2009) . in addition, the use of new icd-9 sepsis codes was compared to previous methods. our main outcome measure was annual national incidence and in-hospital mortality of severe sepsis. results: the average annual incidence varied by as much as 3.5 fold depending on method used and ranged from 894,013 (300 / 100,000 population) to 3,110,630 (1,031 / 100,000) using the methods of dombrovskiy and wang, respectively. average annual increase in the incidence of severe sepsis was similar (13.0-13.3%) across all methods. total mortality mirrored the increase in incidence over the 6-year period ( background: radiation exposure from medical imaging has been the subject of many major journal articles, as well as the topic of mainstream media. some estimate that one-third of all ct scans are not medically justified. it is important for practitioners ordering these scans to be knowledgeable of currently discussed risks. objectives: to compare the knowledge, opinions, and practice patterns of three groups of providers in regards to cts in the ed. methods: an anonymous electronic survey was sent to all residents, physician assistants, and attending physicians in emergency medicine (em), surgery, and internal medicine (im) at a single academic tertiary care referral level i trauma center with an annual ed volume of over 160,000 visits. the survey was pilot tested and validated. all data were analyzed using the pearson's chi-square test. results: there was a response rate of 32% (220/668). data from surgery respondents were excluded due to a low response rate. in comparison to im, em respondents correctly equated one abdominal ct to between 100 and 500 chest x-rays, reported receiving formal training regarding the risks of radiation from cts, believe that excessive medical imaging is associated with an increased lifetime risk of cancer, and routinely discuss the risks of ct imaging with stable patients more often (see table 1 ). particular patient factors influence whether radiation risks are discussed with patients by 60% in each specialty (see table 2 ). before ordering an abdominal ct in a stable patient, im providers routinely review the patient's medical imaging history less often than em providers surveyed. overall, 67% of respondents felt that ordering an abdominal ct in a stable ed patient is a clinical decision that should be discussed with the patient, but should not require consent. conclusion: compared with im, em practitioners report greater awareness of the risks of radiation from cts and discuss risks with patients more often. they also review patients' imaging history more often and take this, as well as patients' age, into account when ordering cts. these results indicate a need for improved education for both em and im providers in regards to the risks of radiation from ct imaging. background: in nebraska, 80% of emergency departments have annual visits less than 10,000, and the predominance are in rural settings. general practitioners working in rural emergency departments have reported low confidence in several emergency medicine skills. current staffing patterns include using midlevels as the primary provider with non-emergency medicine trained physicians as back-up. lightly-embalmed cadaver labs are used for resident's procedural training. objectives: to describe the effect of a lightlyembalmed cadaver workshop on physician assistants' (pa) reported level of confidence in selected emergency medicine procedures. methods: an emergency medicine procedure lab was offered at the nebraska association of physician assistants annual conference. each lab consisted of a 2-hour hands-on session teaching endotracheal intubation techniques, tube thoracostomy, intraosseous access, and arthrocentesis of the knee, shoulder, ankle, and wrist to pas. irb-approved surveys were distributed pre-lab and a post-lab survey was distributed after lab completion. baseline demographic experience was collected. pre-and post-lab procedural confidence was rated on a six-point likert scale (1-6) with 1 representing no confidence. the wilcoxon signed-rank test was use to calculate p values. results: 26 pas participated in the course. all completed a pre-and post-lab assessment. no pa had done any one procedure more than 5 times in their career. pre-lab modes of confidence level were £3 for each procedure. post-lab modes were >4 for each procedure except arthrocentesis of the ankle and wrist. however, post lab assessments of procedural confidence significantly improved for all procedures with p values <0.05. conclusion: midlevel providers' level of confidence improved for emergent procedures after completion of a procedure lab using lightly-embalmed cadavers. a mobile cadaver lab would be beneficial to train rural providers with minimal experience. background: use of automated external defibrillators (aed) improves survival in out-of-hospital cardiopulmonary arrest (ohca). since 2005, the american heart association has recommended that individuals one year of age or older who sustain ohca have an aed applied. little is known about how often this occurs and what factors are associated with aed use in the pediatric population. objectives: our objective was to describe aed use in the pediatric population and to assess predictors of aed use when compared to adult patients. methods: we conducted a secondary analysis of prospectively collected data from 29 u.s. cities that participate in the cardiac arrest registry to enhance survival (cares). patients were included if they had a documented resuscitation attempt from october 1, 2005 through december 31, 2009 and were ‡1 year old. patients were considered pediatric if they were less than 19 years old. aed use included application by laypersons and first responders. hierarchical multivariable logistic regression analysis was used to estimate the associations between age and aed use. results: there were 19,559 ohcas included in this analysis, of which 239 (1.2%) occurred in pediatric patients. overall aed use in the final sample was 5,517, with 1,751 (8.9%) total survivors. aeds were applied less often in pediatric patients (19.7%, 95% ci: 14.6%-24.7% vs 28.3%, 95% ci: 27.7%-29.0%). within the pediatric population, only 35.4% of patients with a shockable rhythm had an aed used. in all pediatric patients, regardless of presenting rhythm, aed use demonstrated a statistically significant increase in return of spontaneous circulation (aed used 29.8%, 95% ci: 16.2-43.4 vs aed not used 16.8%, 95% ci: 11.4-22.1, p < 0.05), although there was no significant increase in survival to hospital discharge (aed used 12.8%; aed not used 5.2%; p = 0.057). in the adjusted model, pediatric age was independently associated with failure to use an aed (or 0.61, 95% ci: 0.42-0.87) as was female sex (or 0.88, 95% ci: 0.81-0.95). patients who had a public arrest (or 1.35, 95% ci: 1.24-1.46) or one that was witnessed by a bystander (or 1.20. 95%: ci 1.11-1.29) were also predictive of aed use. conclusion: pediatric patients who experience ohca are less likely to have an aed used. continued education of first responders and the lay public to increase aed use in this population is necessary. does implementation of a therapeutic hypothermia protocol improve survival and neurologic outcomes in all comatose survivors of sudden cardiac arrest? ken will, michael nelson, abishek vedavalli, renaud gueret, john bailitz cook county (stroger), chicago, il background: the american heart association (aha) currently recommends therapeutic hypothermia (th) for out of hospital comatose survivors of sudden cardiac arrest (cssca) with an initial rhythm of ventricular fibrillation (vf). based on currently limited data, the aha further recommends that physicians consider th for cssca, from both the out and inpatient settings, with an initial non-vf rhythm. objectives: investigate whether a th protocol improves both survival and neurologic outcomes for cssca, for out and inpatients, with any initial rhythm, in comparison to outcomes previously reported in literature prior to th. methods: we conducted a prospective observational study of cssca between august 2009 and may 2011 whose care included th. the study enrolled eligible consecutive cssca survivors, from both out and inpatient settings with any initial arrest rhythm. primary endpoints included survival to hospital discharge and neurologic outcomes, stratified by sca location, and by initial arrest rhythm. results: overall, of 27 eligible patients, 11 (41%, 95% ci 22-66%) survived to discharge, 7 (26%, 95% ci 9-43%) with at least a good neurologic outcome. twelve were out and 15 were inpatients. among the 12 outpatients, 6 (50%, 95% ci 22-78%) survived to discharge, 5 (41%, 95% ci 13-69%) with at least a good neurologic outcome. among the 15 inpatients, 5 (33%, 95% ci 9-57) survived to discharge, 2 (13%, 95% ci 0-30%) with at least a good neurologic outcome. by initial rhythm, 6 patients had an initial rhythm of vf/t and 21 non-vf/t. among the 6 patients with an initial rhythm of vf/t, 4 (67%, ci 39-100%) survived to discharge, all 4 with at least a good outcome, including 3 out and 1 inpatients. among the 21 patients with an initial rhythm of non-vf/t, 7 (33%, ci 22-53%) survived to discharge, 3 (14%, ci 0-28%) with at least a good neurologic outcome, including 2 out and 1 inpatients. conclusion: our preliminary data initially suggest that local implementation of a th protocol improves survival and neurologic outcomes for cssca, for out and inpatients, with any initial rhythm, in comparison to outcomes previously reported in literature prior to th. subsequent research will include comparison to local historical controls, additional data from other regional th centers, as well as comparison of different cooling methods. protocolized background: therapeutic hypothermia (th) has been shown to improve the neurologic recovery of cardiac arrest patients who experience return of spontaneous circulation (rosc). it remains unclear as to how earlier cooling and treatment optimization influence outcomes. objectives: to evaluate the effects of a protocolized use of early sedation and paralysis on cooling optimization and clinical outcomes in survivors of cardiac arrest. methods: a 3-year (2008-2010), pre-post intervention study of patients with rosc after cardiac arrest treated with th was performed. those patients treated with a standardized order set which lacked a uniform sedation and paralytic order were included in the pre-intervention group, and those with a standardized order set which included a uniform sedation and paralytic order were included in the post-intervention group. patient demographics, initial and discharge glasgow coma scale (gcs) scores, resuscitation details, cooling time variables, severity of illness as measured by the apache ii score, discharge disposition, functional status, and days to death were collected and analyzed using student's t-tests, man-whitney u tests, and the log-rank test. results: 232 patients treated with th after rosc were included, with 107 patients in the pre-intervention group and 125 in the post-intervention group. the average time to goal temperature (33°c) was 227 minutes (pre-intervention) and 168 minutes (post-intervention) (p = 0.001). a 2-hour time target was achieved in 38.6% of the patients (post-intervention) compared to 24.5% in the pre-group (p = 0.029). twenty-eight day mortality was similar between groups (65.4% and 65.3%) though hospital length of stay (10 days pre-and 8 days post-intervention) and discharge gcs (13 preand 14-post-intervention) differed between cohorts. more post-intervention patients were discharged to home (55.8%) compared to 43.2% in the pre-intervention group. conclusion: protocolized use of sedation and paralysis improved time to goal temperature achievement. these improved th time targets were associated with improved neuroprotection, gcs recovery, and disposition outcome. standardized sedation and paralysis appears to be a useful adjunct in induced th. background: ct is increasingly used to assess children with signs and symptoms of acute appendicitis (aa) though concerns regarding long-term risk of exposure to ionizing radiation have generated interest in methods to identify children at low risk. objectives: we sought to derive a clinical decision rule (cdr) of a minimum set of commonly used signs and symptoms from prior studies to predict which children with acute abdominal pain have a low likelihood of aa and compared it to physician clinical impression (pci). methods: we prospectively analyzed 420 subjects aged 2 to 20 years in 11 u.s. emergency departments with abdominal pain plus signs and symptoms suspicious for aa within the prior 72 hours. subjects were assessed by study staff unaware of their diagnosis for 17 clinical attributes drawn from published appendicitis scoring systems and physicians responsible for physical examination estimated the probability of aa based on pci prior to their medical disposition. based on medical record entry rate, frequently used cdr attributes were evaluated using recursive partitioning and logistic regression to select the best minimum set capable of discriminating subjects with and without aa. subjects were followed to determine whether imaging was used and use was tabulated by both pci and the cdr to assess their ability to identify patients who did or did not benefit based on diagnosis. results: this cohort had a 27.3% prevalence (118/431 subjects) of aa. we derived a cdr based on the absence of two out of three of the following attributes: abdominal tenderness, pain migration, and rigidity/ guarding had a sensitivity of 89.8% (95% ci: 83.1-94.1), specificity of 47.6% (95% ci: 42.1-53.1), npv of 92.5% (95% ci: 87.4-95.7), and negative likelihood ratio of 0.21 (95% ci: 0.12-0.37). the pci set at aa <30% pre-test probability had a sensitivity of 94.1% (95% ci: 88.3-97.1), specificity of 49.4% (95% ci: 43.9-54.9), npv of 95.7% (95% ci: 91.3-97.9), and negative likelihood ratio of 0.12 (95% ci: 0.06-0.25). the methods each classified 37% of the patients as low risk for aa. our cdr identified 29.1% (43/148) of low risk subjects who received ct but being aa (-), could have been spared ct, while the pci identified 20.1% (30/149). conclusion: compared to physician clinical impression, our clinical decision rule can identify more children at low risk for appendicitis who could be managed more conservatively with careful observation and avoidance of ct. negative background: abdominal pain is the most common complaint in the ed and appendicitis is the most common indication for emergency surgery. a clinical decision rule (cdr) identifying abdominal pain patients at a low risk for appendicitis could lead to a significant reduction in ct scans and could have a significant public health impact. the alvarado score is one of the most widely applied cdrs for suspected appendicitis, and a low modified alvarado score (less than 4) is sometimes used to rule out acute appendicitis. the modified alvarado score has not been prospectively validated in ed patients with suspected appendicitis. objectives: we sought to prospectively evaluate the negative predictive value of a low modified alvarado score (mas) in ed patients with suspected appendicitis. we hypothesized that a low mas (less than 4) would have a sufficiently high npv (>95%) to rule out acute appendicitis. methods: we enrolled patients greater than or equal to 18 years old who were suspected of having appendicitis (listed as one of the top three diagnosis by the treating physician before ancillary testing) as part of a prospective cohort study in two urban academic eds from august 2009 to april 2010. elements of the mas and the final diagnosis were recorded on a standard data form for each subject. the sensitivity, specificity, negative predictive value (npv), and positive predictive value (ppv) were calculated with 95% ci for a low mas and final diagnosis of appendicitis. background: evaluating children for appendicitis is difficult and strategies have been sought to improve the precision of the diagnosis. computed tomography is now widely used but remains controversial due to the large dose of ionizing radiation and risk of subsequent radiation-induced malignancy. objectives: we sought to identify a biomarker panel for use in ruling out pediatric acute appendicitis as a means of reducing exposure to ionizing radiation. methods: we prospectively enrolled 431 subjects aged 2 to 20 years presenting in 11 u.s. emergency departments with abdominal pain and other signs and symptoms suspicious for acute appendicitis within the prior 72 hours. subjects were assessed by study staff unaware of their diagnosis for 17 clinical attributes drawn from appendicitis scoring systems and blood samples were analyzed for cbc differential and 5 candidate proteins. based on discharge diagnosis or post-surgical pathology, the cohort exhibited a 27.3% prevalence (118/431 subjects) of appendicitis. clinical attributes and biomarker values were evaluated using principal component, recursive partitioning, and logistic regression to select the combination that best discriminated between those subjects with and without disease. mathematical combination of three inflammation-related markers in a panel comprised of myeloid-related protein 8/14 complex (mrp), c-reactive protein (crp), and white blood cell count (wbc) provided optimal discrimination. results: this panel exhibited a sensitivity of 98% (95% ci, 94-100%), a specificity of 48% (95% ci, 42-53%), and a negative predictive value of 99% (95% ci, 95-100%) in this cohort. the observed performance was then verified by testing the panel against a pediatric subset drawn from an independent cohort of all ages enrolled in an earlier study. in this cohort, the panel exhibited a sensitivity of 95% (95% ci, 87-98%), a specificity of 41% (95% ci, 34-50%), and a negative predictive value of 95% (95% ci, 87-98%). conclusion: appyscore is highly predictive of the absence of acute appendicitis in these two cohorts. if these results are confirmed by a prospective evaluation currently underway, the appyscore panel may be useful to classify pediatric patients presenting to the emergency department with signs and symptoms suggestive of, or consistent with, acute appendicitis and thereby sparing many patients ionizing radiation. background: there are no current studies on the tracking of emergency department (ed) patient dispersal when a major ed closes. this study demonstrates a novel way to track where patients sought emergency care following the closure of saint vincent's catholic medical center (svcmc) in manhattan by using de-identified data from a health information exchange, the new york clinical information exchange (nyclix). nyclix matches patients who have visited multiple sites using their demographic information. on april 30, 2010, svcmc officially stopped providing emergency and outpatient services. we report the patterns in which patients from svcmc visited other sites within nyclix. objectives: we hypothesize that patients often seek emergency care based on geography when a hospital closes. methods: a retrospective pre-and post-closure analysis was performed of svcmc patients visiting other hospital sites. the pre-closure study dates were january 1, 2010-march 31, 2010. the post closure study dates were may 1, 2010-july 31, 2010. a svcmc patient was defined as a patient with any svcmc encounter prior to its closure. using de-identified aggregate count data, we calculated the average number of visits per week by svcmc patients at each site (hospital a-h). we ran a paired t-test to compare the pre-and post-closure averages by site. the following specifications were used to write the database queries: of patients who had one or more prior visits to svcmc for each day within the study return the following: a. eid: a unique and meaningless proprietary id generated within the nyclix master patient index (mpi). b. age: thru the age of 89. persons over 90 were listed as ''90 + '' c. ethnicity/race d. type of visit: emergency e. location of visit: specific nyclix site. results: nearby hospitals within 2 miles saw the highest number of increased ed visits after svcmc closed. this increase was seen until about 5 miles. hospitals >5 miles away did not see any significant changes in ed visits. see table. conclusion: when a hospital and its ed close down, patients seem to seek emergency care at the nearest hospital based on geography. other factors may include the patient's primary doctor, availabilities of outpatient specialty clinics, insurance contracts, or preference of ambulance transports. this study is limited by the inclusion of data from only the eight hospitals participating in nyclix at the time of the svcmc closure. upstream methods: data were collected on all ed ems arrivals from the metro calgary (population 1.1 million) area to its three urban adult hospitals. the study phases consisted of the 7 months from february to october 2010 (pre-ocp) compared against the same months in 2011 (post-ocp). data from the ems operational database and the regional emergency department information system (redis) database were linked. the primary analysis examined the change in ems offload delay defined as the time from ems triage arrival until patient transfer to an ed bed. a secondary analysis evaluated variability in ems offload delay between receiving eds. conclusion: implementation of a regional overcapacity protocol to reduce ed crowding was associated with an important reduction in ems offload delay, suggesting that policies that target hospital processes have bearing on ems operations. variability in offload delay improvements is likely due to site-specific issues, and the gains in efficiency correlate inversely with acuity. methods: a pre-post intervention study was conducted in the ed of an adult university teaching hospital in montreal (annual visits = 69 000). the raz unit (intervention), created to offload the acu of the main ed, started operating in january, 2011. using a split flow management strategy, patients were directed to the raz unit based on patient acuity level (ctas code 3 and certain code 2), likelihood to be discharged within 12 hours, and not requiring an ed bed for continued care. data were collected weekdays from 9:00 to 21:00 for 4 months (september -december 2008) (pre-raz) and for 1.5 months (february -march 2011) (post-raz). in the acu of the main ed, research assistants observed and recorded cubicle access time, and nurse and physician assessment times. databases were used to extract socio-demographics, ambulance arrival, triage code, chief complaint, triage and registration time, length of stay, and ed occupancy. background: telephone follow-up after discharge from the ed is useful for treatment and quality assurance purposes. ed follow-up studies frequently do not achieve high (i.e. ‡ 80%) completion rates. objectives: to determine the influence of different factors on the telephone follow-up rate of ed patients. we hypothesized that with a rigorous follow-up system we could achieve a high follow-up rate in a socioeconomically diverse study population. methods: research assistants (ras) prospectively enrolled adult ed patients discharged with a medication prescription between november 15, 2010 and september 9, 2011 from one of three eds affiliated with one health care system: (a) academic level i trauma center, (b) community teaching affiliate, and (c) community hospital. patients unable to provide informed consent, non-english speaking, or previously enrolled were excluded. ras interviewed subjects prior to ed discharge and conducted a telephone follow-up interview 1 week later. follow-up procedures were standardized (e.g. number of calls per day, times to place calls, obtaining alternative numbers) and each subject's follow-up status was monitored and updated daily through a shared, web-based data system. subjects who completed follow-up were mailed a $10 gift card. we examined the influence of patient (age, sex, race, insurance, income, marital status, usual major activity, education, literacy level, health status), clinical (acuity, discharge diagnosis, ed length of stay, site), and procedural factors (number and type of phone numbers received from subjects, offering two gift cards for difficult to reach subjects) on the odds of successful followup using multivariate logistic regression. results: of the 3,940 enrolled, 45% were white, 59% were covered by medicaid or uninsured, and 44% reported an annual household income of <$26,000. 86% completed telephone follow-up with 41% completing on the first attempt. the table displays the factors associated with successful follow-up. in addition to patient demographics and lower acuity, obtaining a cell phone or multiple phone numbers as well as offering two gift cards to a small number of subjects increased the odds of successful follow-up. conclusion: with a rigorous follow-up system and a small monetary incentive, a high telephone follow-up rate is achievable one week after an ed visit. methods: an interrupted time-series design was used to evaluate the study question. data regarding adherence with the following pneumonia core measures were collected pre-and post-implementation of the enhanced decision-support tool: blood cultures prior to antibiotic, antibiotic within 6 hours of arrival, appropriate antibiotic selection, and mean time to antibiotic administration. prescribing clinicians were educated on the use of the decision-support tool at departmental meetings and via direct feedback on their cases. results: during the 33-month study period, complete data were collected for 1185 patients diagnosed with cap: 613 in the pre-implementation phase and 572 post-implementation. the mean time to antibiotic administration decreased by approximately one minute from the pre-to post-implementation phase, a change that was not statistically significant (p = 0.824). the proportion of patients receiving blood cultures prior to antibiotics improved significantly (p < 0.001) as did the proportion of patients receiving antibiotics within 6 hours of ed arrival (p = 0.004). a significant improvement in appropriate antibiotic selection was noted with 100% of patients experiencing appropriate selection in the post-phase, p = 0.0112. use of the available support tool increased throughout the study period, v 2 = 78.13, df = 1, p < 0.0001. all improvements were maintained 15 months following the study intervention. conclusion: in this academic ed, introduction of an enhanced electronic clinical decision support tool significantly improved adherence to cms pneumonia core measures. the proportion of patients receiving blood cultures prior to antibiotics, antibiotics within 6 hours, and appropriate antibiotics all improved significantly after the introduction of an enhanced electronic clinical decision support tool. background: emergency medicine (em) residency graduates need to pass both the written qualifying exam and oral certification exam as the final benchmark to achieve board certification. the purpose of this project is to obtain information about the exam preparation habits of recent em graduates to allow current residents to make informed decisions about their individual preparation for the abem written qualifying and oral certification exams. objectives: the study sought to determine the amount of residency and individual preparation, to determine the extent of the use of various board review products, and to elicit evaluations of the various board review products used for the abem qualifying and certification exams. methods: design: an online survey instrument was used to ask respondents questions about residency preparation and individual preparation habits, as well as the types of board review products used in preparing for the em boards. participants: as greater than 95% of all em graduates are emra members, an online survey was sent to all emra members who have graduated for the past three years. observations: descriptive statistics of types of preparation, types of resources, time, and quantitative and qualitative ratings for the various board preparation products were obtained from respondents. results: a total of 520 respondents spent an average of 9.1 weeks and 15 hours per week preparing for the written qualifying exam and spent an average of 5 weeks and 7.8 hours per week preparing for the oral certification exam. in preparing for the written qualification exam, 90% used a preparation textbook with 16% using more than one textbook and 47% using a board preparation course. in preparing for the oral qualifying exam, 56% used a preparation textbook while 34% used a preparation course. sixty-seven percent of respondents reported that their residency programs had a formalized written qualifying exam preparation curriculum of which 48% was centered on the annual in-training exam. eight-five percent of residency programs had a formalized oral certification exam preparation. respondents reported spending on average $715 preparing for the qualifying exam and $509 for the certification exam. conclusion: em residents spend significant amounts of time and money and make use of a wide range of residency and commercially available resources in preparing for the abem qualifying and certification exams. background: communication and professionalism skills are essential for em residents but are not wellmeasured by selection processes. the multiple mini-interview (mmi) uses multiple, short structured contacts to measure these skills. it predicts medical school success better than the interview and application. its acceptability and utility in em residency selection is unknown. objectives: we theorized that the mmi would provide novel information and be acceptable to participants. methods: 71 interns from three programs in the first month of training completed an eight-station mmi developed to focus on em topics. pre-and post-surveys assessed reactions using five-point scales. mmi scores were compared to application data. results: em grades correlated with mmi performance (f(1.66) = 4:18, p < 0.05) with honors students having higher mmi summary scores. higher third year clerkship grades trended to higher mmi performance means, although not significantly. mmi performance did not correlate with a match desirability rating and did not predict other individual components of the application including usmle step 1 or usmle step 2. participants preferred a traditional interview (mean difference = 1.36, p < 0.0001). a mixed format was preferred over a pure mmi (mean difference = 1.1, p < 0.0001). preference for a mixed format was similar to a traditional interview. mmi performance did not significantly correlate with preference for the mmi; however, there was a trend for higher performance to associate with higher preference (r = 0.15, t(65) = 1.19, n.s.) performance was not associated with preference for a mix of interview methods (r = 0.08, t(65) = 0.63, n.s.). conclusion: while the mmi alone was viewed less favorably than a traditional interview, participants were receptive to a mixed methods interview. the mmi appears to measure skills important in successful completion of an em clerkship and thus likely em residency. future work will determine whether mmi performance correlates with clinical performance during residency. background: the annual american board of emergency medicine (abem) in-training exam is a tool to assess resident progress and knowledge. when the new york-presbyterian (nyp) em residency program started in 2003, the exam was not emphasized and resident performance was lower than expected. a course was implemented to improve residency-wide scores despite previous em literature failing to exhibit improvements with residency-sponsored in-training exam interventions. objectives: to evaluate the effect of a comprehensive, multi-faceted course on residency-wide in-training exam performance. methods: the nyp em residency program, associated with cornell and columbia medical schools, has a 4year format with 10-12 residents per year. an intensive 14-week in-training exam preparation program was instituted outside of the required weekly residency conferences. the program included lectures, pre-tests, high-yield study sheets, and remediation programs. lectures were interactive, utilizing an audience response system, and consisted of 13 core lectures (2-2.5 hours) and three review sessions. residents with previous in-training exam difficulty were counseled on designing their own study programs. the effect on intraining exam scores was measured by comparing each resident's score to the national mean for their postgraduate year (pgy). scores before and after course implementation were evaluated by repeat measures regression modeling. overall residency performance was evaluated by comparing residency average to the national average each year and by tracking abem national written examination pass rates. results: resident performance improved following course implementation. following the course's introduction, the odds of a resident beating the national mean increased by 3.9 (95% ci 1.9-7.3) and the percentage of residents exceeding the national mean for their pgy year increased by 37% (95% ci 23%-52%). following course introduction, the overall residency mean score has outperformed the national exam mean annually and the first-time abem written exam board pass rate has been 100%. conclusion: a multi-faceted in-training exam program centered around a 14-week course markedly improved overall residency performance on the in-training exam. limitations: this was a before and after evaluation as randomizing residents to receive the course was not logistically or ethically feasible. .0 years of practice. among the nonresidency trained, non-boarded em physicians, the percentage of individuals with board actions against them was significantly higher (6.9% vs. 1.9%, 95% ci for difference of 5.0% = 3.1 to 7.5%), but the incidence of actions was not significant (1.3 vs. 3.4 events/ 1000 years of practice, 95% ci for difference of 2.1/ 1000 = )3/1000 to +8/1000), but the power to detect a difference was 30%. conclusion: in this study population, em-trained physicians had significantly fewer total state medical board disciplinary actions against them than non-em trained physicians, but when adjusted for years of practice (incidence), the difference was not significantly different at the 95% confidence level. the study was limited by low power to detect a difference in incidence. objectives: we chose pain documentation as a long term project for quality improvement in our ems system. our objectives were to enhance the quality of pain assessment, to reduce patient suffering and pain through improved pain management, to improve pain assessment documentation, to improve capture of initial and repeat pain scales, and to improve the rate of pain medication. this study addressed the aim of improving pain assessment documentation. methods: this was a quasi-experiment looking at paramedic documentation of the pqrst mnemonic and pain scales. our intervention consisted of mandatory training on the importance and necessity of pain assessment and treatment. in addition to classroom training, we used rapid cycle individual feedback and public posting of pain documentation rates (with unique ids) for individual feedback. the categories of chief complaint studied were abdominal pain, blunt injury, burn, chest pain, headache, non-traumatic body pain, and penetrating injury. we compared the pain documentation rates in the 3 months prior to intervention, the 3 months of intervention, and 3 months post intervention. using repeated-measures anova, we compared rates of paramedic documentation over time. results: our ems system transported 42166 patients during the study period, of whom 15490 were for painful conditions in the defined chief complaint categories. there were 168 paramedics studied, of whom 149 had complete data. documentation increased from 1819 of 5122 painful cases (35.5%) in qtr 1 to 4625 of 5180 painful cases (89.3%) in qtr 3. the trend toward increased rates of pain documentation over the three quarters was strongly significant (p < 0.001). paramedics were significantly more likely to document pain scales and pqrst assessments over the course of the study with the highest rates of documentation compliance in the final 3-month period. conclusion: a focused intervention of education and individual feedback through classroom training, one on one training, and public posting improves paramedic documentation rates of perceived patient pain. background: emergency medical services (ems) systems are vital in the identification, assessment, and treatment of trauma, stroke, myocardial infarction, and sepsis and improving early recognition, resuscitation, and transport to adequate medical facilities. ems personnel provide similar first-line care for patients with syncope, performing critical actions such as initial assessment and treatment as well as gathering key details of the event. objectives: to characterize emergency department patients with syncope receiving initial care by ems and their role as initial providers. methods: we prospectively enrolled patients over 18 years of age who presented with syncope or near syncope to a tertiary care ed with 72,000 annual patient visits from june 2009 to june 2011. we compared patient age, sex, comorbidities, and 30-day cardiopulmonary adverse outcomes (defined as myocardial infarction, pulmonary embolism, significant cardiac arrhythmia, and major cardiovascular procedure) between ems and non-ems patients. descriptive statistics, two-sided ttests, and chi-square testing were used as appropriate. results: of the 669 patients enrolled, 254 (38.0%) arrived by ambulance. the most common complaint in patients transported by ems was fainting (50.4%) or dizziness (45.7%); syncope was reported in 28 (11.0%). compared to non-ems patients, those who arrived by ambulance were older (mean age (sd) 64.5 (18.7), vs. 60.6 (19.5) years, p = 0.012). there were no differences in the proportion of patients with hypertension (20.0% vs 32.0%, p = 0.75), coronary artery disease (8.85% vs 15.3%, p = 0.67), diabetes mellitus (6.5% vs 9.5%, p = 0.57), or congestive heart failure (3.8% vs 6.6%, p = 0.74). sixtynine (10.8%) patients experienced a cardiopulmonary event within 30 days. twenty-eight (4.4%) patients who arrived by ambulance and 41 (6.4%) non-ems patients had a subsequent cardiopulmonary adverse event (rr 1.08, 95%ci 0.68-1.69) within 30 days. the table tabulates interventions provided by ems prior to ed arrival. conclusion: ems providers care for more than one third of ed syncope patients and often perform key interventions. ems systems offer opportunities for advancing diagnosis, treatment, and risk stratification in syncope patients. background: abdominal pain is the most common reason for visiting an emergency department (ed), and abdominopelvic computed tomography (apct) use has increased dramatically over the past decade. despite this, there has been no significant change in rates of admission or diagnosis of surgical conditions. objectives: to assess whether an electronic accountability tool affects apct ordering in ed patients with abdominal or flank pain. we hypothesized that implementation of an accountability tool would decrease apct ordering in these patients. methods: before and after study design using an electronic medical record at an urban academic ed from jul-nov 2011, with the electronic accountability tool implemented in oct 2011 for any apct order. inclusion criteria: age >= 18 years, non-pregnant, and chief complaint or triage pain location of abdominal or flank pain. starting oct 17 th , 2011, resident attempts to order apct triggered an electronic accountability tool which only allowed the order to proceed if approved by the ed attending physician. the attending was prompted to enter the primary and secondary diagnoses indicating apct, agreement with need for ct and, if no agreement, who was requesting this ct (admitting or consulting physician), and their pretest probability (0-100) of the primary diagnosis. patients were placed into two groups: those who presented prior to (pre) and after (post) the deployment of the accountability tool. background: there has been a paradigm shift in the diagnostic work-up for suspected appendicitis. edbased staged protocols call for the use of ultrasound prior to ct scanning because of its lack of radiation, and the morbidity related to contrast. a barrier to implementation is the lack of 24/7 availability of ultrasound. objectives: to evaluate the impact of the implementation of ed performed appendix ultrasounds (apus) on ct utilization in the staged workup for appendicitis in the emergency department. methods: we performed a quasi-experimental, before/ after study. we compared data from the first 8 months of 2009, before the availability of ed performed apus, with the same interval in 2011 after introduction of ed apus. we excluded patients who had appendectomies for reasons other than appendicitis or had been diagnosed prior to arrival. no patient identifiers were included in the analysis and the study was approved by the hospital irb. we report the following descriptive statistics (percentages, sensitivities, and absolute utilization changes conclusion: implementation of an ed apus in the staging work up of appendicitis was associated with a significant reduction in overall ct utilization in the ed. objectives: this study aims to evaluate ed patients' knowledge of radiation exposure from ct and mri scans as well as the long-term risk of developing cancer. we hypothesize that ed patients will have a poor understanding of the risks, and will not know the difference between ct and mri. methods: design -this was a cross-sectional survey study of adult, english-speaking patients at two eds from 6/13/11-8/13/11. setting -one location was a tertiary care center with an annual ed census of 45,000 patient visits and the other was a community hospital with annual ed census of 35,000 patient visits. obser-vations -the survey consisted of six questions evaluating patients' understanding of radiation exposure from ct and mri as well as long-term consequences of radiation exposure. patients were then asked their age, sex, race, highest level of education, annual household income, and whether they considered themselves health care professionals. results: there were 500 participants in this study, 315 (of 5,589 total) from the academic center and 185 (of 4,988 total) from the community hospital during the study period. overall, only 10% (95% ci 7-12%) of participants understood the radiation risks associated with ct scanning. 60% (95% ci 56-65%) of patients believed that an abdominal ct had the same or less radiation as a chest x-ray. 25% (95% ci 21-29%) believed that there was an increased risk of developing cancer from repeated abdominal cts. only 22% (95% ci 19-26%) of patients knew that mri scans had less radiation than ct. 44% (95% ci 39-49%) either didn't know or believed that repeated mris were associated with an increased risk of developing cancer. higher educational level, household income, and identification as a health care professional all were associated with correct responses, but even within these groups, a majority gave incorrect responses. conclusion: in general, ed patients do not understand the radiation risks associated with advanced imaging modalities. we need to educate these patients so that they can make informed decisions about their own health care. background: homelessness has been associated with many poor health outcomes and frequent ed utilization. it has been shown that frequent use of the ed in any given year is not a strong predictor of subsequent use. identifying a group of patients who are chronic high users of the ed could help guide intervention. objectives: the purpose of this study is to identify if homelessness is associated with chronic ed utilization. methods: a retrospective chart review was accomplished looking at the records of the 100 most frequently seen patients in the ed for each year from 2005-2010 at a large, urban academic hospital with an annual volume of 55,000. patients' visit dates, chief complaints, dispositions, and housing status were reviewed. homelessness was defined by self-report at registration. patients were categorized according to their ed utilization with those seen >4 times in at least three of the five years of the study identified as chronic high utilizers; and those who visited the ed >20 times in at least three of the five years of the study were identified as chronic ultra-high utilizers. descriptive statistics with confidence intervals were calculated, and comparisons were made using non-parametric tests. results: during the 5-year study period, 189,371 unique patients were seen, of whom 0.7% patients were homeless. 335 patients were identified as frequent users. there were patients who presented on the top 100 utilizer lists from multiple years. 67 (20%, 95%ci 16-25) patients were identified as homeless. 148 patients were seen >4 times in at least three of the 5 years and 23 (16%, 11-22) were homeless. 12 patients were seen >20 times in at least three of the 5 years and 5 (41%, 19-68) were homeless. our facility has a 40% admission rate; however, non homeless chronic ultra-high utilizers had admission rates of 24% and homeless chronic ultra-high utilizers were admitted 14%. conclusion: chronic ultra-high utilizers of our ed are disproportionately homeless and present with lower severity of illness. these patients may prove to be a cost-effective group to house or otherwise involve with aggressive case management. the debate over homeless housing programs and case management solutions can be sharpened by better defining the groups who would most benefit and who represent the greatest potential saving for the health system. background: the prevalence of obese patients presenting to our emergency department (ed) is 38%: obese patients present in disproportionate number compared to the general population (us rate = 27%). in spite of this, there is a disconnect in patients' perceptions of weight and health: many patients underestimate their weight and report a key barrier to weight loss is patient-provider communications; such discussions have proven to be highly effective in smoking, drug, and alcohol cessation, an important initial step toward promoting wellness. information about patient provider communication is essential for designing and implementing emergency department (ed) based interventions to help increase patient awareness about weightrelated medical issues and provide counseling for weight reduction. objectives: we assessed patients' perceptions about obesity as disease and patient communication with their providers through two questions: do you believe your present weight is damaging to your health? has a doctor or other health professional every told you that you are overweight? methods: a descriptive cross-sectional study was performed in an academic tertiary care ed. a randomized sample of patients (every fifth) presenting to the ed (n = 453) was enrolled. pregnant patients, patients who were medically unstable, cognitively impaired, or who were unable or unwilling to provide informed consent were excluded. percentages of ''yes'' and ''no'' are reported for each question based on patient bmi, ethnicity, sex, and the number of comorbid conditions. regression analysis was used to determine differences in responses between subgroups. results: among overweight/obese, white/black patients, 42.5% do not feel their weight is damaging to their health and 54.7% reported they have not been told by a doctor they are overweight. of individuals who have been told by a doctor they were overweight, 23.2% still believe their present weight is not damaging to their health. of individuals who have not been told by a doctor they were overweight, 41.5% believe their present weight is damaging to their health. differences in race and age were not found. p values <0.05 for all results. conclusion: our data point toward a disconnect regarding patients' perceptions of health and weight. timely education about the burden of obesity may lead to a decrease in its overall prevalence. (originally submitted as a ''late-breaker.'') objectives: to examine the attitudes and expectations of patients admitted for inpatient care following an emergency department visit. methods: a descriptive study was done by surveying a voluntary sample of adult patients (n = 210) admitted to the hospital from the emergency department in one urban teaching hospital in the midwest. a short, ninequestion survey was developed to assess patient attitudes and expectations towards hiv testing, consent, and requirements. analyses consisted of descriptive statistics, correlations, and chi-square analyses. results: the majority of patients report that hiv testing should be a routine part of health care screening (82.4%) and that the hospital should routinely test admitted patients for hiv (78.6%). despite these overall positive attitudes towards hiv testing, the data also suggest that patients have strong attitudes towards consent requirements with 80% acknowledging that hiv testing requires special consent and 72% reporting that separate consent should be required. the data also showed a statistically significant difference in the proportion of patients who believed that hiv testing is a part of routine health care screening by race (v2 = 6.825, df = 1, p = .009). conclusion: patients attitudes and expectations towards routine hiv testing are consistent with the cdc recommendations. emergency departments are an ideal setting to initiate hiv testing and the findings suggest that patients expect hospital policies outline procedures for obtaining consent and screening all patients who are admitted to the hospital from the ed. results: the analysis revealed a ''hot spot'', a cluster of 833 counties (24.5%) with high ca rates adjacent to counties with high ca rates, located across the southeastern us (p < 0.001). within these counties, the average ca rate was 14% higher than the national average. a ''cool spot'', a cluster of 548 counties (16.1%) with low rates, was located across the midwest (p < 0.001). in this cool spot the average ca rate was 12% lower than the national average. figures 1 and 2 show us adjusted rates and spatial autocorrelation of ca deaths, respectively. conclusion: we identify geographic disparities in ca mortality and describe the cardiac arrest belt in the southeastern us. a limitation of this analysis was the use of icd-10 codes to identify cardiac arrest deaths; however, no other national data exist. an improved understanding of the drivers of this variability is essential to targeted prevention and treatment strategies, especially given the recent emphasis on development of cardiac resuscitation centers and cardiac arrest systems of care. an understanding of the relation between population density, cardiac arrest count, and cardiac arrest rate will be essential to the design of an optimized cardiac arrest system. we defined ed utilization during the past 12 months as non-users (0 visits), infrequent users (1-3 visits), frequent users (4-9 visits), and super-frequent users ( ‡10 visits). we compared demographic data, socioeconomic status, health conditions, and access to care between these ed utilization groups. results: overall, super-frequent use was reported by 0.4% of u.s. adults, frequent use by 2%, and infrequent ed use by 19%. higher ed utilization was associated with increased self-reported fair to poor health (55% for super-frequent, 48% for frequent, 22% for infrequent, 10% for non-ed users). frequent ed users were also more likely to be impoverished, with 31% of superfrequent, 25% of frequent, 13% of infrequent, and 9% of non-ed users reporting a poverty-income ratio <1. adults with higher ed utilization were more likely to report the ed as the place they usually go when sick (10% for super-frequent, 6% for frequent, 2% for infrequent, 0.5% for non-ed users). they also reported greater outpatient resource utilization, with 73% of super-frequent, 48% of frequent, 25% of infrequent, and 10% of non-ed users reporting ‡10 outpatient visits/year. frequent ed users were also more likely than non-ed users to be covered by medicaid (34% for super-frequent, 26% for frequent, 12% for infrequent, 5% for non-ed users). conclusion: frequent ed users were a vulnerable population with lower socioeconomic status, poor overall health, and high outpatient resource utilization. interventions designed to divert frequent users from the ed should also focus on chronic disease management and access to outpatient services, rather than focusing solely on limiting ed utilization. objectives: we explored factors associated with specialty provider willingness to provide urgent appointments to children insured by medicaid/chip. methods: as part of a mixed method study of child access to specialty care by insurance status, we conducted semi-structured qualitative interviews with a purposive sample of 26 specialists and 14 primary care physicians (pcps) in cook county, il. interviews were conducted from april to september 2009, until theme saturation was reached. resultant transcripts and notes were entered into atlas.ti and analyzed using an iterative coding process to identify patterns of responses in the data, ensure reliability, examine discrepancies, and achieve consensus through content analysis. results: themes that emerged indicate that pcps face considerable barriers getting publicly insured patients into specialty care and use the ed to facilitate this process. ''if i send them to the emergency room, i'm bypassing a number of problems. i'm fully aware that i'm crowding the emergency room.'' specialty physicians reported that decisions to refuse or limit the number of patients with medicaid/chip are due to economic strain or direct pressure from their institutions ''in the last budget revision, we were [told], 'you are losing money, so you need to improve your patient mix'''. in specialty practices with limited medicaid/chip appointment slots, factors associated with appointment success included: high acuity or complexity, personal request from or an informal economic relationship with the pcp, geography, and patient hardship. ''if it's a really desperate situation and they can't find anybody else, i will make an exception''. specialists also acknowledged that ''patients who can't get an appointment go to the er and then i am obligated to see them if they're in the system.'' conclusion: these exploratory findings suggest that a critical linkage exists between hospital eds and affiliated specialty clinics. as health systems restructure, there is an opportunity for eds to play a more explicit role in improving care coordination and access to specialty care. albert amini, erynne a. faucett, john m. watt, richard amini, john c. sakles, asad e. patanwala university of arizona, tucson, az background: trauma patients commonly receive etomidate and rocuronium for rapid sequence intubation (rsi) in the ed. due to the long duration of action of rocuronium and short duration of action of etomidate, these patients require prompt initiation of sedatives after rsi. this prevents the potential of patient awareness under pharmacological paralysis, which could be a terrifying experience. objectives: the purpose of this study was to evaluate the effect of the presence of a pharmacist during traumatic resuscitations in the ed on the initiation of sedatives and analgesics after rsi. we hypothesized that pharmacists would decrease the time to provision of sedation and analgesia. methods: this was an observational, retrospective cohort study conducted in a tertiary, academic ed that is a level i trauma center. consecutive adult trauma patients who received rocuronium in the ed for rsi were included during two time periods: 07/01/07 to 07/ 30/08 (pre-phase -no pharmacy services in the ed) and 07/01/09 to 06/30/11 (post-phase -pharmacy services in the ed). since the pharmacist could not respond to all traumas in the post-phase, this was further categorized based on whether the pharmacist was present or absent at the trauma resuscitation. data collected included patient demographics, baseline injury data, and medications used. the median time from rsi to initiation of sedatives and analgesics was compared between the pre-phase group (group 1), post-phase pharmacist absent group (group 2), and post-phase pharmacist present group (group 3) using the kruskal-wallis test. results: a total of 200 patients were included in the study (group 1 = 100, group 2 = 70, and group 3 = 30). median age was 35, 48.5, and 54.5 years in groups 1, 2, and 3, respectively (p = 0.005). there were no other differences between groups with regard to demographics, mechanism of injury, presence of traumatic brain injury, glasgow coma scale score, vital signs, ed length of stay, or mortality. median time between rsi and post-intubation sedative use was 13, 15, and 6 minutes in groups 1, 2 and 3, respectively (p < 0.001). median time between rsi and post-intubation analgesia use was 80, 16, and 10 minutes in groups 1, 2, and 3, respectively (p < 0.001). the presence of a pharmacist during trauma resuscitations decreases time to provision of sedation and analgesia after rsi. background: outpatient antibiotics are frequently prescribed from the ed, and limited health literacy may affect compliance with recommended treatments. objectives: among patients stratified by health literacy level, multimodality discharge instructions will improve compliance with outpatient antibiotic therapy and follow-up recommendations. methods: this was a prospective randomized trial that included consenting patients discharged with outpatient antibiotics from an urban county ed with an annual census of 100,000. patients unable to receive text messages or voicemails were excluded. health literacy was assessed using a validated health literacy assessment, the newest vital sign (nvs). patients were randomized to a discharge instruction modality: 1) usual care, typed and verbal medication and case-specific instructions; 2) usual care plus text messaged instructions sent to the patient's cell phone; or 3) usual care plus voicemailed instructions sent to the patient's cell phone. antibiotic pick-up was verified with the patient's pharmacy at 72 hours. patients were called at 30 days to determine antibiotic compliance. z-tests were used to compare 72-hour antibiotic pickup and patient-reported compliance across instructional modality and nvs score groups. results: 758 patients were included (55% female, median age 30, range 5 months to 71 years); 98 were excluded. 23% had an nvs score of 0-1, 31% 2-3, and 46% 4-6. the proportion of prescriptions filled at 72 hours varied significantly across nvs score groups; self-reported medication compliance at 30 days revealed no difference across different instructional modalities nor nvs scores (table 1) . conclusion: in this sample of urban ed patients, 72hour prescription pickup varied significantly by validated health literacy score, but not by instruction delivery modality. in this sample, patients with lower health literacy are at risk of not filling their outpatient antibiotics in a timely fashion. has been developed, validated, and utilized to study the processes of care involved in successful care transitions from inpatient to outpatient settings, but has not been utilized in the ed. objectives: we hypothesized that the ctm-3 could be successfully implemented in the ed without differential item difficulty by age, sex, education, or race; and would be associated with measures of quality of care and likelihood of following physician recommendations. methods: a descriptive study design based on exit surveys was used to measure ctm-3 scores and likelihood of following treatment recommendations. surveys were administered to a daily cross-sectional sample of all patients leaving the ed between 7a-12a by research assistants in an urban academic ed setting for 3 weeks in november 2011. we report means and standard deviations, and analysis of variance to identify differences in ctm-3 scores for those who planned and did not plan to follow ed recommendations. results: 750 surveys were completed; patients were 43 ± 19 years old, 58% black, 61% female, 56% with at least some college education, and 38% were admitted. average ctm-3 score was 87.1 ± 21.6 (range 0-100). scores were not associated with sex (p = 0.57), race (p = 0.19), or education level (p = 0.25). lower ctm scores were associated with increasing age (p = 0.03), patient perceptions that the ed team was less likely to use words that they understood, listen carefully to them, inspire their confidence and trust, or encourage them to ask questions (all p < 0.01). those who reported they were ''very likely'' to follow ed treatment had an average score of 89 ± 21, while those who were ''unlikely'' or ''very unlikely'' to follow ed treatment plans had an average score 47 ± 28 (p = 0.00). conclusion: the ctm-3 performs well in the ed and exhibited only differential item difficulty by age; there was no significant difference by race, sex, or education level. furthermore, it is highly associated with likelihood of following physician recommendations. future studies will focus on ctm-3 scores ability to discriminate between patients who did or did not experience a subsequent ed visit or rehospitalization. age and race were found to be significant predictors of the race pathway. regression of the data by race revealed blacks (or 1.9: ci 1.3-2.6; p < 0.0002), hispanics (or 3.0: ci 1.3-2.6; p = 0.0001), and asians (or 2.3: ci 1.1-4.9; p = 0.03), were more likely to enter the race cohort than were whites; however, much of this discrepancy is accounted for by age. the mean age of minority patients was 62 years, while white patients were older at 71 years (p = 0.002). conclusion: in a diverse demographic population we found that racial minorities were presenting at younger ages for chest pain and were more likely to receive cardiac testing at bedside than their white counterparts; and hence, were selected to a lower level of care (nonmonitored unit background: expanding insurance coverage is designed to improve access to primary care and reduce use of emergency services. whether expanding coverage achieves this is of paramount importance as the united states prepares for the affordable care act. objectives: we examined ed and outpatient department use after the state children's health insurance program (schip) coverage expansion, focusing on adolescents (a major target group for schip) versus young adults (not targeted). we hypothesized that coverage would increase use of outpatient services and emergency department services would decrease. methods: using the national ambulatory medical care survey and the national hospital ambulatory medical care survey, we analyzed years 1992-1996 as baseline and then compared use patterns in 1999-2009 after schip launch. primary outcomes were populationadjusted annual visits to ed versus non-emergency outpatient settings. interrupted time-series were performed on use rates to ed and outpatient departments between adolescents (11-18 years old) and young adults (19-29 years old) in the pre-schip and schip periods. outpatient-to-ed ratios were calculated and compared across time periods. results: the mean number of outpatient adolescent visits increased by 299 visits per 1000 persons (95% ci, 140-457), while there was no statistically significant increase in young adult outpatient visits across time periods. there was no statistically significant change in the mean number of adolescent ed visits across time periods, while young adult ed use increased by 48 visits per 1000 persons (95% ci, 24-73). the adolescent outpatient-to-ed ratio increased by 1.0 (95% ci, 0.49-1.6), while the young adults ratio decreased by 0.53 across time periods (95% ci, )0.90 to )0.16). conclusion: since schip, adolescent non-ed outpatient visits increased while ed visits remained unchanged. in comparison to young adults, expanding insurance coverage to adolescents improved access to health care services and suggests a shift to non-ed settings. as an observational study we are unable to control for secular trends during this time period. also as an ecological study we are unable to examine individual variation. expanding insurance through the affordable care act of 2010 will likely increase use of outpatient services but may not decrease emergency department volumes. background: cancer patients are receiving a greater proportion of their care on an outpatient basis. the effect of this change in oncology care patterns on ed utilization is poorly understood. objectives: to examine the characteristics of ed utilization by adult cancer patients. methods: between july 2007 and march 2009, all new adult cancer patients referred to a tertiary care cancer centre were recruited into a study examining psychological distress. these patients were followed prospectively until september 2011. the collected data were linked to administrative data from three tertiary care eds. variables evaluated in this study included basic we have previously shown that reducing non-value-added activities through the application of the lean process improvement methodology improves patient satisfaction, physician productivity and emergency department length of stay. objectives: in this investigation, we tested the hypothesis that non-value-added activities reduce physician job satisfaction. methods: to test this hypothesis, we conducted timemotion studies on attending emergency physicians working in an academic setting and categorized their activities into value-added (time in room with patient, time discussing cases and educating medical learners, time in room with patient and learner), necessary non-valueadded activities (charting, sign out, looking up labs), and unnecessary non-value-added activities (looking for things, looking for people, on the phone). the physicians were then surveyed using a 10-point likert scale to determine their relative satisfaction with each of the individual tasks (1 worst part of day, 10 best part of day). results: physicians spent 46% of their shift performing value-added work, 38% of their shift performing necessary non-value-added activities, and 16% of their shift performing unnecessary non-value-added activities (waste). weighted physician satisfaction (satisfaction x [percent time spent performing the activity / percent time engaged in activity category]) was highest when the physician was performing value-added work (8.75) compared to performing either necessary non-valueadded work (3.35) or waste (2.61). conclusion: the attending physicians we studied spent the majority of their time performing non-value-added activities, which were associated with lower satisfaction. application of process improvement techniques such as lean, which focus on reducing non-value-added work, may improve emergency physician job satisfaction. background: rocuronium and succinylcholine are the most commonly used paralytics for rapid sequence intubation (rsi) in the ed. after rsi, patients need sustained sedation while they are mechanically ventilated. however, the longer duration of action of rocuronium may influence subsequent sedation dosing, while the patient is therapeutically paralyzed. objectives: we hypothesized that patients who receive rocuronium would be more likely to receive lower doses of post-rsi sedation compared to patients who receive succinylcholine. methods: this was an observational, retrospective cohort study conducted in a tertiary, academic ed. consecutive adult patients, who received rsi using etomidate for induction of sedation between 07/01/09 to 06/30/10, were included. patients were then categorized based on whether they received rocuronium or succinylcholine for paralysis. the dosing of post-rsi sedative infusions was compared at 0, 30, 60, and 120 minutes after initiation between the two groups using the wilcoxon rank-sum test. results: a total of 254 patients were included in the final analysis (rocuronium = 127, succinylcholine = 127). mean age was 52 and 47 years in the rocuronium and succinylcholine groups, respectively (p = 0.04). there were no other baseline differences between groups with regard to demographics, reason for intubation, stroke, traumatic brain injury, glasgow coma scale score, pain scores, or vital signs. in the overall cohort, 90.2% (n = 229) of patients were given a sedative infusion or bolus in the ed. most patients were initiated on propofol (n = 169) or midazolam (n = 49) infusions. median propofol infusion rates at 0, 30, 60, and 120 minutes were 20, 20, 27.5, and 30 mcg/kg/min in the rocuronium group and 20, 40, 45, and 45 mcg/kg/ min in succinylcholine group, respectively. the difference was statistically significant at 30 (p < 0.001) and 60 (p = 0.003) minutes. median midazolam infusion rates at 0, 30, 60, and 120 minutes were 2, 2, 2, and 3 mg/hour in the rocuronium group and 2, 3, 4, and 4.5 mg/hour in succinylcholine group, respectively. the difference was statistically significant at 60 (p = 0.003) and 120 (p = 0.04) minutes. conclusion: patients who receive rocuronium are more likely to receive lower doses of sedative infusions post-rsi due to sustained therapeutic paralysis. this may put them at risk for being awake under paralysis. what is the impact of the implementation of an there was a difference in presenting pain (p < 0.001), stress (p < 0.001), and anxiety (p < 0.001) among patients that received an opioid in the ed. there was a difference in presenting pain (p < 0.001) for patients discharged with an opioid prescription, but not for stress (p = 0.32) or anxiety (p = 0.90). conclusion: patient-reported pain, stress, and anxiety are higher among patients who received an opiate in the ed than in those who did not, but only pain is higher among patients who received a discharge prescription for an opioid. methods: this was a prospective, randomized crossover study on the use of gvl and dl by incoming pediatric interns prior to advanced life support training. at the start of the study, the interns received a didactic session and expert modeling of the use of both devices for intubation. two scenarios were used: (1) normal intubation with a standard airway and (2) difficult intubation with tongue edema and pharyngeal swelling. interns then intubated laerdal simbaby in each scenario with both gvl and dl for a total of four randomized intubation scenarios. primary outcomes included time to successful intubation and the rate of successful intubation. the interns also rated their satisfaction with the devices using a visual analog scale (0-10) and chose their preferred device for their next intubation. results: 29 interns were included in this study. in the normal airway scenario, there were no differences in the mean time for intubation with gvl or dl (62.9 ± 24.1 vs 61.8 ± 26.2 seconds, p = ns) or the number of interns who performed successful intubation (23 vs 22, p = ns). in the difficult airway scenario, the interns took longer to intubate with gvl than dl (92.3 ± 26.6 vs 59.9 ± 22.7 seconds, p = 0.008), but there were no differences in the number of successful intubations (17 vs 19, p = ns). interns rated their satisfaction higher for gvl than dl (7.3 ± 1.8 vs 6.5 ± 1.5, p = 0.05) and gvl was chosen as the preferred device for their next intubation by a majority of the interns (19/29, 66%). conclusion: for novice clinicians, gvl does not improve the time to intubation or intubation success objectives: to determine the time to intubation, the number of attempts, and the occurrence of hypoxia, in patients intubated with a c-mac device versus those intubated using a standard laryngoscope. methods: randomized controlled trial using exception from informed consent that included patients undergoing endotracheal intubation with a standard laryngoscope at an urban level i trauma center. eligible patients were randomized to undergo intubation using the c-mac or standard laryngoscopy. standard laryngoscopy was performed using a c-mac device laryngoscope with the video output obstructed to ensure equivalent laryngoscope blades in the two groups. data were collected by a trained research assistant at the patient's bedside and video review by the investigators. the number of attempts made, the initial and lowest oxygen saturation (spo 2 ), and the total time until the intubation was successful was recorded. hypoxia was defined as an oxygen saturation <93%. data were compared with wilcoxon rank sum and chi-square tests. results: thirty-eight patients were enrolled, 20 (70% male, median age 58, range 28 to 86, median spo 2 97%, range 79 to 100) in the standard laryngoscopy group and 18 (67% male, median age 58, range 19 to 73, median spo 2 96.5%, range 78 to 100) in the c-mac group. the median number of attempts for standard laryngoscopy was 1, range 1 to 3, and for c-mac was 1, range 1 to 2 (p = 0.43). the median time to intubation for the standard laryngoscopy group was 54 seconds (range 7 to 89) and for the c-mac group was 41 seconds (range 4 to 101)(p = 0.05). hypoxia was detected in 5/20 (20%) in the standard laryngoscopy group and 1/18 (6%) in the c-mac group (p = 0.15). the median decrease in oxygen saturation during the attempt was 5.4% (range 0% to 31%) for the standard laryngoscopy group and 2.3% (range 0% to 16%) for the c-mac group. conclusion: we did not detect a difference in number of attempts, the occurrence of hypoxia, or the diagnosis of aspiration pneumonia between standard laryngoscopy and the c-mac. the time to successful intubation was shorter for patients intubated with the c-mac. the c-mac device appears to be superior to standard laryngoscopy for emergent endotracheal intubation. (originally submitted as a ''late-breaker.'') the background: aspiration pneumonia is a complication of endotracheal intubation that may be related to the difficulty of the airway procedure. objectives: to determine the association of the device used, the time to intubation, the number of attempts to intubate, and the occurrence of hypoxia with the subsequent development of aspiration pneumonia. methods: this was a prospective observational study of patients undergoing endotracheal intubation by emergency physicians at an urban level i trauma center conducted from 7/1/2010 until 11/1/2011. the device used on the initial attempt to intubate was at the discretion of the treating physician. data were collected by a trained research assistant at the patient's bedside. the device used, the number of attempts made to intubate, the lowest oxygen saturation during the attempt, and the total time until intubation was successfully accomplished were recorded. patient's medical records were reviewed for the subsequent diagnosis of aspiration pneumonia. hypoxia was defined as an oxygen saturation <93%. data were analyzed using multinomial logistic regression and odds ratios (or). results: 654 patients were enrolled; 141 (22%) subsequently developed aspiration pneumonia. 328 were intubated with a standard laryngoscope (sl), 277 using the c-mac, 26 with an intubating laryngeal mask, and 23 with nasotracheal intubation (ni) (or 0.87, 95% ci = 0.70-1.06). comparison of individual devices versus sl did not show an association by device type. the median number of attempts for patients with aspiration pneumonia was 1, range 1 to 3, and for those without was 1, range 1 to 9 (or 0.78, 95%ci = 0.43-1.38). the median time to intubation for patients who developed aspiration pneumonia was 55 seconds (range 4 to 756) and for those who did not was 54 seconds (range 4 to 721)(or 1.00, 95%ci = 0.99-1.00). hypoxia during intubation was detected in 53/141 (38%) in the aspiration pneumonia group and 175/513 (34%) in the no aspiration pneumonia group (or 1.06, 95% ci = 0.65-1.72). conclusion: there was not an association between the device used, the number of attempts, the time to intubation, or the occurrence of hypoxia during the intubation, and the subsequent occurrence of aspiration pneumonia. background: japanese census data estimate that 35 million, or nearly 29% of the overall population, will be over age 65 by the year 2020. similar trends are apparent throughout the developed world. although increased patient age affects airway management, comprehensive information in emergency airway management for the elderly is lacking. objectives: we sought to characterize emergency department (ed) airway management for the elderly in japan including success rate, and major adverse events using a large multi-center registry. methods: design and setting: we conducted a multicenter prospective observational study using the japanese emergency airway network (jean) registry of eds at 11 academic and community hospitals in japan between 2010 and 2011 inclusive. data fields included ed characteristics, patient and operator demographics, methods of airway management, number of attempts, success rate, and adverse events. participants: patient inclusion criteria were all adult patients who underwent emergent tracheal intubation in the ed. primary analysis: patients were divided to into two groups defined as follows: 18 to 64 years old and over 65 years old. we describe primary success rates and major adverse events using simple descriptive statistics. categorical data are reported as proportions and 95% confidence intervals (cis). results: the database recorded 2710 patients (capture rate 98%) and 2623 met the inclusion criteria. of 2623 patients, 1104 patients were 18 to 64 years old (62%) and 1519 were over 65 years old (38%). the older group had a significantly higher success rate at first attempt intubation (1074/1519; 70.7%, 95% ci 68.8-72.6%) compared with the younger group (710/1104; 64.3%, 95% ci 61.9-66.7%). the older group had similar major adverse event rates (112/1519; 7.4%, 95% ci 6.3-8.5%) compared with the younger group (83/1104; 7.5%, 95% ci 6.2-8.8%). (see table 1) background: the degree to which a patient's report of pain is associated with changes in blood pressure, heart rate, and respiratory rate is not known. objectives: to determine to what degree a standardized painful stimulus effects a change in systolic blood pressure (sbp), diastolic blood pressure (dbp), heart rate (hr), or respiratory rate (rr), and compare changes in vital signs between patients based on pain severity. methods: prospective observational study of healthy human volunteers. subjects had their sbp, dbp, hr, and rr measured prior to pain exposure, immediately after, and 10 minutes after. pain exposure consisted of subjects placing their hand in a bath of 0 degree water for 45 seconds. the bath was divided into two sections; the larger half was the reservoir of cooled water monitored to be 0 degrees, the other half filled from constant overflow over the divider. water drained from this section into the cooling unit and was then pumped up into the base of the reservoir through a diffusion grid. subjects completed a 100 mm visual analog scale (vas) representing their perceived pain during the exposure and graded their pain as minimal, moderate or severe. data were compared using 95% confidence intervals. results: 90 subjects were enrolled, mean pain vas 40 mm, range 0 to 77, 49 reported mild pain, 41 moderate pain, and 0 severe pain. the percent change from baseline in vital signs during the exposure and 10 minutes after are presented in the table. conclusion: there was a wide variety in reported pain among subjects exposed to a standard painful stimulus. there was a larger change in heart rate during the exposure among subjects who described a standardized painful exposure as moderate than in those who described it as severe. the small observed changes in blood pressure and respiratory rate seen during the exposure did not differ by pain report or persist after 10 minutes. background: vital signs are often used to validate intensity of pain. however, few studies have looked at the capacity of vital signs to estimate pain intensity, particularly in patients with a diagnosis that a majority of physicians would agree produce significant pain in the ed. objectives: to determine the association between pain intensity and vital signs in consecutive ed patients and in a sub-group of patients with diagnosis known to cause significant pain. methods: we performed a post-hoc analysis of prospectively acquired data in a cohort study done in an urban teaching hospital with computerized triage and nurses records. we included all consecutive ed adult patients ( ‡16 years old), who had any level of pain intensity measured during triage, from march 2008 to november 2010. the primary outcome was the mean heart rate, systolic and diastolic blood pressure for every pain intensity level from 1 to 10 on a verbal numerical scale. our secondary outcomes where the same but limited to patients with the following diagnosis: fracture, dislocation, and renal colic. we performed descriptive statistics, one-way and two-way anovas when appropriate. results: during our study period, 42,947 patients ‡16 years old where triaged with a pain intensity of at least 1/10 and 3939 had a diagnosis known to cause significant pain. 56.5% of patients were female, with a mean pain intensity of 6.8/10, mean age of 47.9 years (±19.3), and 22.3% were ‡65 years old. there was a statistically significant difference (p < 0.05) in mean heart rate, systolic and diastolic blood pressure for each level of pain intensity, ex: difference between 1/10 and 10/10 for mean heart rate was 3.9 beats per minutes, for systolic pressure was 4.0 mmhg and for diastolic 4.5 mmhg. results are similar for painful diagnosis: difference for mean heart rate was 0.3 beats per minutes, for systolic pressure was 6.5 mmhg and diastolic 8.8 mmhg. however, these differences are not clinically significant. conclusion: although our study is a post hoc analysis, pain intensity, heart rate, systolic and diastolic pressures during triage are usually reliable data and a prospective study would likely produce the same result. these vital signs cannot be used to estimate or validate pain intensity in the emergency department. 8% had a positive urine drug screen. logistic multivariate regressions analyses revealed the following factors to be significantly associated with the risk of having an abnormal head ct: association with seizure (p = 0.0072); length of time of loss of consciousness, ranging from none to 0-30 min to >30 min (p = 0.0013); alteration of consciousness (p = 0.00009); post-traumatic amnesia (p = 0.0132); alcohol intake prior to injury (p = 0,0003); and initial ed gcs (p = 0.0255). conclusion: in an emergency department cohort of patients with traumatic brain injury, symptoms including loss of or alteration in consciousness, seizure, post traumatic amnesia, and alcohol intake appear to be significantly associated with abnormal findings on head ct. these clinical findings on presentation may be useful in helping triage head injury patients in a busy emergency department, and can further define the need for urgent or emergent imaging in patients without clearly apparent injuries. background: the etiology of neurogenic shock is classically attributed to diminished peripheral vascular resistance (pvr) secondary to loss of sympathetic outflow to the peripheral vasculature. however, the sympathetic nervous system also controls other key elements of the cardiovascular system such as the heart and capacitance vessels and disruptions in their function could complicate the hemodynamic presentation. objectives: we sought to systematically examine the hemodynamic profiles of a series of trauma patients with neurogenic shock. methods: consecutive trauma patients with documented spinal cord injury complicated by clinical shock were enrolled. hemodynamic data including systolic and diastolic blood pressure, heart rate (hr), impedance-derived cardiac output, pre-ejection period (pep), left ventricular ejection time (lvet), and calculated systemic pvr were collected in the ed. data were normalized for body surface area and a validated integrated computer model of human physiology (guyton model) was used to analyze and categorize the hemodynamic profiles based on etiology of the hypotension using a systems analysis. correlation between markers of sympathetic outflow (hr, pep, lvet) and shock etiology category was examined. results: of 9 patients with traumatic neurogenic shock, the etiology of shock was decrease in pvr in 4 (45%; 95% ci 19 to 73%), loss of vascular capacitance in 3 (33%; 12 to 65%), and mixed peripheral resistance and capacitance responsible in 2 (22%; 6 to 55%). the markers of sympathetic outflow had no correlation to any of the elements in the patients' hemodynamic profiles. conclusion: neurogenic shock is often considered to have a specific well-characterized pathophysiology. results from this study suggest that neurogenic shock can have multiple mechanistic etiologies and represents a spectrum of hemodynamic profiles. this understanding is important for the treatment decisions made in the management of these patients. -year (2008-2010) , pre-post intervention study of trauma patients requiring massive blood transfusion was performed. we divided the population into two cohorts: a pre-protocol group (pre) which included trauma patients receiving mbt not aided by a protocol, and a post-protocol group (post) who underwent mbt via the mbtp. patient demographics, 24hour blood component totals, timing of blood component delivery, trauma injury severity score (iss), initial glasgow coma scale (gcs) score, trauma mechanism, and patient mortality data were collected and analyzed using fisher's exact tests, student's t-tests, and mann-whitney u tests. results: fifty-two patients were included for study. median times to delivery of first products were reduced for prbcs (4 minutes), ffp (16 minutes), and platelets (33 minutes) between the pre and post cohorts. median time to delivery of any subsequent blood product was significantly reduced (10 minutes) in the post cohort (p = 0.024). the median number of blood products delivered was increased by 5.5 units for prbcs, 4 units for ffp, 0.5 units for platelets, and 1 unit for cryoprecipitate after implementation of mbtp. the percentage of patients receiving higher blood product ratios (>3:1) was reduced between the pre and post cohorts for prbc to ffp (25% reduction) and prbc to platelet ratio groups (7 % reduction). despite improved transfusion timing and ratios, we found no significant difference in mortality (p = 0.129) between pre and post cohorts when we adjusted for injury severity. conclusion: protocolized delivery of massive blood transfusion might reduce time to product availability and delivery, though it is unclear how this affects patient mortality in all us trauma centers. background: burns are common injuries that can result in significant scarring leading to poor function and disfigurement. unlike mechanical injuries, burns often progress both in depth and size over the first few days after injury, possibly due to inflammation and oxidative stress. a major gap in the field of burns is the lack of an effective therapy that reduces burn injury progression. objectives: since mesenchymal stem cells (msc) have been shown to improve healing in several injury models, we hypothesized that species-specific msc would reduce injury progression in a rat comb burn model. methods: using a 150 gm brass comb preheated to 100 degrees celsius, we created four rectangular burns, separated by three unburned interspaces on both sides of the backs of male sprague-dawley rats (300 g). the interspaces represented the ischemic zones surround-ing the central necrotic core. left untreated, most of these interspaces become necrotic. in an attempt to reduce burn injury progression, 20 rats were randomized to tail vein injections of 1 ml rat-specific msc 10 6 cells/ml (n = 10) or normal saline (n = 10) 60 minutes after injury. tracking of the stem cells was attempted by injecting several rats with quantum dot-labeled msc. results: by four days post-injury, all of the interspaces in the control rats (54/54, 100%) became necrotic while in the experimental group, 29/48 (60%) of the interspaces became necrotic (fisher's exact test; p < 0.001). at 7 days, the percentage of the unburned interspaces that became necrotic in the msc treated group was significantly less than in the control group (80% vs. 100%, p < 0.0001). we were unable to identify any quantum dot labeled msc in the injured skin. no adverse reactions or wound infections were noted in rats injected with msc. conclusion: intravenous injection of rat msc reduced burn injury progression in a rat comb burn model. although basic demographics of bicyclists in accidents have been described, there is a paucity of data describing the street surface involved in accidents, and whether designated bicycle roadways offer protection. this lack of information limits informed attempts to change infrastructure in a way that will decrease morbidity and/or mortality of cyclists. objectives: to identify road surface types involved in pedal cyclist injuries and determine the relationship between injury severity and the use of designated bicycle roadways (dbr) versus non-designated roadways (ndr). we hypothesized that more severe injuries would happen at intersections regardless of dbr versus ndr. methods: this retrospective cohort study reviewed the trauma database from a level i trauma center in tucson, az. we identified all bicyclists in the database injured in accidents involving a motor vehicle from january 1, 2009 1, through december 31, 2009 . the patients were then linked to a local government database that documents location (latitude/longitude) and direction of travel of the cyclist. seventy-eight total incidents were identified and categorized as occurring on a dbr versus ndr and occurring at an intersection versus not at an intersection. results: only one patient who arrived at the trauma center died. fifty-one of the accidents (65%) occurred on dbrs; 63% of accidents occurring on dbrs took place in intersections. conversely, 63% of accidents on ndrs occurred outside of intersections. the odds of an injury occurring at an intersection versus not at an intersection were 2.9 times higher (95% ci: 1.0-8.5) for dbrs compared to ndrs. the odds of a trauma being severe (admitted) versus not severe (discharged home) were 2.7 times higher (95% ci: 0.9-8.7) when a collision occurred not at an intersection versus at an intersection. conclusion: contrary to our hypothesis, in this study group severe injuries were more likely outside of an intersection. however, intersections on dbrs were identified as problematic as cyclists on a dbr were more likely to be injured in an intersection. future city planning could target improved cyclist safety in intersections. background: minor thoracic injury (mti) is frequent and a significant proportion will still have moderate to severe pain at 90 days. there is a lack of risk factors to orient specific treatment at ed discharge. objectives: to determine risk factors of having pain ( ‡3/10, on a numerical intensity pain score from 0 to 10) at 90 days in a population of minor thoracic injury patients discharged from the ed. methods: a prospective multi-center cohort study was conducted in four canadian eds, from november 2006 to january 2010. all consecutive patients, 16 years and older, with mti (with or without rib fracture), a normal chest x-ray, and discharged from the ed were eligible. a standardized clinical and radiological evaluation was done at 1 and 2 weeks. standardized phone interviews were done at 30 and 90 days. pain evaluation occurred at five time points (ed visit, 1 and 2 weeks, 30 and 90 days). using a pain trajectory model (sas), we planned to identify groups with different pain evolution at 90 days. the final model was based on the importance of difference in pain evolution, confidence intervals, and number of patients in each group. to judge the adequacy of the final model, we examined whether the posteriori probabilities (i.e., a participant's probability of belonging to a certain trajectory group) averaged at least 70% for each trajectory group. then using logistic multinomial regression and the low risk group of having pain as the control group, we identified significant predictors of patients in the moderate and high risk groups having pain at 90 days. results: in our cohort of 1,057 patients, 1,025 had an evaluation at 90 days. we identified three groups at low (34%), moderate (50.6%), and high risk (15.4%) of having pain ‡3/10 at 90 days. using risk factor identified by univariate analysis, we created a model to identify patients at risk containing the following predictors: age ‡ 30 years old, women, current smoker, two or more rib fractures, complaint of dyspnea, and saturation <95% at initial visit. posteriori probabilities for low, moderate, and high risk were 76%, 74%, and 88%. conclusion: to our knowledge, this is the first study to identify potential risk factor for having pain at 90 days after minor thoracic injury. these risk factors should be validated in a prospective study to guide specific treatment plan. the use of ultrasound to evaluate traumatic optic neuropathy benjamin burt, lisa montgomery, cynthia garza meissner, sanja plavsic-kupesic, nadah zafar ttuhsc -paul l foster school of medicine, el paso, tx background: whenever head trauma occurs, there is the possibility for a patient to have an optic nerve injury. the current method to evaluate optical nerve swelling is to look for proptosis. however, by the time proptosis presents, significant damage has already occurred. therefore, there is a need to establish a method to evaluate nerve injury prior to the development of proptosis. objectives: fundamental to understanding the pathophysiology of optic nerve injury and repair is an understanding of the optic nerve's temporal response to trauma including blood flow changes and vascular reactivity. the aim of our study was to assess the dependability and reproducibility of ultrasound techniques to sequence optic nerve healing and monitor the vascular response of the ophthalmic artery following an optic nerve crush. methods: the rat's orbit was imaged prior to and following a direct injury to the optic nerve, at 72 hours and at 28 days. 3d, 2d, and color doppler techniques were used to detect blood flow and the course of the ophthalmic artery and vein, to evaluate the course and diameter of the optic nerve, and to assess the extent of optic nerve trauma and swelling. the parameters used to evaluate healing over time were pulsatility and resistance indices of the ophthalmic artery. results: we have established baseline ultrasound measurements of the optic nerve diameter, normal resistance and pulsatility indices of the ophthalmic artery, and morphological assessment of the optic nerve in a rat model. longitudinal assessment of 2d and 3d ultrasound parameters were used to evaluate vascular response of the ophthalmic artery to optic nerve crush injury. we have developed a rat model system to study traumatic optic nerve injury. the main advantages of ultrasound are low cost, non-invasiveness, lack of ionizing radiation, and the potential to perform longitudinal studies. our preliminary data indicate that 2d and 3d color doppler ultrasound may be used for the evaluation of ophthalmic artery and total orbital perfusion following trauma. once baseline ultrasound and doppler measurements are defined there is the opportunity to translate the rat model to evaluate patients with head trauma who are at risk for optic nerve swelling and to assess the usefulness of treatment interventions. background: alcoholism is a chronic disease that affects an estimated 17.6 million american adults. a common presentation to the emergency department (ed) is a trauma patient with altered sensorium who is presumed to be alcohol intoxicated by the physicians based on their olfactory sense. often ed physicians may leave patients suspected of alcohol intoxication aside until the effects wear off, potentially missing major trauma as the source of confusion or disorientation. this practice often results in delays in diagnosing acute potentially life-threatening injuries in the patients with presumed alcohol intoxication. objectives: this study will determine the accuracy of physicians' olfactory sense for diagnosing alcohol intoxication. methods: patients suspected of major trauma in the ed underwent an evaluation by the examining physician for the odor of alcohol as well as other signs of intoxication. each patient had determination of blood alcohol level. alcohol intoxication was defined as a serum ethanol level ‡80 mg/dl. data were reported as means with 95% confidence intervals (95% ci) or proportions with inter-quartile ranges (iqr 25%-75%). results: one hundred and fifty one patients (70% males) were enrolled in the study, median age 45 years (iqr 33-56). the median score for glasgow coma scale was 15. the level of training of examining physician was a median of pgy 4 (iqr pgy 3 -attending). prevalence of alcohol intoxication was 43% (95% ci: 35% to 51%). operating characteristics: physician assessment of alcohol intoxication, sensitivity 84% (95% ci: 73% to 92%), specificity 87% (95% ci: 78% to 93%), positive likelihood ratio 6.6 (95% ci: 3.8 to 11.6), negative likelihood ratio 0.18 (95% ci: 0.1 to 0.3), and accuracy 86% (95% ci: 80% to 91%). patients who were falsely suspected of being intoxicated were 7.3% (95% ci: 4% to 13%). conclusion: although the physicians had a high degree of accuracy in identifying patients with alcohol intoxication based on their olfactory sense, they still falsely overestimated intoxication in a significant number of non-intoxicated trauma patients. the background: optimal methods for education and assessment in emergency and critical care ultrasound training for residents are not known. methods of assessment often rely on surrogate endpoints which do not assess the ability of the learner to perform the imaging and integrate the imaging into diagnostic and therapeutic decisions. we designed an educational strategy that combines asynchronous learning to teach imaging skills and interpretation with a standardized assessment tool using a novel ultrasound simulator to assess the learner's ability to acquire and interpret images in the setting of a standardized patient scenario. objectives: to assess the ability of emergency medicine and surgical residents to integrate and apply information and skills acquired in an asynchronous learning environment in order to identify pathology and prioritize relevant diagnoses using an advanced cardiac ultrasound simulator. methods: 12 em r2 residents and 12 r2 surgical residents completed an online focused training program in cardiac ultrasonography (iccu elearning, https:// www.caeiccu.com/lms). this consisted of approximately 14 hours of intensive training in cardiac ultrasound. residents were then given cases with a patient scenario that lacked significant details that would suggest a specific diagnosis. the resident was then given a list of 17 possible diagnoses and asked to rank the top five diagnoses in order of most likely to least likely. each resident (blinded to the pathology displayed by the simulator) then imaged using an ultrasound simulator. after imaging, the residents were given the same list of potential diagnoses, and asked to rank them again from 1-5. results: overall, residents ranked the correct diagnosis in the top five significantly more times post-ultrasound than pre-ultrasound. additionally, the residents made the correct diagnosis significantly more times postultrasound than pre-ultrasound. similar patterns occur for congestive heart failure, pericardial effusion with tamponade, and pleural effusion. there was no significant difference pre-and post-ultrasound for pulmonary embolism and anterior infarction. conclusion: an asynchronous online learning program significantly improves the ability of emergency medicine and surgical residents to correctly prioritize the correct diagnosis after imaging with a standardized pathology imaging simulator. mark favot, jacob manteuffel, david amponsah henry ford hospital, detroit, mi background: em clerkships are often the only opportunity medical students have to spend a significant amount of time caring for patients in the ed. it is imperative that students gain exposure to as many of the various fields within em as possible during this time. if the exposure of medical students to ultrasound is left to the discretion of the supervising physicians, we feel that many students would complete an em clerkship with limited skills and knowledge in ultrasound. the majority of medical students receive no formal training in ultrasound during medical school and we believe that the em clerkship is an excellent opportunity to fill this educational gap. objectives: evaluate the usefulness and effectiveness of a focused ultrasound curriculum for medical students in an em clerkship at a large, urban, academic medical center. methods: prospective cohort study of fourth year medical students doing an em clerkship. as part of the clerkship requirements, the students have a portion of the curriculum dedicated to the fast exam and ultrasound-guided vascular access. at the end of the month they take a written test, and 1 month later they are given a survey via e-mail regarding their ultrasound experience. em residents also completed the test to serve as a comparison group. all data analysis was done using sas 9.2. scores were integers ranging between 0 and 10. descriptive statistics are given as count, mean, standard deviation, median, minimum, and maximum for each group. due to non-gaussian nature of the data and small group sizes, a wilcoxon two-sample test was used to compare the distributions of scores between the groups. results: in the table, the distribution of scores was compared between the residents (controls) and the students (subjects). the mean and median scores of the student group were higher than those of the resident group. the difference in scores between the two groups was statistically significant (p = 0.021). conclusion: our data reveal that after completing an em clerkship with time devoted to learning ultrasound for the fast exam and vascular access, fourth year medical students are able to perform better than em residents on a written test. what remains to be determined is if their skills in image acquisition and in performance of ultrasound-guided vascular access procedures also exceed those of em residents. results: there were 106 respondents (total response rate 24.71%). compared to non-em students, students pursuing em (8 students, 7.55%) were more drawn to their specialty for work hour control (p < 0.0009) and shorter residency length (p < 0.0338). em students were less likely than non-em students to be drawn to their chosen specialty for future academic opportunities (p < 0.0085). em students formed their mentorships by referral significantly more than non-em students (p < 0.0399), though there was no statistical difference in quality of existing mentorships amongst students. of the 93 students not currently and never formerly interested in em, the most common response (25.8%) for why they did not choose em was the lack of a strong mentor in the field. conclusion: the results confirmed previous findings of lifestyle factors drawing students to em. future academic opportunities were less likely to draw students to em than students pursuing other specialties. lack of mentorship in the field was the most common reason given for why students did not consider em. given the lack of direct em exposure until late in the curriculum of most medical schools, mentorship may be particularly important for em and future study should focus on this area. background: misdiagnosis is a major public health problem. dizziness leads to 10 million visits annually in the us, including 2.6 million to the emergency department (ed). despite extensive ed workups, diagnostic accuracy remains poor, with at least 35% of strokes missed in those presenting with dizziness. ed physicians need and want support, particularly in the best method for diagnosis. strong evidence now indicates the bedside oculomotor exam is the best method of differentiating central from peripheral causes of dizziness. objectives: after a vertigo day that includes instruction in head impulse testing, emergency medicine residents will feel comfortable discharging a patient with signs of vestibular neuritis and a positive head impulse test without ordering a ct scan. methods: post graduate year 1-4 emergency medicine residents participated in a four hour vertigo day. we developed a mixed cognitive and systems intervention with three components: an online game that began and ended the day, a didactic taught by dr. newman-toker, and a series of small group exercises. the small group sessions included the following: a question and answer session with the lecturer; vertigo special tests (cerebellar assessment, dix hall-pike, epley maneuver); a head impulse hands-on tutorial using a mannequin; and a video lecture on other tests useful in vertigo evaluation (nystagmus, test of skew, vestibulocular reflex, ataxia). results: thirty emergency medicine residents were studied. before and after the intervention the residents were given a survey in which one question asked ''in a patient with acute vestibular syndrome and a history and exam compatible with vestibular neuritis, i would be willing to discharge the patient without neuroimaging based on an abnormal head impulse test result that i elicited''. resident answers were based on a sevenpoint likert scale from strongly agree to strongly disagree. twenty-five residents completed both surveys. of the seven residents who changed their responses pre to post,a significant proportion (100%) changed their answer from disagree/neutral to agree after a 4hour vertigo day (mcnemar's test, p value = 0.0082). conclusion: in this single-center study, teaching headimpulse testing as part of a vertigo day increases resident comfort with discharging a patient with vestibular neuritis without a ct scan. background: previous studies have been inconsistent in determining the effect of increased ed census on resident workload and productivity. we examined resident workload and productivity after the closure of a large urban ed near our facility, which resulted in a rapid 21% increase in our census. objectives: we hypothesized that the closure of a nearby hospital closure with a resulting influx of ed patients to our facility would not change resident productivity. methods: this computer-assisted retrospective study compared new patient workups per hour and patient load before and after the closure of a large nearby hospital. specifically, new patient workups per hour and the 4 pm patient census per resident were examined for a one-year period in the calendar year prior to the closing and also for one year after the closing. we did not include the four month period surrounding the closure in order to determine the long-term overall effect. background: emergency medicine residents use simulation for training due to multiple factors including the acuity of certain situations they are faced with, and the rarity of others. current training on highfidelity mannequin simulators is often critiqued by residents over the physical exam findings present, specifically the auscultatory findings. this detracts from the realism of the training, and may also lead a resident down a different diagnostic or therapeutic pathway. wireless remote programmed stethoscopes represent a new tool for simulation education which allows any sound to be wirelessly transmitted to a stethoscope receiver. objectives: our goal was to determine if a wireless remote programmed stethoscope was a useful adjunct in simulation-based cases using a high-fidelity mannequin. our hypothesis was that this would represent a useful adjunct in simulation education of emergency medicine residents. methods: starting june 2011, pgy1-3 emergency medicine residents were assessed in two simulation-based cases using pre-determined scoring anchors. an experimental randomized crossover design was used in which each resident performed a simulation case with and without a remote programmed stethoscope on a highfidelity mannequin. scoring anchors and surveys were used to collect data with differences of means calculated. results: fourteen residents participated in the study. residents noted most realistic physical exam findings associated with the case with the adjunct in 13/14 (93%) and that their preference was for the use of the adjunct in 13/14 (93%). based off of a five-point likert scale, with 5 being the most realistic, the adjunct-associated case averaged 4.4 as compared to 3.0 without (difference of means 1.4, p = 0.00017). average scores of residents with the adjunct were 2.5/3 with the use of the adjunct and 2.3/3 without (difference of means 0.2, p = 0.076). average total times were 28:49 with the adjunct as compared to 30:02 without. conclusion: a wireless remote programmed stethoscope is a useful adjunct in simulation training of emergency medicine residents. residents noted physical exam findings to be more realistic, preferred its use, and had approached significant improvement of scores when using the adjunct. background: prior studies predict an ongoing shortage of emergency physicians to staff the nation's eds, especially in rural areas. to address this, em organizations have discussed broadening access to acgme or aoa accredited em residency programs to physicians who previously trained in another specialty and focusing on physicians already practicing in rural areas. objectives: to investigate whether em program directors (pds) from allopathic and osteopathic residency programs would be willing to accept applicants previously trained in other specialties and whether this willingness is modified by applicants' current practice in rural areas. methods: a five-question web-based survey was sent to 200 u.s. em pds asking questions about their policies on accepting residents with past training and from rural practices. questions included whether a pd would accept a resident with prior training in other specialties, how many years from this training would the applicant be still a competitive candidate and if a physician was practicing in a rural region would the likelihood of acceptance to the program be improved. different characteristics of the residency programs were recorded including length of program, years in existence, size, type, and location of program. we compared responses by program characteristics using chi-square test. results: of the 96 (48%) pds responding to date, a large majority (87%) reported they do accept applicants with previous residency training, although directors of osteopathic programs were less likely to accept these applicants (56% vs 94% for allopathic; p < 0.001). overall, 28% of pds reported no limit on the length of time from prior training to when they are accepted at an em program. 73% reported it is very or possibly realistic they would accept a candidate who had completed training and was board certified in another specialty. a majority of all respondents (61%) felt a physician practicing in a rural setting might be viewed as a more favorable candidate, even if the resident would only be in the program for 2 years after receiving training credit. directors of newer programs (<5 years of existence) were more likely to view these candidates favorably than older programs (91% vs 53%; p = 0.02). conclusion: there appear to be many em residency programs that would at least review the application and consider accepting a candidate who trained in another specialty. a qualitative assessment of emergency medicine self-reported strengths todd guth university of colorado, aurora, co background: self-reflection has been touted as a useful way to assess the acgme core competencies. objectives: the purpose of this study is to gain insight into resident physician professional development through analysis of self-perceived strengths. a secondary purpose is to discover potential topics for selfreflective narrative essays relating to the acgme core competencies. methods: design: a small qualitative study was performed to explore the self-reported strengths of emergency medicine (em) residents in a single four-year residency. participants: all 54 residents regardless of year of training were also asked to report their selfperceived strengths. observations: residents were asked: ''what do you feel are your greatest strengths as a resident? provide a quick description.'' the author and another reviewer identified themes from within each year of residency with abraham maslow's conscious competence conceptual framework in mind. occurrences of each theme were counted by the reviewers and organized according to frequency. once the top ten themes for each year of residency were identified and exemplar quotes identified, the two reviewers identified trends. inter-rater agreements were calculated. results: representing unconscious incompetency, the first trend was the reported presence of ''enthusiasm and a positive attitude'' from residents early in their training that decreases further along in training. additionally, a ''willingness and motivation to improve and learn'' was reported as a strength throughout all the years of training but most frequently reported in the first two years of residency. entering into conscious incompetence, the second trend identified was ''recognition of limitations and openness to constructive feedback'' that was mentioned frequently in the second and third years of residency. demonstrating conscious competence, the third trend identified was the increase in identification of the strengths of ''educational leadership, teamwork skills and communication, and departmental patient flow and efficiency'' in the later years of residency. conclusion: self-reported strengths has helped to identify both themes within each year of residency and trends among the years of residency that can serve as areas to explore in self-reflective narratives relating to the acgme core competencies. training. pofu can also be used to assess the acgme core competency of practice-based learning. the exact form or frequency of pofu assessment among various em residencies, however, is not currently known. objectives: we aimed to survey em residencies across the country to determine how they fulfill the pofu requirement and whether certain program structure variables were associated with different pofu systems. we hypothesized that implementation of pofu systems among em residencies would be highly variable. methods: in this irb-approved study, all program directors of acgme allopathic em residencies were invited to complete a 10-question survey on their current approaches to pofu. respondents were asked to describe their current pofu system's characteristics and rate its ease of use, effectiveness, and efficiency. data were collected using surveymonkey(tm) and reported using descriptive statistics. results: of 158 residencies surveyed, 81 (51%) submitted complete data. 77.5% were completed by program directors and over three-fourths (76.1%) of em residencies require monthly completion of pofus. the mean total pofus required per year was 78 (95% ci 58-98), with a median of 64 and a range of 2-400. almost 2/3 (63%) of residencies use an electronic pofu system. most (84%) 4-year em residencies use an electronic pofu system, compared with half (54%) of 3-year residencies (difference 30%, p = 0.025, 95% ci 5.1%-47.2%). seven commercially available electronic programs are used by 71% of the residencies, while 29% use a customized product. most respondents (88%) rated their pofu system as easy to use, but less than half (49%) felt it was an effective learning tool or an efficient one (45%). onethird (34%) would use a different pofu system if available, and almost half (44%) would be interested in using a multi-residency pofu system. conclusion: em residency programs use many different strategies to fulfill the rrc requirement for pofu. the number of required pofus and the method of documentation vary considerably. about two-thirds of respondents use an electronic pofu system. less than half feel that pofu logs are an effective or efficient learning tool. background: certification of procedural competency is requisite to graduate medical education. however, little is known regarding which platforms are best suited for competency assessment. simulators offer several advantages as an assessment modality, but evidence is lacking regarding their use in this domain. furthermore, perception of an assessment environment has important influence on the quality of learning outcomes, and procedural skill assessment is ideally conducted on a platform accepted by the learner. objectives: to ascertain if a simulator performs as well as an unembalmed cadaver with regard to residents' perception of their ability to demonstrate procedural competency during ultrasound (us) guided internal jugular vein (ij) catheterization. methods: in this cross-sectional study at an urban community hospital during july of 2011, 15 residents in their second or third year of training from a 3-year em residency program performed us guided catheterizations of the ij on both an unembalmed cadaver and a simulator manufactured by blue phantom. after the procedure, residents completed an anonymous survey ascertaining how adequately each platform permitted their demonstration of proficiency on predefined procedural steps. answers were provided on a likert scale of 1 to 10, with 1 being poor and 10 being excellent. p values < 0.10 were considered educationally significant. results: the median overall rating of the simulator (s) to serve as an assessment platform was similar to that of the cadaver (c) with scores of 8.0 and 8.3 respectively, p = 0.89. median ratings for permitting the demonstration of specific procedural steps were as follows: conclusion: senior em residents positively rate the blue phantom simulator as an assessment platform and similarly to that of a cadaver with regard to permitting their demonstration of procedural competency for us guided ij catheterization, but did prefer the cadaver to a greater degree when identifying and guiding the needle into the ij. methods: in fall 2011, wcmc and wcmc-q students taking the course completed a 20 question pre-and post-test. wcmc-q students also completed a postcourse single-station objective structured clinical examination (osce) that evaluated their ability to identify and perform eight actions critical for a first responder in an emergency situation (table 1) . results: on both campuses, mean post-test scores were significantly higher than mean pre-test scores (p £ 0.001). on the pre-test, mean wcmc student scores were significantly higher than for wcmc-q students (p = 0.02); however, no difference was found in mean post-test scores (p = 0.895). there was no association between the scores on the osce (mean = 7.01, sd = 1.00) and the post-test (p = 0.683) even after adjusting for a possible evaluators' effect (table 2) . clinical skills course was effective in enhancing student knowledge in both qatar and new york as evidenced by the significant improvement in scores from the pre-to post-tests. the course was able to bring wcmc-q student scores and presumably knowledge up to the same level as wcmc students. students performed well on the osce, suggesting that the course was able to teach them the critical actions required of a first responder. the lack of association between the post-test and osce scores suggests that student knowledge does not independently predict ability to learn and demonstrate critical actions required of a first responder. future studies will evaluate whether the course affects the students' clinical practice. assess breathing 3 assess circulation 4 call ems 5 call ems and assess abcs prior to other interventions 6 immobilize 7 localize and control bleeding 8 splint fractured extremity and skills specific to wilderness medicine by incorporating simulated medical scenarios into a day-long adventure race. this event has gained acceptance nationally in wilderness medical circles as an excellent way to appreciate the challenges of wilderness medicine, however its effectiveness as a teaching tool has not yet been verified. objectives: the objective of this study was to determine if improvement in simulated clinical and didactic performance can be demonstrated by teams participating in a typical medwar event. methods: we developed a complex clinical scenario and written exam to test the basic tenets that are reinforced through the medwar curriculum. teams were administered the test and scored on a standardized scenario immediately before and after the 2011 midwest medwar race. teams were not given feedback on their pre-race performance. scenario performance was based on the number of critical actions correctly performed in the appropriate time frame. data from the scenario and written exams were analyzed using a standard paired difference t-test. results: a total of 31 teams participated in both the pre-and post-event scenarios. the teams' pre-race scenario performance was 71.0% (sd = 17.0, n = 31) of critical actions met compared to a post-race performance of 89.7 % (sd = 11.4, n = 31). the mean improvement was 18.7% (sd = 18.7, n = 31, 95% ci 12. 1, 25. 3) with a significant paired two-tailed t-test (p £ 0.01). a total of 95 individual subjects took the written pre-and posttests. the written scores averaged pre-race 84.5% (sd = 12.5, n = 95) and post-race 88.7% (sd = 11.5, n = 95). the mean improvement was 4.2% (sd = 11.7, n = 95, ci )7.5, 15.9), with a significant paired twotailed t-test (p £ 0.01). conclusion: medwar participants demonstrated a significant improvement in both written exam scores and the management of a simulated complex wilderness medical scenario. this strongly suggests that medwar is an effective teaching platform for both wilderness medicine knowledge and skills. palliative methods: ed residents and faculty of an urban, tertiary care, level i trauma center were asked to complete an anonymous survey (6/2010-10/2011). participants ranked 22 statements on a five-point likert scale (1 = strongly disagree-5 = strongly agree). statements covered four main domains of barriers related to: 1) education/training, 2) communication, 3) ed environment; 4) personal beliefs. respondents were also asked if they would call pc consult for 15 ed clinical scenarios (based on established triggers). results: 30/45 (67%) eligible participants completed the survey (23 residents, 7 faculty), average age was 31 years, 52% (15/29) male, and 58% (15/26) caucasian. respondents identified two major barriers to ed-pc provision: lack of 24 hour availability of pc team (mean score 4.4) and lack of access to complete medical records (4.2). listed domain barriers included: communication-related issues (mean 3.3) like access to family or primary providers, ed environment (2.8) for example chaotic setting with time-constraints, education/training (2.7) related to pain/pc, and personal beliefs regarding end-of-life (2.5). all respondents agreed that they would call pc consult for a 'hospice patient in respiratory distress', and a majority (73%) would consult pc for 'massive intracranial hemorrhage, traumatic arrest, and metastatic cancer'. however, traditional in-patient triggers like frequent re-admits for organ failure issues (dementia, congestive heart failure, and obstructive pulmonary disease exacerbations) were infrequently (10%) chosen for pc consult. conclusion: to enhance pc provision in the ed setting, two main ed physician perceived barriers will likely need to be addressed: lack of access to medical records and lack of 24-7 availability of pc team. ed physicians may not use the same criteria to initiate pc consults as compared to the traditionally established inpatient pc consult trigger models. percent of charts with an mse by ait prior to resident evaluation (a measure of reduced diagnostic uncertainty and decision-making), (4) ed volume. results: there were no educationally significant differences in productivity or acuity between the pre-ait and post-ait groups. mse was recorded in the chart prior to resident evaluation in 10.9% of cases. ed volume rose by 9.0% between periods. conclusion: ait did not affect productivity or acuity of patients seen by em2s. while some volume was directed away from residents by ait (patients treated-andreleased by ait only), overall volume increased and made up the difference. this is similar to previously reported rankings that program directors gave to the same criteria. although medical students agreed with program directors on the importance of most aspects of the nrmp application areas of discordance included higher medical student ranking for extracurricular activities and a lower relative ranking for aoa status than program directors. this can have implications for medical student mentoring and advising in the future. background: emergency care of older adults requires specialized knowledge of their unique physiology, atypical presentations, and care transitions. older adults often require distinctive assessment, treatment and disposition. emergency medicine (em) residents should develop expertise and efficiency in geriatric care. older adults represent over 25% of most emergency department (ed) volumes. yet many em residencies lack curricula or assessment tools for competent geriatric care. the geriatric emergency medicine competencies (gemc) are high-impact geriatric topics developed to help residencies meet this demand. objectives: to examine the effect of a brief gemc educational intervention on em resident knowledge. methods: a validated 29-question didactic test was administered at six em residencies before and after a gemc focused lecture delivered summer and fall of 2009. scores were analyzed as individual questions and in defined topic domains using a paired student's t-test. results: a total of 301 exams were included. the testing of didactic knowledge before and after the gemc educational intervention had high internal reliability (87.9%). the intervention significantly improved scores in all domains (table 1) . graded increase in geriatric knowledge occurred by pgy year with the greatest improvement seen at the pgy 3 level (table 2) . conclusion: even a brief gemc intervention had a significant effect on em resident knowledge of critical geriatric topics. a formal gemc curriculum should be considered in training em residents for the demands of an ageing population. the overall procedure experience of this incoming class was limited. most r1s had never received formal education in time management, conflict of interest management, or safe patient trade-off. the majority lacked confidence in their acute and chronic pain management skills. these entry level residents lacked foundational skill levels in many knowledge areas and procedures important to the practice of em. ideally medical school curricular offerings should address these gaps; in the interim, residency curricula should incorporate some or all of these components essential to physician practice and patient safety. background: the american heart association and international liaison committee on resuscitation recommend patients with return of spontaneous circulation following cardiac arrest undergo post-resuscitation therapeutic hypothermia. in post-cardiac arrest patients presenting with a rhythm of vf/vt, therapeutic hypothermia has been shown to reduce neurologic sequelae and decrease overall mortality. objectives: to explore clinical practice regarding the use of therapeutic hypothermia and compare survival outcomes in post-cardiac arrest patients. a secondary outcome was to assess whether the initial presenting cardiac arrest rhythm (ventricular fibrillation/ventricular tachycardia (vf/vt) versus pulseless electrical activity (pea) or asystole) was associated with differences in outcomes. methods: a retrospective medical record review was conducted for all adult ( ‡18 years) post-cardiac arrest patients admitted to the icu of an academic tertiary care centre (annual ed census 150,000) from 2006-2007. data were extracted using a standardized data collection tool by trained research personnel. results: 200 patients were enrolled. mean (sd) age was 66 (16) and 56.5% were male. of 58 (29.0%) patients treated with hypothermia, 27 (46.6%) presented with an initial rhythm of vf/vt and 31 (53.4%) presented with pea or asystole. nine (33.3%) patients with vf/vt were treated with therapeutic hypothermia and discharged from hospital compared to 2 (6.4%) patients with pea or asystole (d 26.9%; 95% ci: 6.4%, 46.3%). of 142 patients not treated with hypothermia, 37 (26.1%) presented with vf/vt, 93 (65.5%) presented with pea or asystole, and 12 (8.4%) initial rhythms were unknown. fifteen (40.5%) patients with vf/vt, not treated with hypothermia, were discharged from hospital compared to 13 (13.9%) patients with pea or asystole (d 26.6%; 95% ci: 10.0%, 43.5%). regardless of initial presenting rhythm or initiation of therapeutic hypothermia, 37 (88.1%) discharged patients had good neurological function as assessed by the cerebral performance category (cpc score 1-2). conclusion: although recommended, post-cardiac arrest therapeutic hypothermia was not routinely used. patients with vf/vt and treated with hypothermia had better outcomes than those with pea or asystole. further research is needed to assess whether cooling patients with presenting rhtyhms of pea or asystole is warranted. racial background: chronic obstructive pulmonary disease (copd) is a major public health problem in many countries.the course of the disease is characterised by episodes, known as acute exacerbations (ae), when symptoms of cough, sputum production, and breathlessness become much worse. the standard prehospital management of patients suffering from an aecopd includes oxygen therapy, nebulised bronchodilators, and corticosteroids. high flow oxygen is used routinely in prehospital areas for breathless patients with copd. there is little high quality evidence on the benefits or potential dangers in this setting but audits have shown increased mortality, acidosis, and hypercarbia in patients with aecopd treated with high flow oxygen. objectives: to compare standard high flow oxygen treatment with titrated oxygen treatment for patients with an aecopd in the prehospital setting. methods: cluster randomized controlled parallel group trial comparing high flow oxygen treatment with titrated oxygen treatment in the prehospital setting. in an intention to treat analysis (n = 405), the risk of death was significantly lower in the titrated oxygen arm compared with the high flow oxygen arm for all patients and for the subgroup of patients with confirmed copd (n = 214). overall mortality was 9% (21 deaths) in the high flow oxygen arm compared with 4% (7 deaths) in the titrated oxygen arm; mortality in the subgroup with confirmed copd was 9% (11 deaths) in the high flow arm compared with 2% (2 deaths) in the titrated oxygen arm. titrated oxygen treatment reduced mortality compared with high flow oxygen by 58% for all patients (p = 0.02) and by 78% for the patients with confirmed chronic obstructive pulmonary disease (p = 0.04). patients with copd who received titrated oxygen according to the protocol were significantly less likely to have respiratory acidosis or hypercapnia than were patients who received high flow oxygen. conclusion: titrated oxygen treatment significantly reduced mortality, hypercapnia, and respiratory acidosis compared with high flow oxygen in aecopd. these results provide strong evidence to recommend the routine use of titrated oxygen treatment in patients with breathlessness and a history or clinical likelihood of copd in the prehospital setting. (originally submitted as a ''late-breaker.'') trial registration australian new zealand clinical trials register actrn12609000236291. background: toxic particulates and gases found in ambulance exhaust are associated with acute and chronic health risks. the presence of such materials in areas proximate to ed ambulance parking bays, where emergency services' vehicles are often left running, is potentially of significant concern to ed patients and staff. objectives: investigators aimed to determine whether the presence of ambulances correlated with ambient particulate matter concentrations and toxic gas levels at the study site ed. methods: the ambulance exhaust toxicity in healthcare-related exposure and risk [aether] program conducted a prospective observational study at an academic urban ed / level i trauma center. environmental ambient gas was sampled over a continuous five-week period from september to october 2011. two sampling locations in the public triage area (public patient dropoff area without ambulances) and three sampling locations in the ambulance triage area were randomized for 24-hour monitoring windows with a temporal resolution of 2 minutes to obtain 7 days of non-contiguous data for each location. concentrations of particulate matter less than 2.5 microns in aerodynamic size (pm2.5), oxygen, hydrogen sulfide (h 2 s), and carbon monoxide (co) as well as lower explosive limit for methane (lel) were monitored with professionally calibrated devices. ambulance traffic was recorded through offline review of 24/7 security video footage of the site's ambulance bays. results: 4,118 measurements at the public triage nurse desk space revealed pm2.5 concentrations with a mean of 21.32 ± 27.01 lg/m 3 (median 15.95 lg/m 3 ; maximum 1,152.58 lg/m 3 ). 4,867 ambulance triage nurse desk space pm2.5 concentrations recorded a mean of 60.45 ± 53.38 lg/m 3 (p < 0.0001, unpaired t test; median 43.37 lg/m 3 ; maximum 580.78 lg/m 3 ). oxygen levels remained steady throughout the study period; co, h 2 s, and lel were not detected. ambulance activity levels had the highest correlations with pm2.5 concentrations at the ambulance triage foyer (r = 0.47) and desk area (r = 0.42) where patients wait and ed staff work 8-12 hr shifts. conclusion: ed spaces proximate to ambulance parking bays had higher levels of pm2.5 than areas without ambulance traffic. concentrations of ambient particulate matter in acute care environments may pose a significant health threat to patients and staff. an ems ''pit crew'' model improves ekg and stemi recognition times in simulated prehospital chest pain patients sara y. baker 1 , salvatore silvestri 1 , christopher d. vu 1 , george a. ralls 1 , christopher l. hunter 1 , zack weagraff 2 , linda papa 1 1 orlando regional medical center, orlando, fl; 2 florida state university college of medicine, orlando, fl background: prehospital teams must minimize time to ekg acquisition and stemi recognition to reduce overall time from first medical contact to reperfusion. auto-racing ''pit crews'' model rapid task completion by pre-assigning roles to team members. objectives: we compared time-to-completion of key tasks during chest pain evaluation in ems teams with and without pre-assigned roles. we hypothesized that ems teams using the ''pit crew'' model would improve time to recognition and treatment of stemi patients. methods: a randomized, controlled trial of paramedic students was conducted over 2 months at orlando medical institute, a state-approved paramedic training center. we compared a standard ems chest pain management algorithm (control) with a pre-assigned tasks (''pit crew'') algorithm (intervention) in the evaluation of simulated chest pain patients. students were randomized into groups of three; intervention and control groups did not interact after randomization. all students reviewed basic prehospital chest pain management and either the standard or pre-assigned tasks algorithm. groups encountered three simulated patients. laerdal simmanò software was used track completion of tasks: taking vital signs, iv access, ekg acquisition and interpretation, asa administration, hospital stemi notification, and total time on scene. results: we conducted 54 simulated-patient encounters (30 control / 24 intervention encounters). mean time-to-completion of each task was compared in the control and intervention groups respectively. time to obtain vital signs was 4:18 vs. 2:21 min (p = 0.001); time to asa administration was 3:54 vs 2:00 min (p < 0.001); time to ekg acquisition was 5:39 vs 3:42 min (p < 0.001); time to ekg interpretation was 6:43 vs 4:21 min (p < 0.001); time to iv access was 5:42 vs 4:45 min (p = 0.05); time to stemi notification was 7:19 vs 4:26 min (p < 0.001); and time to scene completion was 9:02 vs 5:27 min (p < 0.001). conclusion: paramedic student teams with pre-assigned roles (the ''pit crew'' model) were faster to obtain vital signs, administer asa, acquire and interpret the ekg, stemi notification, and overall time on scene during simulated patient encounters. further study with experienced ems teams in actual patient encounters is necessary to confirm the relevance of these findings. background: use of automated external defibrillators (aed) has remained low in the u.s. understanding the effect of neighborhoods on the probability of having an aed used in the setting of a public arrest may provide important insights for future placement of aeds. objectives: to determine associations between the racial and income composition of neighborhoods (as defined by u.s. census tracts), individual arrest characteristics, and whether bystanders or first responders initiate aed use. methods: cohort study using surveillance data prospectively submitted by emergency medical services systems and hospitals from 29 u.s. sites to the cardiac arrest registry to enhance survival between october 1, 2005 and december 31, 2009 . neighborhoods were defined as high-income vs. low-income based on the median household income being above or below $50,000 and as white or black if >90% of the census tract was of one race. neighborhoods without a predominant racial composition were defined as integrated. arrests that occurred within a public location (excluding medical facilities and airports) were eligible for inclusion. hierarchical multi-level modeling, using stata v11.0, was used to determine the association between individual and census tract characteristics on whether an aed was used. results: of 2,769 eligible cases, an aed was used in 1336 arrests (48.2%) by a first responder (n = 1,127, 40.8%) or bystander (n = 209, 7.5%). patients whose arrest was witnessed (odds ratio [or] 1.26; 95% confidence interval [ci] 1.06-1.50) were more likely to have an aed used (table) . when compared to high-income white neighborhoods, arrest victims in low-income black neighborhoods were least likely to have an aed used (or 0.54; 95% ci 0.33-0.87). arrest victims in lowincome white (or 0.57; 95% ci 0.32-1.02) and lowincome integrated (or 0.70; 95% ci 0.51-0.96) were also less likely to have an aed used. conclusion: arrest victims in black and low-income neighborhoods are least likely to have an aed used by a layperson or first responder. future research is needed to better understand the reasons for low rates of aed use for cardiac arrests in these neighborhoods. the impact of an educational intervention on the pre-shock pause interval among patients experiencing an out-of-hospital cardiac arrest jonathan studnek 1 , eric hawkins 1 , steven vandeventer 2 1 carolinas medical center, charlotte, nc; 2 mecklenburg ems agency, charlotte, nc background: pre-shock pause duration has been associated with survival to hospital discharge (std) among patients experiencing out-of-hospital cardiac arrest (oohca) resuscitation. recent research has demonstrated that for every 5-second increase in this interval there is an 18% decrease in std. objectives: determine if a decrease in the pre-shock pause interval for patients experiencing oohca could be realized after implementation of an educational intervention. methods: this was a retrospective analysis of data obtained from a single als urban ems system from 1/1/2010 to 12/31/10 and 8/1/11 to 11/6/2011. in august 2011, an educational intervention was designed and delivered to approximately 150 paramedics emphasizing the importance of reducing the time off chest during cpr. specifically, the time period just prior to defibrillation was emphasized by having rescuers count every 20th compression and pre-charge the defibrillator on the 180th compression. in order to determine if this change resulted in process improvement, 12 months of data were assessed before and 3 months after the educational intervention. pre-shock pause was the outcome variable and was defined as the time period after compressions ceased until a shock was delivered. this interval was measured by a cpr feedback device connected to the defibrillator. inclusion criteria were adult patients who required at least one defibrillation and had the cpr feedback device connected during the defibrillation attempt. analysis was descriptive utilizing means and 95% ci as well as wilcoxon rank sum test to assess difference between the two time periods. results: in the pre-intervention period there were 117 patients who received 211 defibrillations compared to 30 patients receiving 71 defibrillations in the post-intervention phase. the mean duration of the pre-shock pause pre-intervention was 35 seconds (95% ci 20-50) while the post-intervention duration was 9 seconds (95% ci 7-12). the difference in pre-shock pause duration was statistically significant with p < 0.001. conclusion: these data indicate that after a simple educational intervention emphasizing decreasing time off chest prior to defibrillation the pre-shock pause duration decreased. future research must describe the sustainability of this intervention as well as the effects this process measure may have on outcomes such as survival to hospital discharge. background: the broselow tape (bt) has been used as a tool for estimating medication dosing in the emergency setting. the obesity trend has demonstrated a tendency towards insufficient pediatric weight estimations from the bt, and thus potential under-dosing of resuscitation medications. objectives: this study compared drug dosing based on the bt with dosing from a novel electronic tool (et) that accounts for provider estimation of body habitus. methods: data were obtained from a prospective convenience sample of children ages 1 to 8 years arriving to a pediatric emergency department. a clinician performed an assessment of body habitus (average/underweight, overweight, or obese), blinded to the patient's actual weight and parental weight estimate. parental estimate of weight and measured length and weight were collected. epinephrine dosing was calculated from the measured weight, the bt measurement, as well as from a smart-phone tool based on the measured length and clinician's estimate of body habitus, and a modified tool (mt) incorporating the parent estimate of habitus. the wilcoxson rank-sum test was used to compare median percent differences in dosing. results: one hundred children (mean age 3 years) were analyzed; 47% were overweight or obese. clinicians correctly identified children as overweight/obese 23% of time (ci 0.12-0.38). adding parent estimate of weight improved this to a sensitivity of 74% (ci 0.59-0.86). the median difference between the weight-based epinephrine dose and bt dose was 11%. for the et the median difference from the weight-based dose was 7% (p = 0.05 compared to the bt), and for the mt was 1.7% (p < 0.01 compared to the bt). when a clinically significant difference was defined as ±10% of the actual dose, bt was within that range 40% of the time, et was within range 56% of the time (p = 0.02), and mt was within range 64% of the time ( background: in most out-of-hospital cardiac arrest (ohca) events, a call to 9-1-1 is the first action by bystanders. accurate diagnosis of cardiac arrest by the call taker depends on the caller's verbal description. if cardiac arrest is not suspected, then no telephone cpr instructions will be given. objectives: we measured the effect of a change in the ems call taker question sequence on the accuracy of diagnosis of cardiac arrest by 9-1-1 call takers. methods: we retrospectively reviewed the cardiac arrest registry to enhance survival (cares) dataset for january 1, 2009 through june 30, 2011 from a city, population 750,000, with a longstanding telephone cpr program (apco). we included ohca cases of any age who were in arrest prior to the arrival of ems and for whom resuscitation was attempted. in early 2010, 9-1-1 call takers were taught to follow a revised telephone script that emphasized focused questions, assertive control of the caller, and provision of hands-only cpr instructions. the medical director personally explained the reasons for the changes, emphasizing the importance of assertive control of the caller and the comparative safety of chest compressions in patients not in cardiac arrest. beginning in 2010, call recordings were reviewed regularly with feedback to the call taker by the 9-1-1 center leadership. the main outcome measure was sensitivity of the 9-1-1 call taker in diagnosing cardiac arrest. bystander cpr was reported by ems crews attending the event. we compared 2009 with 2010 and 2011 using the v 2 test and odds ratios (or). results: there were 504 ohca cases in 2009, 457 cases in 2010, and 287 in the first half of 2011 (68/100,000 population). the mean age was 57 ± 21 years, and 27% of the events were witnessed. before the revision, 40% of ohca cases were identified by 9-1-1 dispatchers; and after the revised questioning sequence, 74% were identified (or 4.3, 95% ci 3.2-5.6). the false positive rate changed little (from 56/month to 72/month). the mean time to question callers was unchanged (53 vs 51 seconds). bystander cpr was performed in 37.3% of events in 2009, 39.2% in 2010, and 49.1% of events in 2011 (p < 0.001). conclusion: emphasis on scripted assessment improved sensitivity without loss of specificity in identifying ohca. with repeated feedback, it translated to an increase in victims receiving bystander cpr. in an out-of hospital cardiac arrest population confirmed by autopsy salvatore silvestri, christopher hunter, george ralls, linda papa orlando regional medical center, orlando, fl background: quantitative end-tidal carbon dioxide (etco 2 ) measurements (capnography) have consistently been shown to be more sensitive than qualitative (colorimetric) ones, and the reliability of capnography for assessing airway placement in low perfusion states has sometimes been questioned in the literature. objectives: this study examined the rate of capnographic waveform presence of an intubated out-of-hospital cardiac arrest cohort and its correlation to endotracheal tube location confirmed by autopsy. our hypothesis is that capnography is 100% accurate in determining endotracheal tube location, even in low perfusion states. methods: this cross-sectional study reviewed a detailed prehospital cardiac arrest database that regularly records information using the utstein style. in addition, the ems department quality manager routinely logs the presence of an alveolar (four-phase) capnographic waveform in this database. the study population included all cardiac arrest patients from january 1, 2009 through december 31, 2009 managed by a single ems agency in orange county, florida. patients were included if they had endotracheal intubation performed, had capnographic measurement obtained, failed to regain return of spontaneous circulation (rosc), and had an autopsy performed. the main outcome was the correlation of the presence of an alveolar waveform and the location of the ett at autopsy. results: during the study period, 921 cardiac arrests were recorded. of these, 263 had an advanced airway placed (ett or laryngeal tube airway), and no rosc. of the 263 advanced airway cases, 73 were managed with an ett. autopsies were performed on 30 of these patients and resulted in our study cohort. the location of the ett at autopsy was recorded on all 30 of these cases. capnographic waveforms were recorded in the field in all 30 of these study patients, and 100% of the tubes were located within the trachea at autopsy. the sensitivity of capnography in determining proper endotracheal tube location was 100% in this study. conclusion: in our study, the presence of a capnographic waveform was 100% reliable in confirming proper placement of endotracheal tubes placed in outof-hospital patients with poor perfusion states. results: over 60 variables were presented to the 34 ems medical directors responding (100% survey population captured). among the myriad of responses, 14 (42%) initiate cardiopulmonary resuscitation (cpr) at 30 compressions to 2 ventilations consistent with il-cor/aha guidelines. seven (21%) initiate continuous chest compressions from the start of cpr with no pause and interposed ventilations. nine (26%) begin chest compressions only during the first 2-3 minutes, with either passive oxygenation by oxygen mask (six; 18%) or no oxygen (three; 9%). airway management following non-invasive oxygenation and ventilation by primary endotracheal intubation occurs in 12 systems (35%), while six (18%) use supraglottic devices. fourteen (42%) allow paramedics to decide between endotracheal and supraglottic device placement. thirty systems (88%) utilize continuous waveform capnography. the initial approach to non-ems witnessed ventricular fibrillation is chest compression prior to first defibrillation in 30 systems (88%). eighteen systems (52%) escalate defibrillation energy settings, with four systems (12%) utilizing dual sequential defibrillation. twenty (59%) initiate therapeutic hypothermia in the field. conclusion: wide variability in ca care standards exists in america's largest urban ems systems in mid-2011, with many current practices promoting more continuity in chest compressions than specified in the 2010 ilcor/aha guidelines. endotracheal intubation, a past mainstay of ca airway management, is deemphasized in many systems. immediate defibrillation of non-ems witnessed ventricular fibrillation is uncommon. objectives: determine the out-of-hospital cardiac arrest survival in this area of puerto rico using the utstein method. methods: prospective observational cohort study of adult patients presenting with an out-of-hospital cardiac arrest to the upr hospital ed. study endpoints will be survival and neurologically intact survival at hospital discharge, 6 months, and 12 months. results: a total of 144 consecutive cardiac arrest events were analyzed for a period of 2 years. one-hundred fifteen events met criteria for primary cardiac etiology (79.86%). the average age for this group was 68.47 years. there were 45 female (39.13%) and 70 male (60.86%) participants. the average time to start cpr was 14.60 minutes. transportation to the ed was 71.3% by ems and 25.22% by private vehicle. a total of 68 events were witnessed (59.13%). the survival rate to hospital admission was 23.66%. the overall cardiac arrest survival was 9.30% and overall neurologically intact survival was 4.30%. neurologically intact survival at 6 and 12 months was 2.15%. the rate of bystander cpr in our population was 16.13% with a survival rate of 6.66%. conclusion: survival from out-of-hospital cardiac arrest in the area served by the upr hospital is low but comparable to other cities in the us as reported by the cdc cardiac arrest registry to enhance survival (cares). this low survival rate might be due to low bystander cpr rate and prolonged time to start cpr. background: hyperventilation has been directly correlated with increased mortality for out-of-hospital cpr. ems providers may hyperventilate patients at levels above national bls guidelines. real-time feedback devices, such as ventilation timers, have been shown to improve cpr ventilation rates towards bls standards. it remains unclear if the combination of a ventilation timer and pre-simulation instruction would influence overall ventilation rates and potentially reduce undesired hyperventilation. objectives: this study measured ventilation rates of standard cpr (and pre-instruction on effects of hyperventilation) compared to cpr with the use of a commercial ventilation timer (and pre-instruction on effects of hyperventilation). we propose that use of a ventilation timer, measuring and displaying to ems providers real-time ventilations delivered, will have no difference in ventilation rates when comparing these groups. methods: this prospective study placed ems providers into four groups: two controls measuring ventilation rates before (1a) and after instruction (1b) on the deleterious effects of hyperventilation, and a concurrent intervention pair with before (2a) and after instruction (2b), with the second pair measuring ventilation rates with a ventilation timer that provides immediate feedback on respirations given. ventilation rates were measured for a 60-second period after one minute of simulated cpr using mannequins. the control set without instruction (1a, n = 12) averaged 14.21 breaths (95% ci = 10.31-18.11) and with instruction (1b, n = 13) averaged 20.23 breaths (95% ci = 16.16-24.30). the intervention set without instruction (2a, n = 11) averaged 13.04 breaths (95% ci = 9.29-16.78) and with instruction (2b, n = 13) averaged 11.77 breaths (95% ci = 8.02-15.51). there was a significant improvement (p = 0.016) in ventilation rates with use of a ventilation timer (control group versus intervention group regardless of pre-instruction). there was no statistically significant difference between groups with respect to instruction alone (p = 0.223). conclusion: the use of a ventilation timer significantly reduced overall ventilation rates, providing care closer to bls guidelines. the addition of pre-simulation instruction added no significant benefit to reducing hyperventilation. background: in 2010, the american heart association (aha) recommended a compression rate of (roc) 100/ min and a depth of compressions (doc) at least 2 inches for effective cpr. as an educational tool for lay rescuers, the aha as adopted the catch phrase ''push hard, push fast''. objectives: in this irb-exempt study, we sought to determine if persons without formal cpr training could perform non-ventilated cpr as well as those who have been trained in the past or those currently certified. methods: a convenience sample of patrons of the new york state fair was asked to perform 2 minutes of hands-only cpr on a prestan pp-am-100m adult cpr manikin. these devices provide visual indicators of acceptable rate and depth of compressions. each subject was video recorded on a dell latitude 620 laptop computer with a logitech quick cam using logitech quick cam 8.4.6 for windows software. results: a total of 175 volunteers (74 male, 102 female) aged 16-68 years participated: 52 were never certified (nc) in cpr, 73 were previously certified (pc), and 50 were currently certified (cc). there was no difference in age across the groups. the cc group had a higher proportion of females (chi-square = 9.71, p < 0.008). cc volunteers sustained roc and doc for an average of 57.1 seconds as compared to an average of 18.5 seconds (pc) and 2.3 seconds (nc) respectively. (f = 27.8, p < 0.001). the cc maintained roc of closer to 100/ min (mean 111.6/min) when compared to the pc (mean 85.3/min) and nc (mean 86.0/min) groups (f = 14.7, p < 0.001). a higher proportion of volunteers of the cc group were able to perform adequate doc (chi-square = 11.2, p < 0.004), and hand placement (chisquare = 19.21, p < 0.001) when compared to the other two groups. conclusion: compared to the target roc and doc, none of the groups did well and only 14 subjects met target roc/doc. increased out-of-hospital cardiac arrest survivability due to lay rescuer intervention is only assured if cpr is effectively administered. the effect and benefit of maintaining formal cpr training and certification is clear. background: more than 300,000 out-of-hospital cardiac arrests (ohcas) occur annually in the united states (us). automated external defibrillators (aeds) are life-saving devices in public locations that can significantly improve survival. an estimated 1 million aeds have been sold in the us; however, little is known about whether locations of aeds match oh-cas. these data could help determine optimal placement of future aeds and targeted cpr/aed training to improve survival. objectives: we hypothesized that the majority (>50%) of aeds are not located in close proximity (200 feet) to the occurrence of cardiac arrests in a major metropolitan city. methods: this was a retrospective review of prospectively collected cardiac arrest data from philadelphia ems from january 1, 2008 until december 31, 2010. included were ohcas of presumed cardiac etiology in individuals 12 years of age or older. excluded were oh-cas of presumed traumatic etiology, cases where resuscitation was terminated at the scene, and those dead on arrival. aed locations in philadelphia were obtained from myheartmap, a database of installed and wallmounted aeds in pennsylvania. we used gis mapping software to visualize where ohcas occurred relative to where aeds were located and to determine the radius of ohcas to aeds. arrests within a 200, 400, and 600 foot radius of aeds were identified using the attribute location selection option in arcgis. the lengths of radii were estimated based on the average time it would take for a person to walk to and from an aed (200 feet2 minutes; 400 feet4 minutes; 600 feet6 minutes). results: we mapped 3,483 ohcas and 2,314 aeds in philadelphia county. ohcas occurred in males (55%; 1916/3483) and the mean age was 65.4 years. ventricular fibrillation occurred in 19% (662/3483). aeds were primarily located in schools/universities (30%), office buildings (22%), and residential buildings (4%). aeds were not identified within 200 feet in 93% (3,239) of ohcas, within 400 feet of 90% (3,135) of ohcas, and within 600 feet in 79% (2,752) of ohcas. the figure (large black circles) illustrates aed/ohca within 200 feet on the left and 600 feet on the right. conclusion: aeds were rarely close to the locations of ohcas, which may be a contributor to low cardiac arrest survival rates. innovative models to match aed availability with ohcas should be explored. (originally submitted as a ''late-breaker.'') potential background: early and frequent epinephrine administration is advocated by acls; however, epinephrine research has been conducted primarily with standard cpr (std). active compression-decompression cpr with an impedance threshold device (acd-cpr + itd) has become the standard of care for out of hospital cardiac arrest in our area. the hemodynamic effects of iv epinephrine under this technique are not known. objectives: to determine the hemodynamic effects of iv epinephrine in a swine model undergoing acd-cpr+itd. methods: six female swine (32 ± 1kg) were anesthetized, intubated, and mechanically ventilated. intracranial, thoracic aorta, and right atrial pressures were recorded via indwelling catheters. carotid blood flow (cbf) was recorded via doppler. etc0 2 , sp0 2 , and ekg were monitored. ventricular fibrillation was induced and went untreated for 6 minutes. three minutes each of standard cpr (std), std-cpr+itd, and acd-cpr+itd was preformed. at minute 9 of the resuscitation, 40 lg/kg of iv epinephrine was administered and acd-cpr+itd was continued for 1 minute. statistical analysis was performed with a paired t-test. results: aortic pressure and calculated cerebral and carotid perfusion pressures increased from std < std+itd < acd-cpr+itd (p £ 0.001). epinepherine administered during acd-cpr+itd signficantly increased mean aortic (29 ± 5vs42 ± 12, p = 0.01), cerebral (12 ± 5 vs 22 ± 10, p = 0.01), and coronary perfusion pressures (8 ± 7 vs 17 ± 4, p = 0.02); however, mean cbf and etco 2 decreased (respectively 29 ± 15 vs 14 ± 7.0, p = 0.03; 20 ± 7 vs 18 ± 6, p = 0.04). conclusion: the administration of epinepherine during acd-cpr+itd signficantly increased markers of macrocirculation, while significantly decreasing etco 2 , a proxy for organ perfusion. while the calculated cerebral perfusion pressures increased, the directly measured cbf decreased. this calls into question the ability of calculated perfusion pressures to accurately reflect blood flow and oxygen delivery to end organs. hypoxia background: during cardiac arrest most patients are placed on 100% oxygen with assisted ventilations. after return of spontaneous circulation (rosc), 100% oxygen is typically continued for an extended time. animal data suggest that immediate post-arrest titration of oxygen by pulse oximetry produces better neurocognitive/ histologic outcomes. recent human data suggest that arterial hyperoxia is associated with worse outcomes. objectives: to assess the relationship between hypoxia, normoxia, and hyperoxia post-arrest and outcomes in post-cardiac arrest patients treated with therapeutic hypothermia. methods: we conducted a retrospective chart review of 190 post-arrest patients admitted to an academic medical center between january, 2000 and december, 2007 who had arterial blood gases (abg) drawn after rosc. demographic variables were analyzed using anova and chi-square tests as appropriate. unadjusted logistic regression analyses were performed to assess the relationship between hypoxia (pao 2 < 60 mmhg), normoxia (60-300 mmhg), hyperoxia (>300 mmhg), and mortality. results: on first abg (190 patients), 37 (19.5%) were hypoxic, 92 (48.4%) normoxic, and 61 (32.1%) hyperoxic. the average age of the cohort was 62.8 years (no difference for hypoxic, normoxic, and hyperoxic patients). overall mortality was 70.5% (134/190). there were no significant differences between initial heart rate, systolic blood pressure, sex, race, or pre-arrest functional status. in-hospital mortality was significantly higher when the first abg demonstrated hypoxia (94.6%; 35/ 37) than for normoxia (68.5%; 63/92) or hyperoxia (59%; 36/61). in unadjusted logistic regression analysis of first pao 2 values, hyperoxia was not associated with increased mortality (or 0.7; 95% ci 0.3-1.4) but hypoxia was associated with increased mortality (or 6.1; 95% ci 1.4-27.5). conclusion: hypoxia but not hyperoxia on first abg was associated with mortality in a cohort of post-arrest patients. background: there are over 330,000 deaths due to cardiac arrest per year in the us. the aha recommends monitoring the quality of cpr primarily through the use of end tidal co 2 (etco 2 ). the level of etco 2 is significantly dependant on minute ventilation and altered by pressor and bicarbonate use. cerebral oximetry (cereox) uses near infrared spectroscopy to non-invasively measure oxygen saturation of the frontal lobes of the brain. cereox has been correlated with cerebral blood flow and jugular vein bulb saturations. objectives: the objective of this study is to compare the simultaneous measurement of etco 2 and cereox to investigate which monitoring method provides the best measure of cpr quality as defined by return of spontaneous circulation (rosc). methods: a prospective cohort of a convenient sample of patients using out-of-hospital and ed cardiac arrest from two large eds. patients were monitored simultaneously by etco 2 and cereox during cpr. patient demographics and arrest data were collected using the utstein criteria. all patients were monitored throughout the resuscitation efforts. rosc was defined as a palpable pulse and a measurable blood pressure for a minimum of thirty minutes. results: twenty two patients were enrolled with complete data sets; 27% of the subjects had rosc. average down time of rosc subjects was 12 minutes (sd ± 14.6) and 31 minutes (sd ± 17.8) for subjects without rosc. the inability to obtain a value of 30 either for etco 2 or cereox was 50% and 75% specific with an 80% and 100% npv respectively for predicting lack of rosc. obtaining a value of 30 either for etco 2 or cereox was 66% and 100% sensitive, respectively in identifying rosc. subjects with rosc had sustained values above 30 for 1.25 mins on cereox and 4.9 mins on etco 2 prior to rosc. the increase in values over a three minute period prior to rosc was 13.5 on cereox and 1.3 on etco 2 . conclusion: the inability to obtain a value of 30 on either the etco 2 or cereox strongly predicted lack of rosc. cereox provides a larger magnitude and closer temporal increase prior to rosc than etco 2 . attaining a value of 30 on cereox was more predictive of rosc than etco 2. an discrepancies due to communicating information to multiple listeners in a short amount of time. this creates a communication barrier not always apparent to practitioners. we examine the perceptions of ems and ed personnel on the transfer of care and its correlation to missing patient data. objectives: evaluate provider perception of information transfer by ems and ed personnel and compare this to an external observer's objective assessment. methods: this is a retrospective quality improvement program at an academic level i trauma center. transfers of medical and trauma patients from ems to ed personnel were attended by trained external observers, research associates (ra). ra recorded the data communicated: name, age, past medical history (pmh), allergies, medications, events, active problems, vital signs (vs), level of consciousness (loc), iv access, and treatments given. then, ems and ed staff rated their perception of transfer on a 1-10 rating scale. results: ra evaluated 448 patient transfers (268 medical and 180 trauma). transfer time did not differ, 4.05 minutes for medical (95% ci: 3.77-4.32), 3.92 minutes for trauma patients (95% ci: 3.53-4.31)(p = 0.57). missing data between the two groups also did not differ, except loc and treatment were missed more in medical transfers, while pmh was missed more in the trauma transfers. comparing the transfers with all vs present (67%, 300/448) and all vs missing (12%, 55/ 448), with all vs missing, there was no difference in perception of transfer for ems (9.6/10 vs present vs 9.4/10 vs absent) or ed staff (9.5/10 vs present, 9.4/10 vs absent). when all vital signs were missing, ra rated 69.1% of transfers as poor, whereas when all vs were present 80.8% of transfers were considered good. conclusion: ems and ed staff felt transfers of care were professional, teams were attentive, and had similar amounts of interruptions for both medical and trauma cases. their perception of transfer of care was similar even when key information was missing, although external observers rated a significant amount of transfers poorly. thus, ems and ed staffs were not able to evaluate their own performance in a transfer of care and external observers were found to be better evaluators of transfers of care. swati singh, john brown, prasanthi ramanujam ucsf, san francisco, ca background: ems transports a large number of psychiatric emergencies to emergency departments (ed) across the us. research on paramedic education related to behavioral emergencies is sparse, but based on expert opinion we know that gaps in paramedic knowledge and training exist. in our system, paramedics triage patients to medical, detoxification, and purely psychiatric destinations, so a paramedic's understanding of these emergencies directly affects the flow of patients in our eds. objectives: our objectives were to understand the gaps in current training and develop a targeted curriculum for field providers with a long term goal of appropriately recognizing and triaging subjects to the ed. methods: data were collected using a survey that was distributed during a paramedic association meeting in october 2011. subjects were excluded if they did not complete the survey. survey questions addressed demographics of paramedics, frequency of various psychiatric emergencies and their confidence in managing these emergencies. data were collated, analyzed, and presented as descriptive statistics. results: forty-nine surveys were distributed with a response rate of 82% (n = 40/49). of the respondents, 70% (n = 28) were male and 68% (n = 27) had at least five years experience. mood, thought, and cognitive disorders were the most frequently encountered presentations and 65% (n = 26) of respondents came across psychiatric emergencies multiple times a week. many respondents did not feel confident managing agitated delirium (n = 16, 40%), acute psychosis (n = 17, 43%), and intimate partner or elder abuse (n = 14, 35%). a third to a half of the respondents felt they have little or no training in chemical sedation (n = 18, 45%), verbal de-escalation (n = 14, 35%), and triaging patients (n = 21, 53%). conclusion: we identified a need for a revised curriculum on management of psychiatric emergencies. future steps will focus on development of a curriculum and change in knowledge after implementation of this curriculum. background: prehospital endotracheal intubation has long been a cornerstone of resuscitative efforts for critically ill or injured patients. paramedic airway management training will need to be modified due to the 2011 acc/aha guidelines to ensure maintenance of competency in overall management of airway emergencies. how best to modify the training of paramedics requires an understanding of current experience. objectives: the purpose of this report is to characterize the airway management expertise of experienced and non-experienced paramedics in a single ems system. methods: we retrospectively reviewed all prehospital intubations from an urban/suburban ambulance service (professional ambulance, inc.) over a five-year period (january 01, 2006 to december 31, 2010). characteristics of airway management by paramedics with 0-5 years of experience (group 1) were compared to those with greater than 5 years of experience (group 2). airway management was guided by massachusetts statewide treatment protocols governing direct laryngoscopy and all adjunctive approaches. attempts are characterized by laryngoscope blade passing the lips. difficult and failed airways were managed with extraglottic devices (egd) or needle cricothyroidotomy. we reviewed patient characteristics, intubation methods, rescue techniques, and adverse events. results: 150 patients required airway management: 120 (80%) were performed by group 1 and 30 (20%) were performed by group 2. group 1 was both faster to intubate (1.39 vs 1.83 attempts, p = 0.0035) and less likely to use a rescue device (19.1% vs 50.0%, p = 0.0009). both are equally likely to go directly to a rescue device (10% vs 10%, p = 1.0). all patients were successfully oxygenated and ventilated with either an endotracheal tube or egd. no surgical airways were performed and no patients died as a result of a failed airway. conclusion: while intubation success rates of paramedics with less than and greater than five years of experience are similar, less experienced paramedics use fewer attempts and are less likely to use a rescue device. both recognize difficult airways and go directly to rescue devices equally. this highlights difficulties faced maintaining competence. education requirements must be evaluated and redesigned to allow paramedics to maintain competence and emphasize airway management according to the latest resuscitation guidelines. how well do ems 9-1-1 protocols predict ed utilization for pediatric patients? stephanie j. fessler 1 , harold k. simon 1 , daniel a. hirsh 1 , michael colman 2 1 emory university, atlanta, ga; 2 grady health systems, atlanta, ga background: the use of emergency medical services (ems) for low-acuity pediatric problems has been well documented. however, it is unclear how accurately general ems dispatch protocols predict the subsequent ed utilization for these patients. objectives: to determine the ed resource utilization rate of pediatric patients categorized as low acuity by 9-1-1 dispatch protocols and then subsequently transferred to a children's hospital. methods: all transports for pediatric patients from the scene by a large urban general ems provider that were prioritized as low acuity by initial 9-1-1 dispatch protocols were identified. protocols were based on the national academy of medical priority dispatch system, v12. starting on jan 1, 2010, 100 consecutive cases of patients transported to three pediatric emergency departments (ped) of a large tertiary care pediatric health care system were reviewed. demographics, ped visit characteristics, resource utilization, and disposition were recorded. those patients who received meds other than po antipyretics, had labs other than a strep test, a radiology study, a procedure, or were not discharged home were categorized into the significant ed resource utilization group. results: 93% of the patients were african american and either had public insurance or self-pay (86%, 13% respectively). the median age was 11 months (4d-13yr). 54% were female. none of these low-acuity patients were upgraded by ems operators en route. upon arrival to the ped, 45% of transported patients were classified into the significant utilization group. six of the 100 total patients were admitted, including a 2 y/o requiring emergent intubation, an 8 m/o old with a broken cvl, a 6 y/o with sickle cell pain crisis, and a 2 y/o with altered mental status. the remainder of the significant resource utilization group consisted of children needing procedures, anti-emetics, narcotic pain control, labs, and xrays. conclusion: in this general ems 9-1-1 system, dispatch protocols for pediatric patients classified as low priority did poorly in predicting subsequent ed utilization with 45% requiring significant resources. further, ems operators did not recognize a critical child who needed emergent intervention. opportunity exists to refine general ems 9-1-1 protocols for children in order to more accurately define an ems priority status that better correlates with ultimate needs and resource utilization. the objectives: determine if there is an association between a patient's impression of the overall quality of care and his or her satisfaction with provided pain management. it was hypothesized that satisfaction with pain management would be significantly associated with a patient's impression of the overall quality of care. methods: this was a retrospective review of patient satisfaction survey data initially collected by an urban als ems agency from 1/1/2007 to 8/1/2010. participants were randomly selected from all patients transported proportional to their paramedic defined acuity; categorized as low, medium, or high with a goal of 100 interviews per month. the proportions of patients sampled from each acuity level were 25% low, 50% medium, and 25% high. patients were excluded if there was no telephone number recorded in the prehospital patient record or they were pronounced dead on scene. all satisfaction questions used a five-point likert scale with ratings from excellent to poor that were dichotomized for analysis as excellent or other. the outcome variable of interest was the patient's perception of the overall quality of care. the main independent variable had patients rate the staff who treated them at the scene on their helping to control or reduce their pain. demographic variables were assessed for potential confounding. results: there were 2,759 patients with complete data for the outcome and main independent variable with 45.0% male respondents and an average age of 54.1 (sd = 22.7). overall quality of care was rated excellent by 66.0% of patients while 59.1% rated their pain management as excellent. of patients who rated their pain management as excellent, 87.9% rated overall quality of care as excellent while only 34.2% of patients rated overall quality excellent if pain management was not excellent. when controlling for potential confounding variables, those patients who perceived their pain management to be excellent were 13.9 (95% ci 11.5-16.9) times more likely to rate their overall quality of care as excellent compared to those with non-excellent perceived pain management. conclusion: patients' perceptions of the overall quality of care were significantly associated with their perceptions of pain management. objectives: the purpose of this study is to determine whether ground-based paramedics could be taught and retain the skills necessary to successfully perform a cricothyrotomy. methods: this retrospective study was performed in a suburban county with a population of 160,000 and 21,000 ems calls per year. participants were groundbased paramedics in a local ems system who were taught wire-guided cricothyrotomy as part of a standardized paramedic educational update program. as part of the educational program, paramedics were taught wire-guided cricothyrotomy on a simulation model previously developed to train emergency medicine residents. after viewing an instructional video, the participants were allowed to practice using a 16step checklist. not all of these 16 steps were automatic failures. each paramedic was individually supervised performing a cricothyrotomy on the simulator until successful; a minimum of five simulations was required. retention was assessed using the same 16-step checklist during annual skills testing, after a minimum of 6 weeks to a maximum of 3 months posttraining. results: a total of 55 paramedics completed both the initial training and reassessment during the time period studied. during the initial training phase, 100% (55 of 55) of the paramedics were successful in performing all 16 steps of the wire-guided cricothyrotomy. during the retention phase 87.3% (48 of 55) retained the skills necessary to successfully perform the wire-guided cricothyrotomy. of the 16-step checklist, most steps were performed successfully by all the paramedics or missed by only 1 of the 55 paramedics. step #8, which involved removing the needle prior to advancing the airway device over the guidewire, was missed by 34.5% (19 of 55) of the participants. step #8 was not an automatic failure since most participants immediately self-corrected and completed the procedure successfully. conclusion: paramedics can be taught and can retain the skills necessary to successfully perform a wireguided cricothyrotomy on a simulator. future research is necessary to determine if paramedics can successfully transfer these skills to real patients. helicopter emergency medical services in background: netcare911 is one of the largest private providers of emergency air medical care in south africa. each hems (helicopter emergency medical service) crew is manned by a physician-paramedic team and is dispatched based on specific medical criteria, time to definitive care, and need for physician expertise. objectives: to describe the characteristics of net-care911 air medical evacuations in gauteng province and to analyze the role of physicians in patient care and effect on call times. methods: all patients transported by a netcare911 helicopter over a one year period from january -december 2008 were enrolled in the study. injury classifications, demographics, procedures, scene and flight times were collected retrospectively from run sheets. data were described by medians and interquartile intervals. results: a total of 386 patients were transported on 384 flights originating from the netcare911 gauteng helicopter base. ninety-two percent were traumarelated, with 74% resulting from motor vehicle accidents. physician expertise was listed 30% of the time as the indication for air medical response. a total of 105 advanced procedures were performed by physicians on 93 patients, including paralytic-assisted intubations, chest tube placement, and cardiac pacing. the median total call time was 46 minutes with 10 minutes spent on scene, compared with 54 and 24 minutes when advanced procedures were performed by hems (p < 0.001). conclusion: trauma accounts for an overwhelming majority of patients requiring emergency air medical transportation. advanced medical procedures were performed by physicians in nearly a quarter of the patients. there were significant differences in call times when advanced procedures were performed by hems. objectives: we sought to evaluate the level of awareness and adoption of the off-line protocol guidelines by utah ems agencies. methods: we surveyed all ems agencies in utah 18 months after protocol guideline release. medical directors, ems captains, or training coordinators completed a short phone survey regarding their knowledge of the emsc protocol guidelines, and whether their agency had adopted them. in particular, participants were asked about the pain protocol guideline and their management of pediatric pain. results: of the 186 agencies, 182 participated in the survey (98%). of those participating, 15 agencies (8%) were excluded from the analysis: 4 (2%) who only treat adults and 11 (6%) who do not participate in electronic data entry. of the remaining 171 agencies (94%), 155 (91%) were familiar with the utah emsc protocol guidelines; 116 agencies (68%) have either partially or fully adopted the protocol guidelines. 132 agencies (77%) were familiar with the pain treatment protocol guideline; 29 (17%) had adopted it; 34 (21%) planned to either partially or fully adopt the protocol. overall, 84 agencies (49%) had offline protocols allowing the administration of narcotics to children. of those, 49 (58%) had intranasal fentanyl as an available medication and delivery route. of the 84 agencies with offline protocols for pain, 77 (83%) reported familiarity with the emsc pain protocol guideline. conclusion: the creation and dissemination of statewide emsc protocol guidelines results in widespread awareness (91%) and to date 68% of agencies have adopted them. future investigation into factors associated with protocol adoption should be explored. background: intranasal (in) naloxone is safe and effective for the treatment of opioid overdose. while it has been extensively studied in the out-of-hospital environment in the hands of paramedics and lay people, we are unaware of any studies evaluating the safety and efficacy of in naloxone administration by bls providers. in recent years in naloxone has been added to the bls armamentarium; however, most services/states require an als unit be dispatched and attempt an intercept if in naloxone is administered by the bls providers. objectives: the purpose of this study is to evaluate the safety and effectiveness of bls-administered in naloxone in an urban environment. methods: retrospective cohort review as part of the ongoing qa process of all patients who had in naloxone administration by bls providers. the study was part of a special projects waiver by massachusetts oems from february 2011 through november 2011 in a busy urban tiered ems system in the metro-boston area. exclusion criteria: cardiac arrest. demographic information was collected, as well as vital signs, number of naloxone doses by bls, patient response to bls naloxone administration (clinical improvement in mental status and/or respiratory status), als intercept. descriptive statistics and confidence intervals are reported using microsoft excel and spss 17.0. results: fifty-six cases of bls-administered in naloxone were identified, and 2 were excluded as cardiac arrests. the included cases had a mean age of 38.8 years ±13.5 (range 16-82), and 74% (ci 60-85) were male. of the 54 included cases, 76% (ci 62-87) of patients responded to bls administration of naloxone. of the responders, 17% (ci 7-32) required two doses. there were 10 protocol violations representing 19% (ci 9.2-31.4) of the total administrations, however in 100% of these 10 protocol violations the patients had a positive response to the administration of in naloxone. seven of the protocol violations were patients who required a second 2 mg dose of naloxone. eleven cases did not have an als intercept; only 1 of these 11 patients did not respond to bls administration of naloxone. there were no identified adverse events. conclusion: bls providers safely and successfuly administered in naloxone achieving a response rate consistent with studies of als providers' administration of in naloxone. given the success rate of bls providers, it may be feasible for bls to manage responders without the aid of an als intercept. background: an estimated 20% of patients arriving by ambulance to the ed are in moderate to severe pain. however, the management of pain in the prehospital setting has been shown to be inadequate, and untreated pain may have negative consequences for patients. objectives: to determine if focused education on pediatric pain management and implementation of a pain management protocol improved the prehospital assessment and treatment of pain in adult patients. specifically, this study aimed to determine if documentation of pain scores and administration of morphine by ems personnel improved. methods: this was a retrospective before and after study conducted by reviewing a county-wide prehospital patient care database. the study population included all adult patients transported by ems between 01 february 2006 and 28 february 2010 with a working assessment of trauma or burn. ems patient care records were searched for documentation of pain scores and morphine administration 2 years before and 2 years after an intensive pediatric focused pain management education program and implementation of a pain management protocol. frequencies and 95% cis were determined for all patients meeting the inclusion criteria in the before and after time period and chisquare was used to compare frequencies between time periods. a secondary analysis was conducted using only subjects documented as meeting the protocol's treatment guidelines. results: 7,999 (10%) of 77,122 adult patients transported by ems during the study period met the inclusion criteria: 4,357 in the before and 3,642 in the after period. subject demographics were similar between the two periods. documentation of pain score did not change between the time periods ( background: there is a presumption that ambulance response times affect patient outcome. we sought to determine if shorter response times really make a difference in hospital outcomes. objectives: to determine if ambulance response time makes a difference in the outcomes of patients transported for two major trauma (motor vehicle crash injuries, penetrating trauma) and two major medical (difficulty breathing and chest pain complaints) emergencies. methods: this study was conducted in a metropolitan ems system serving a population total of 800,000 including urban and rural areas. cases were included if the private ems service was the first medical provider on scene, the case was priority 1, and the patient was 13 years and older. a 12-month time period was used for the data evaluation. four diagnoses were examined: motor vehicle crash injuries, penetrating trauma, difficulty breathing, and chest pain complaints. ambulance response times were assessed for each of the four different complaints. the patients' initial vital signs were assessed and the number of vital signs out of range was recorded. a sampling of all cases which went to the single major trauma center was selected for evaluation of hospital outcome. using this hospital sample, number of vital signs out of range were assessed as a surrogate marker indicating severity of hospital outcome. correlation coefficients were used to evaluate interactions between independent and outcome variables. results: of the 2164 cases we reviewed over the 12month period, we found that the ems service responded significantly faster to trauma complaints at 4.53 minutes (n = 254) than medical complaints at 5.92 minutes (n = 1910) . in the hospital sample of 587 cases, number of vital signs out of range were positively correlated with hospital days (r = 0.11), admits (r = 0.12), icu admits (r = 0.10), and deaths (r = 0.09), but not response times (r = (-)0.08). in the entire sample, there was no correlation between vital signs out of range and response times for any diagnosis (see figure) . conclusion: conclusions: based on our hospital sample which showed that number of vital signs out of range was a surrogate marker of worse hospital outcomes, we find that hospital outcomes are not related to initial response times. adverse effects following prehospital use of ketamine by paramedics eric ardeel baylor college of medicine, houston, tx background: ketamine is widely used across specialties as a dissociative agent to achieve sedation and analgesia. emergency medical services (ems) use ketamine to facilitate intubation and pain control, as well as to sedate acutely agitated patients. published studies of ems ketamine practice and effects are scarce. objectives: describe the incidence of adverse effects occurring after ketamine administration by paramedics treating under a single prehospital protocol. methods: a retrospective analysis was conducted of 98 consecutive patients receiving prehospital ketamine from paramedics in the suburban/rural ems system of montgomery county hospital district, texas between august 1, 2010 and october 25, 2011. ketamine administration indications were: need for rapid control of violent/agitated patients requiring treatment and transport; sedation and analgesia after trauma; facilitation of intubation and mechanical ventilation. ketamine administration contraindications were: equivalent ends achieved by less invasive means; hypertensive crisis; angina; signs of significantly elevated intracranial pressure; anticipated inability to support or control airway. all patients were included, regardless of indication for ketamine administration. data were abstracted from electronic patient care records and available continuous physiologic monitoring data, and analyzed for the presence of adverse effects as defined a priori in ''clinical practice guidelines for emergency department ketamine dissociative sedation: 2011 update.'' results: no patients were identified as experiencing adverse effects as defined by the referenced literature. ketamine was utilized most often for patients with the following nemsis provider's primary impression: 25 (26%) altered level of consciousness, 23 (23%) behavioral/psychiatric, 20 (20%) traumatic injury. overall, combativeness was associated with 64 (65%) patients. the mean age was 41 years (range 3-94 years) and 50 (51%) were male. the mean ketamine dose was 150 mg (range 25-500 mg) and twenty-four (24%) patients received multiple administrations. conclusion: in this patient population, our data indicate that prehospital ketamine use by ems paramedics, across all indications for administration, was safe. further study of ketamine's utility in ems is warranted. an background: rigorous evaluation of the effect of implementing nationally vetted evidence-based guidelines (ebgs) has been notoriously difficult in ems. specifically, human subjects issues and the health insurance portability and accountability act (hipaa) present major challenges to linking ems data with distal outcomes. objectives: to develop a model that addresses the human subjects and hipaa issues involved with evaluating the effect of implementing the traumatic brain injury (tbi) ebgs in a statewide ems system. methods: the excellence in prehospital injury care (epic) project is an nih-funded evaluation of the effect of implementing the ems tbi guidelines throughout arizona (ninds-1r01ns071049-01a1). to accomplish this, a partnership was developed between the arizona department of health services (adhs), the university of arizona, and more than 100 ems agencies that serve approximately 85% of the state's population. results: ebg implementation: implementation follows all routine regulatory processes for making changes in ems protocols. in arizona, the entire project must be carried out under the authority of the adhs director. evaluation: a before-after system design is used (randomization is not acceptable). hipaa: as an adhsapproved public health initiative, epic is exempt from hipaa, allowing sharing of protected health information between participating entities. for epic, the state attorney general provided official verification of hi-paa exemption, thus allowing direct linkage of ems and hospital data. irb: once epic was officially deemed a public health initiative, the university irb process was engaged. as an officially sanctioned public health project, epic was determined to not be human subjects research. this allows the project to implement and evaluate the effect of this initiative without requiring individual informed consent. conclusion: by utilizing an ems-public health-university partnership, the ethical and regulatory challenges related to evaluating implementation of new ebgs can be successfully overcome. the integration of the department of health, the attorney general, and the university irb can properly protect citizens while permitting efficient implementation and rigorous evaluation of the effect of ebgs. this novel approach may be useful as a model for evaluation of implementing ems ebgs in other states and large counties. (20.6%-58.1% by age) were transported to non-trauma centers. the most common reasons cited by ems for hospital selection were: patient preference (50.6%), closest facility (20.7%), and specialty center (15.2%). patient preference increased with age (p for trend 0.0001) and paralleled under-triage ( figure 1 ). iss ‡ 16 patients transported to non-trauma hospitals by patient request had lower unadjusted mortality (3.8%, 95%ci 1.9-5.8) than similar patients transported to trauma centers (11.8%, 95%ci 10.7-12.8) or transported for other reasons (12.6%, 95%ci 11.4-13.7) (figure 2) . under-triage appears to be influenced by patient preference and age. self-selection for transport to non-trauma centers may result in under-triaged patients with inherently better prognosis than triagepositive patients. background: only 25% of all out-of-hospital cardiac arrest (ohca) patients receive bystander cpr (cardiopulmonary resuscitation). the neighborhood in which an ohca occurs has significant influence on the likelihood of receiving bystander cpr. objectives: to utilize geographic information systems to identify ''high-risk'' neighborhoods, defined as census tracts with high incidence of ohca and low cpr prevalence. methods: design: secondary analysis of the cardiac arrest registry to enhance survival (cares) dataset for denver county, colorado. population: all consecutive adults (>18 years old) with ohca due to cardiac etiology from january 1, 2009 through december 31, 2010. data analysis: analyses were conducted in arc-gis. three spatial statistical methods were used: local morans i (lmi), getis-ord gi*(gi*), and spatial empirical bayes (seb) adjusted rates. census tracts with high incidence of ohca, as identified by all three spatial statistical methods, were then overlain with low bystander cpr census tracts, which were identified in at least two out of three statistical methods (lmi, gi*, or the lowest quartile of bystander cpr prevalence). overlapping census tracts identified with both high ohca incidence and low cpr prevalence were designated as ''highrisk''. results: a total of 728 arrests in 142 census tracts occurred during the study period, with 595 arrests included in final sample. events were excluded if they were unable to be geocoded (n = 41), outside denver county (n = 8), or occurred in a jail (n = 3), hospital/ physician's office (n = 7), or nursing home (n = 74). for high ohca incidence: lmi identified 29 census tracts, gi* identified 45 census tracts, and the seb method identified 28 census tracts. twenty-five census tracts were identified by all three methods. for low bystander cpr prevalence: lmi identified 9 census tracts, gi* identified 16 census tracts, and 101 census tracts were identified as being in the lowest quartile of cpr prevalence. twenty-four census tracts were identified by two of the three methods. two census tracts were identified as high-risk having both high ohca incidence and low cpr prevalence (figure) . high-risk census tract demographics as compared to denver county are shown in the table. conclusion: the two high-risk census tracts, comprised of minority and low-income populations, appear to be possible sites for targeted community-based cpr interventions. objectives: we sought to assess the accuracy and correlation of geographic information system (gis) derived transport time compared to actual ems transport time in ohca patients. methods: prospective, observational cohort analysis of ohca patients in vancouver, b.c., one of the sites of the resuscitation outcomes consortium (roc). a random sample from all of the ohca cases from 12/05 through 05/07 was selected for analysis from one site of the roc epistry. using gis, ems transport time was derived from reported latitude/longitude coordinates of the ohca event to the actual receiving hospital. this was calculated via the actual network distance using arcgis. this gis-derived time was then compared to the actual ems transport time (in minutes) using the wilcoxon signed rank test. scatter plot analysis of actual vs. gis times were created to evaluate the relationship between actual and calculated time. a linear regression model predicting actual ems transport time from the derived gis-time was also developed in order to examine the potential relationship between the two variables. differences in the relationship were also investigated based on time of the day to reflect varying traffic conditions. results: 641 cases were randomly selected for analysis. the median actual transport time was significantly longer than the median gis derived transport time (7.08 minutes vs. 5.50 minutes). scatter plot analysis did not reveal any significant correlation between actual and gis-based time. additionally, there was poor approximation of gis-based time and actual ems time (r 2 = 0.20) with no evidence of a significant linear relationship between the two. the poorest correlation of time was observed during the morning hours (07:00-09:00; r 2 = 0.02) while the strongest correlation was during the overnight hours (00:00-07:00; r 2 = 0.26). conclusion: gis derived time does not appear to correlate well with actual ems transport time of ohca patients. efforts should be made to accurately obtain actual ems transport times for ohca patients. objectives: we first sought to describe the incidence of ohca presenting to the ed. we then sought to determine the association between hospital characteristics and survival to hospital admission. methods: we identified patients with diagnoses of cardiac arrest or ventricular fibrillation (icd-9 427.5 or 427.41) in the 2007 nationwide emergency department sample, a nationally representative estimate of all ed admissions in the us. eds reporting ‡1 patient with ohca were included. our primary outcome was survival to hospital admission. we examined variability in hospital survival rate and also classified hospitals into high or low performers based on median survival rate. we used this dichotomous hospital level outcome to examine factors associated with survival to admission including hospital and patient demographics, ed volume, cardiac arrest volume, and cardiac catheterization availability. all unadjusted and adjusted analyses were performed using weighted statistics and logistic regressions. results: of the 966 hospitals, 949 (98.2%) were included. in total, 44,782 cases of cardiac arrest were identified, representing an estimated 203,331 cases nationally. overall ed ohca survival to hospital admission was 23.5% (iqr 0.1%, 29.4%) in adjusted analyses, increased survival to admission was seen in hospitals with teaching status (or 2.7, 95% ci 1.7-4.4, p < 0.001), annual ed visits ‡10,000 (or 3.9, 95% ci 2.5-6.1, p < 0.001), and pci capability (or 9.1, 95% ci 1.2-68.2, p = 0.032). in separate adjusted analyses including teaching status and pci capabilities, hospitals with >40 annual cardiac arrest cases (or 3.0, 95% ci 2.2-4.2, p < 0.001) were also shown to have improved survival (figure) . conclusion: ed volume, cardiac arrest volume, and pci capability were associated with improved survival to hospital admission in patients presenting to the ed after ohca. an improved understanding of the contribution of ed care to ohca survival may be useful in guiding the regionalization of cardiac arrest care. background: prior investigations have demonstrated regional differences in out-of-hospital cardiac arrest (ohca) outcomes, but none have evaluated survival variability by hospital within a single major us city. objectives: we hypothesized that 30-day survival from ohca would vary considerably among one city's receiving hospitals. methods: we performed a retrospective review of prospectively collected cardiac arrest data from a large, urban ems system. our population included all ohcas with a recorded social security number (which we used to determine 30-day survival through the social security death index) that were transported to a hospital between 1/1/2008 and 12/31/2010. we excluded traumatic arrests, pediatric arrests, and hospitals receiving less than 10 ohcas with social security numbers over the three-year study period. we examined the associa-tion between receiving hospital and 30-day survival. additional variables examined included: level i trauma center status, teaching hospital status, ohca volume, and whether post-arrest therapeutic hypothermia (th) protocols were in place in 2008. statistics were performed using chi-square tests and logistic regression. results: our study population comprised 550 arrest cases delivered to 18 unique hospitals with an overall 30-day survival of 14.4%. mean age was 69.0 (sd 16.2) years. males comprised 54.2% of the cohort; 53.3% of victims were black. thirty-day survival varied significantly among the hospitals, ranging from 4.8% to 35.0% (chi-square 32.3, p = 0.014). ohcas delivered to level i trauma centers were significantly more likely to survive (19.5% vs. 12.7%, p = 0.05), as were those delivered to hospitals known to offer post-arrest th (19.2% vs. 11.8%, p = 0.018). hospital teaching status and ohca volume were not associated with survival. conclusion: there was significant variability in ohca survival by hospital. patients were significantly more likely to survive if transported to a level i trauma center or hospital with post-arrest th protocols, suggesting a potential role for regionalization of ohca care. limiting our population to ohcas with recorded social security numbers reduced our power and may have introduced selection bias. further work will include survival data on the complete set of ohcas transported to hospitals during the three-year study period. background: traumatic brain injury is a leading cause of death and disability. previous studies suggest that prehospital intubation in patients with tbi may be associated with mortality. limited data exist comparing prehospital (ph) nasotracheal (nt), prehospital orotracheal (ot), and ed ot intubation and mortality following tbi. objectives: to estimate the associations between ph nt, ph ot, and ed ot intubation and in-hospital mortality in patients with moderate to severe tbi, with hypotheses that ph nt and ph ot intubation would be associated with increased mortality when compared to ed ot or no intubation. methods: an analysis using the denver health trauma registry, a prospectively collected database. consecutive adult trauma patients from 1995-2008 with moderate to severe tbi defined as head abbreviated injury scale (ais) scores of 2-5. structured chart abstraction by blinded physicians was used to collect demographics, injury and prehospital care characteristics, intubation status and timing, in-hospital mortality and survival time, and neurologic function at discharge. poor neurologic function was defined as cerebral performance category score of 3-5. multivariable logistic regression and survival analyses were performed, using multiple imputation for missing data. results: of the 3,517 patients, the median age was 38 (iqr 27-51) years. the median ph gcs was 14 (iqr 6-15), median injury severity score was 20 (iqr 13-29), and median head ais was 4 (iqr 3-5). ph nt occurred in 15.8%, ph ot in 9.5%, and ed ot in 17.4%, while mortality occurred in 17.5%. the 24-, 48-, and 72-hour survival analyses are outlined in the table. survival curves for ph nt, ph ot, and ed ot are demonstrated in the figure (p < 0.001) . conclusion: prehospital intubation in patients with moderate to severe tbi is associated with increased mortality. contrary to our initial hypothesis, there was also a significant association between ed intubation and mortality. these associations persisted despite survival time, and while adjusting for injury severity. background: sbdp150 is a breakdown product of the cytoskeletal protein alpha-ii-spectrin found in neurons and has been detected in severe tbi. objectives: this study examined whether early serum levels of sbdp150 could distinguish: 1) mild tbi from three control groups; 2) those with and without traumatic intracranial lesions on ct (+ct vs -ct); and 3) those having a neurosurgical intervention (+nsg vs -nsg) in mild and moderate tbi (mmtbi). methods: this prospective cohort study enrolled adult patients presenting to two level i trauma centers following mmtbi with blunt head trauma with loss of consciousness, amnesia, or disorientation and a gcs 9-15. control groups included uninjured controls and trauma controls presenting to the ed with orthopedic injuries or an mvc without tbi. mild tbi was defined as gcs 15 and moderate tbi as having a gcs <15. blood samples were obtained in all patients within 4 hours of injury and measured by elisa for sbdp150 (ng/ml). the main outcomes were: 1) the ability of sbdp150 to distinguish mild tbi from three control groups; 2) to distinguish +ct from -ct and; 3) to distinguish +nsg from -nsg. data were expressed as means with 95%ci, and performance was tested by roc curves (auc and 95%ci). results: there were 275 patients enrolled: 54 tbi patients (42 gcs 15, 12 gcs 9-14), 23 trauma controls (16 mvc controls and 7 orthopedic controls), and 198 uninjured controls. the mean age of tbi patients was 39 years (range 19-70) with 63% males. fourteen (14%) had a +ct and 9% had +nsg. mean serum sbdp150 levels were 0.764 (95%ci 0.561-0.968) in normal controls, 1.035 (0.091-2.291) in orthopedic controls, 1.209 (0.236-2.181 ) in mvc controls, 2.764 (1.700-3.827 ) in mild tbi with gcs 15, and 5.227 (0.837-9.617) in tbi with gcs 9-14 (p < 0.001). the auc for distinguishing mild tbi from both controls was 0.83 (95%ci 0.68-0.99). mean sbdp150 levels in patients with -ct versus +ct were 2.170 (1.340-3.000) and 6.797 (2.227-11.368) respectively (p < 0.001) with auc = 0.78 (95%ci 0.61-0.95). mean sbdp150 levels in patients with -nsg versus +nsg were 2.492 (1.391-3.593) and 6.867 (3.891-9.843) respectively (p < 0.001) with auc = 0.88 (95%ci 0.77-0.98). conclusion: serum sbdp150 levels were detectable in serum acutely after injury and were associated with measures of injury severity including ct lesions and neurosurgical intervention. further study is required to validate these findings before clinical application. utility of platelet background: pre-injury use of anti-platelet agents (e.g., clopidogrel and aspirin) is a risk factor for increased morbidity and mortality in patients with traumatic intracranial hemorrhage (tich). some investigators have recommended platelet transfusion to reverse the anti-platelet effects in tich. objectives: this evidence-based medicine review examines the evidence regarding the effect of platelet transfusion in emergency department (ed) patients with pre-injury anti-platelet use and tich on patientoriented outcomes. methods: the medline, embase, cochrane library, and other databases were searched. studies were selected for inclusion if they compared platelet transfusion to no platelet transfusion in the treatment of adult ed patients with pre-injury anti-platelet use and tich, and reported rates of mortality, neurocognitive function, or adverse effects as outcomes. we assessed the quality of the included studies using ''grading of recommendations assessment, development and evaluation'' (grade) criteria. categorical data are presented as percentages with 95% confidence interval (ci). relative risks (rr) are reported when clinically significant. results: five retrospective, registry-based studies were identified, which enrolled 635 patients cumulatively. based on standard criteria, three studies were of ''low'' quality evidence and two studies had ''very low'' qualities. one study reported higher in-hospital mortality in patients with platelet transfusion (ohm et al), another showed a lower mortality rate in patients receiving platelet transfusion (wong et al). three studies did not show any statistical difference in comparing mortality rates between the groups (table) . no studies reported intermediate-or long-term neurocognitive outcomes or adverse events. conclusion: five retrospective registry studies with suboptimal methodologies provide inadequate evidence to support the routine use of platelet transfusion in adult ed patients with pre-injury anti-platelet use and tich. abnormal levels of end-tidal carbon dioxide (etco 2 ) are associated with severity of injury in mild and moderate traumatic brain injury (mmtbi) linda papa 1 , artur pawlowicz 2 , carolina braga 1 , suzanne peterson 1 , salvatore silvestri 1 1 orlando regional medical center, orlando, fl; 2 university of central florida, orlando, fl background: capnography is a fast, non-invasive technique that is easily administered and accurately measures exhaled etco 2 concentration. etco 2 levels respond to changes in ventilation, perfusion, and metabolic state, all of which may be altered following tbi. objectives: this study examined the relationship between etco 2 levels and severity of tbi as measured by clinical indicators including glasgow coma scale (gcs) score, computerized tomography (ct) findings, requirement of neurosurgical intervention, and levels of a serum biomarkers of glial damage. methods: this prospective cohort study enrolled adult patients presenting to a level i trauma center following a mmtbi defined by blunt head trauma followed by loss of consciousness, amnesia, or disorientation and a gcs 9-15. etco 2 measurements were recorded from the prehospital and emergency department records and compared to indicators of tbi severity. results: of the 46 patients enrolled, 21 (46%) had a normal etco 2 level and 25 (54%) had an abnormal etco 2 level. the mean age of enrolled patients was 40 (range 19-70) and 32 (70%) were male. mechanisms of injury included motor vehicle collision in 19 (41%), motor cycle collision in 9 (20%), fall in 8 (17%), bicycle/ pedestrian struck in 8 (17%), and other in 2 (4%). eight (17%) patients had a gcs 9-12 and 38 (83%) had a gcs 13-15. of the 11 (24%) patients with intracranial lesions on ct, 10 (91%) had an abnormal etco 2 level (p = 0.006). of the 5 (11%) patients who required a neurosurgical intervention, 100% had an abnormal etco 2 level (p = 0.05). levels of a biomarker indicative of astrogliosis were significantly higher in those with abnormal etco 2 compared to those with a normal etco 2 (p = 0.026). conclusion: abnormal levels of etco 2 were significantly associated with clinical measures of brain injury severity. further research with a larger sample of mmtbi patients will be required to better understand and validate these findings. background: acetaminophen (apap) poisoning is the most frequent cause of acute hepatic failure in the us. toxicity requires bioactivation of apap to toxic metabolites, primarily via cyp2e1. children are less susceptible to apap toxicity; one current theory is that children's conjugative pathway (sulfonation) is more active. liquid apap preparations contain propylene glycol (pg), a common excipient that inhibits apap bioactivation and reduces hepatocellular injury in vitro and in rodents. cyp2e1 inhibition may decrease toxicity in children, who tend to ingest liquid apap preparations, and suggests a potential novel therapy. objectives: to compare phase i (toxic) and phase ii (conjugative) metabolism of liquid versus solid prepara-tions of apap. we hypothesize that ingestion of a liquid apap preparation results in decreased production of toxic metabolites relative to a solid preparation, likely due to the presence of pg in the liquid preparations. methods: design-pharmacokinetic cross-over study. setting-university hospital clinical research center. subjects-adults ages 18-40 taking no chronic medications. interventions-subjects were randomized to receive a 15 mg/kg dose of a commercially available solid or liquid apap preparation. after a washout period of greater than 1 week, subjects received the same dose of apap in the alternate preparation. apap, apap-glucuronide and apap-sulfate (phase 2 metabolites), apap-cysteinate and apap-mercapturate (phase 1 metabolites) were analyzed via lc/ms in plasma over 8 hours. peak concentrations and measured auc were compared using paired-sample t-tests. plasma pg levels were measured. results: fifteen subjects completed the protocol. peak concentrations and aucs of the cyp2e1 derived toxic metabolites were significantly lower following ingestion of the liquid preparation (table, figure) . the glucuronide and sulfate metabolites were not different. pg was present following ingestion of liquid but not solid preparations. conclusion: ingestion of liquid relative to solid preparations in therapeutic doses results in decreased plasma levels of toxic apap metabolites. this may be due to inhibition of cyp2e1 by pg, and may explain the decreased susceptibility in children. a less hepatotoxic formulation of apap can potentially be developed if co-formulated with a cyp2e1 inhibitor. background: pressure immobilization bandages have been shown to delay mortality for up to 8 hours after coral snake envenomation, providing an inexpensive and effective treatment when antivenin is not readily available. however, long-term efficacy has not been established. objectives: determine if pressure immobilization bandages, consisting of an ace wrap and splint, can delay morbidity and mortality from coral snake envenomation, even in the absence of antivenin therapy. methods: institutional animal care and use committee approval was obtained. this was a randomized, observational pilot study using a porcine model. ten pigs (17.3 kg to 25.6 kg) were sedated and intubated for 5 hours. pigs were injected subcutaneously in the left distal foreleg with 10 mg of lyophilized m. fulvius venom resuspended in water, to a depth of 3 mm. pigs were randomly assigned to either a control group (no compression bandage and splint) or a treatment group (compression bandage and splint) approximately 1 minute after envenomation. pigs were monitored daily for 21 days for signs of respiratory depression, decreased oxygen saturations, and paresis/paralysis. in case of respiratory depression, pigs were euthanized and time to death recorded. chi-square was used to compare rates of survival up to 21 days and a kaplan-meier survival curve constructed. results: average survival time of control animals was 412 ± 90 minutes compared to 12,642 ± 7,132 minutes for treated animals. significantly more pigs in the treatment group survived to 24 hours than in the control group (p = 0.03). two of the treatment pigs survived to the endpoint of 21 days, but showed necrosis of the distal lower extremity. conclusion: long-term survival after coral snake envenomation is possible in the absence of antivenin with the use of pressure immobilization bandages. the applied pressure of the bandage is critical to allowing survival without secondary consequences (i.e. necrosis) of envenomation. future studies should be designed to accurately monitor the pressures applied. background: patients exposed to organophosphate (op) compounds demonstrate a central apnea. the kölliker-fuse nuclei (kf) are cholinergic nuclei in the brainstem involved in central respiratory control. objectives: we hypothesize that exposure of the kf is both necessary and sufficient for op-induced central apnea. methods: anesthetized and spontaneously breathing wistar rats (n = 24) were exposed to a lethal dose of dichlorvos using three experimental models. experiment 1 (n = 8) involved systemic op poisoning using subcutaneous (sq) dichlorvos (100 mg/kg or 3x ld50). experiment 2 (n = 8) involved isolated poisoning of the kf using stereotactic microinjections of dichlorvos (625 micrograms in 50 microliters) into the kf. experiment 3 (n = 8) involved systemic op poisoning with isolated protection of the kf using sq dichlorvos (100 mg/kg) and stereotactic microinjections of organophosphatase a (opda), an enzyme that degrades dichlorvos. respiratory and cardiovascular parameters were recorded continuously. histological verification of injection site was performed using kmno4 injections. animals were followed post-poisoning for 1 hour or death. betweengroup comparisons were performed using a repeated measured anova or student's t-test where appropriate. results: animals poisoned with sq dichlorvos demonstrated respiratory depression starting 5.1 min post exposure, progressing to apnea 15.9 min post exposure. there was no difference in respiratory depression between animals with sq dichlorvos and those with dichlorvos microinjected into the kf. despite differences in amount of dichlorvos (100 mg/kg vs 1.8 mg/kg) and method of exposure (sq vs cns microinjection), 10 min following dichlorvos both groups (sq vs microinjection respectively) demonstrated a similar percent decrease in respiratory rate (51.5 vs 72.2, p = 0.14), minute ventilation ( background: patients sustaining rattlesnake envenomation often develop thrombocytopenia, the etiology of which is not clear. laboratory studies have demonstrated that venom from several species, including the mojave rattlesnake (crotalus scutulatus scutulatus), can inhibit platelet aggregation. in humans, administration of crotaline fab antivenom (av) has been shown to result in transient improvement of platelet levels; however, it is not known whether platelet aggregation also improves after av administration. objectives: to determine the effect of c. scutulatus venom on platelet aggregation in vitro in the presence and absence of crotaline fab antivenom. methods: blood was obtained from four healthy male adult volunteers not currently using aspirin, nsaids, or other platelet-inhibiting agents. c. scutulatus venom from a single snake with known type b (hemorrhagic) activity was obtained from the national natural toxins research center. measurement of platelet aggregation by an aggregometer was performed using five standard concentrations of epinephrine (a known platelet aggregator) on platelet-rich plasma over time, and a mean area under the curve (auc) was calculated. five different sample groups were measured: 1) blood alone; 2) blood + c. scutulatus venom (0.3 mg/ml); 3) blood + crotaline fab av (100 mg/ml); 4) blood + venom + av (100 mg/ ml); 5) blood + venom + av (4 mg/ml). standard errors of the mean (sem) were calculated for each group. results: antivenom administration by itself did not significantly affect platelet aggregation compared to baseline (103.8 ± 3.4%, p = 0.47). administration of venom decreased platelet aggregation (72.0 ± 8.5%, p < 0.05). concentrated av administration in the presence of venom normalized platelet aggregation (101.4 ± 6.8%) and in the presence of diluted av significantly increased aggregation (133.9 ± 9.0%); p < 0.05 for both groups when compared to the venom-only group. to control for the effects of the venom and av, each was run independently in platelet-rich plasma without epinephrine; neither was found to significantly alter platelet aggregation. conclusion: crotaline fab av improved platelet aggregation in an in vitro model of platelet dysfunction induced by venom from c. scutulatus. the mechanism of action remains unclear but may involve inhibition of venom binding to platelets or a direct action of the antivenom on platelets. background: routine use of both breathalyzers and hand sanitizers is common across emergency depart-ments. the most common hand sanitizer on the market, purell, contains 62% ethyl alcohol and a lesser amount of isopropyl alcohol. previous investigations have documented that risk is low to the health care worker who applies frequent hand sanitizers to themselves. however, it is unknown whether this alcohol mixture causes false readings on a breathalyzer machine being used to determine alcohol levels on others. objectives: to determine the effect on the measurement of breathalyzer readings in individuals who have not consumed alcohol after hand sanitizer is applied to the experimenter holding a breathalyzer machine. methods: after obtaining informed consent, a breathalyzer reading was obtained in participants who had not consumed any alcohol in the last 24 hours. three different experiments were performed with 25 different participants in each. in experiment 1, two pumps of hand sanitizer were applied to the experimenter. without allowing the sanitizer to dry, the experimenter then measured the breathalyzer reading of the participant. in experiment 2, one pump of sanitizer was applied to the experimenter. measurements of the participant were taken without allowing the sanitizer to dry. in experiment 3, one pump of sanitizer was placed on the experimenter and rubbed until dry according to the manufacturer's recommendations. readings were recorded and analyzed using paired t-tests. results: the initial breathalyzer reading for all participants was 0. after two pumps of hand sanitizer were applied without drying (experiment 1), breathalyzers ranged from 0.02 to 0.17, with a mean above the legalintoxication limit of 0.11 (t(24) = )15.3, p < 0.001). after one pump of hand sanitizer was applied without drying (experiment 2), breathalyzers ranged from 0.02 to 0.11, with a mean of 0.06 (t(24) = )14.1, p < 0.001). after one pump of hand sanitizer was applied according to manufacturer's directions (experiment 3), breathalyzers ranged from 0.0 to 0.02 with a mean of 0.01 (t(24) = )5.1, p < 0.001). conclusion: use of hand sanitizer according to the manufacturer's recommendations results in a small but significant increase in breathalyzer readings. however, the improper and overuse of common hand sanitizer elevates routine breathalyzer readings, and can mimic intoxication in individuals who have not consumed alcohol. stephanie carreiro, jared blum, francesca beaudoin, gregory jay, jason hack objectives: the primary aim of this study is to determine if pretreatment with ile affects the hemodynamic response to epinephrine in a rat model. hemodynamic response was measured by a change in heart rate (hr) and mean arterial pressure (map). we hypothesized that ile would limit the rise in map and hr that typically follow epinephrine administration. methods: twenty male sprague dawley rats (approximately 7-8 weeks of age) were sedated with isoflurane and pretreated with a 15 ml/kg bolus of ile or normal saline, followed by a 15 mcg/kg dose of epinephrine intravenously. intra-arterial blood pressure and hr were monitored continuously until both returned to baseline (biopaq). a multifactorial analysis of variance (manova) was performed to assess the difference in map and hr between the two groups. standardized t-tests were then used to compare the peak change in map, time to peak map, and time to return to baseline map in the two groups. results: overall, a significant difference was found between the two groups in map (p = 0.01) but not in hr (p = 0.34). there was a significant difference (p = 0.023) in time to peak map in the ile group (54 sec, 95% ci 44-64) versus the saline group (40 sec, 95% ci 32-48) and a significant difference (p = 0.004) in time to return to baseline map in ile group (171 sec, 95% ci 148-194) versus the saline group (130 sec, 95% ci 113-147). there was no significant difference (p = 0.28) in the peak change in map of the ile group (75.4, mmhg, 95% ci 66-85) versus the saline group (69.9 mmhg, 95% ci 64-76). conclusion: our data show that in this rat model ile pretreatment leads to a significant difference in map response to epinephrine, but no difference in hr response. ile delayed the peak effect and prolonged the duration of effect on map but did not alter the peak increase in map. this suggests that the use of ile may delay the time to peak effect of epinephrine if the drugs are administered concomitantly to the same patient. further research is needed to explore the mechanism of this interaction. rasch analysis of the agitation severity scale when used with emergency department acute psychiatry patients tania d. strout, michael r. baumann maine medical center, portland, me background: agitation is a frequently observed and problematic phenomenon in mental health patients being treated in the emergency setting. the agitation severity scale (agss), a reliable and valid instrument, was developed using classical test theory to measure agitation in acute psychiatry patients. objectives: the aim of this study was to analyze the agss according to the rasch measurement model and use the results to determine whether improvements to the instrument could be made. methods: this prospective, observational study was irb-approved. 270 adult ed patients with psychiatric chief complaints and dsm-iv-tr diagnoses were observed using the agss. the rasch rating scale model was employed to evaluate the 17 items comprising the agss using winsteps statistical software. unidimensionality, item fit, response category performance, person and item separation reliability, and hierarchical ordering of items were all examined. a principle components analysis (pca) of the rasch residuals was also performed. results: variable maps revealed that all of the agss items were used to some degree and that the items were ordered in a way that makes clinical sense. several duplicative items, indicating the same degree of agitation, were identified. item (5.19) and person (2.01) separation statistics were adequate, indicating appropriate spread of items and subjects along the agitation continuum and providing support for the instrument's reliability. keymaps indicated that the agss items are functioning as intended. analysis of fit demonstrated no extreme misfitting items. pca of the rasch residuals revealed a small amount of residual variance, but provided support for the agss as being unidimensional, measuring the single construct of agitation. the results of this rasch analysis support the agss as a psychometrically robust instrument for use with acute psychiatry patients in the emergency setting. several duplicative items were identified that may be eliminated and re-evaluated in future research; this would result in a shorter, more clinically useful scale. in addition, a gap in items for patients with lower levels of agitation was identified. generation of additional items intended to measure low levels of agitation could improve clinician's ability to differentiate between these patients. background: attempted suicide is one of the strongest clinical predictors of subsequent suicide and occurs up to 20 times more frequently than completed suicide. as a result, suicide prevention has become a central focus of mental health policy. in order to improve current treatment and intervention strategies for those presenting with suicide attempt and self-injury in the emergency department (ed), it is necessary to have a better understanding of the types of patients who present to the ed with these complaints. objectives: to describe the epidemiology of ed visits for attempted suicide and self-inflicted injury over a 16year period. methods: data were obtained from the national hospital ambulatory medical care survey (nhamcs). all visits for attempted suicide and self-inflicted injury (e950-e959) during 1993-2008 were included. trend analyses were conducted using stata's nptrend (a nonparametric test for trends that is an extension of the wilcoxon rank-sum test) and regression analyses. a two-tailed p < 0.05 was considered statistically significant. results: over the 16-year period, there were an average of 420,000 annual ed visits for attempted suicide and self-inflicted injury (1.50 [95% confidence interval (ci) 1.33-1.67] visits per 1,000 us population). the overall mean patient age was 31 years, with visits most common among ages 15-19 (3.70; 95%ci 3.11-4.30). the average annual number of ed visits for suicide attempt and self-inflicted injury more than doubled from 244,000 in 1993-1996 to 538,000 in 2005-2008. during the same timeframe, ed visits for these injuries per 1,000 us population almost doubled for males (0.84 to 1.62), females (1.04 to 1.96), whites (0.94 to 1.82), and blacks (1.14 to 2.10). no temporal differences were found for method of injury or ed disposition; there was, however, a significant decrease in visits determined by the physician to be urgent/emergent from 95% in 1993 to 70% in 2008. conclusion: ed visit volume for attempted suicide and self-inflicted injury has increased over the past two decades in all major demographic groups. awareness of these longitudinal trends may assist efforts to increase research on suicide prevention. in addition, this information may be used to inform current suicide and self-injury related ed interventions and treatment programs. benjamin l. bregman, janice c. blanchard, alyssa levin-scherz george washington university, washington, dc background: the emergency department (ed) has increasingly become a health care access point for individuals with mental health needs. recent studies have found that rates of major depression disorder (mdd) diagnosed in eds are far above the national average. we conducted a study assessing whether individuals with frequent ed visits had higher rates of mdd than those with fewer ed visits in order to help guide screening and treatment of depressed individuals encountered in the ed. objectives: this study evaluated potential risk factors associated with mdd. we hypothesized that patients who are frequent ed visitors will have higher rates of mdd. methods: this was a single center, prospective, crosssectional study. we used a convenience sample of noncritically ill, english speaking adult patients presenting with non-psychiatric complaints to an urban academic ed over 6 months in 2011. we oversampled patients presenting with ‡3 visits over the previous 364 days. subjects were surveyed about their demographic and other health and health care characteristics and were screened with the phq 9, a nine-item questionnaire that is a validated, reliable predictor of mdd. we conducted bivariate (chi-square) and multivariate analysis controlling for demographic characteristics using sta-ta v. 10.0. our principal dependent variable of interest was a positive depression screen (phq 9 score ‡10). our principal independent variable of interest was ‡3 visits over the previous 364 days. results: our response rate was 90.7% with a final sample size of 1012. of our total sample, 313 (30.9%) had three or greater visits within the prior 364 days. one hundred (32%) frequent visitors had a positive phq 9 mdd screen as compared to 142 (20.3%) of subjects with fewer than three visits (p < 0.0001). in our multivariate analysis, the odds for having three or more visits for subjects who had a positive depression screen was 1.42 (1.03, 1.97). of subjects with three or more visits with a positive depression screen, only 116 (37%) were actively being treated for mdd at the time of their visit. conclusion: our study found a high prevalence of untreated depression among frequent users of the ed. eds should consider routinely screening patients who are frequent consumers for mdd. in addition, further studies should evaluate the effect of early treatment and follow up for mdd on overall utilization of ed services. access to psychiatric care among patients with depression presenting to the emergency department janice c. blanchard, benjamin l. bregman, dana rosenfarb, qasem al jabr, eun kim george washington university, washington, dc background: literature suggests that there is a high rate of major depressive disorder (mdd) in emergency department (ed) users. however, access to outpatient mental health services is often limited due to lack of providers. as a result, many persons with mdd who are not in active treatment may be more likely to utilize the ed as compared to those who are currently undergoing outpatient treatment. objectives: our study evaluated utilization rates and demographic characteristics associated with patients with a prior diagnosis of mdd not in active treatment. we hypothesized that patients who present to the ed with untreated mdd will have more frequent ed visits. methods: this was a single center, prospective, crosssectional study. we used a convenience sample of noncritically ill, english speaking adult patients presenting with non-psychiatric complaints to an urban academic ed over 6 months in 2011. subjects were surveyed about their demographic and other health and health care characteristics and were screened with the phq 9, a nine-item questionnaire that is a validated, reliable predictor of mdd. we conducted bivariate (chi-square) and multivariate analysis controlling for demographic characteristics using stata v. 10.0. our principal dependent variable of interest was a positive depression screen (phq 9 ‡ 10). our analysis focused on the subset of patients with a prior diagnosis of mdd with a positive screen for mdd during their ed visit. results: our response rate was 90.7% with a final sample size of 1012. 243 (24.0%) patients screened positive for mdd with a phq 9 score ‡10. of the 243 patients with a positive depression screen, 55.1% reported a prior history of treatment for mdd (n = 134). of these patients, only 57.6% were currently actively receiving treatment. hispanics who screened positive for depression with a history of mdd were less likely to actively be undergoing treatment as compared to non-hispanics (22.2% versus 46.9%, p = 0.041). patients with incomes less than $20,000 were more likely to actively be receiving treatment as opposed to higher incomes (76.3% versus 42.7% p = 0.003). conclusion: patients presenting to our ed with untreated mdd are more likely to be hispanic and less likely to be low income. the emergency department may offer opportunities to provide antidepressant treatment for patients who screen positive for depression but who are not currently receiving treatment. evaluation of a two-question screening tool (phq-2) for detecting depression in emergency department patients jeffrey p. smith, benjamin bregman, janice blanchard, nasser hashim, mary pat mckay george washington university, washington, dc background: the literature suggests there is a high rate of undiagnosed depression in ed patients and that early intervention can reduce overall morbidity and health care costs. there are several well validated screening tools for depression including the nine-item patient health questionnaire (phq-9). a tool using a two-question subset, the phq-2, has been shown to be an easily administered, reasonably sensitive screening tool for depression in primary care settings. objectives: to determine the sensitivity and specificity of the phq-2 in detecting major depressive disorders (mdd) among adult ed patients presenting to an urban teaching hospital. we hypothesize that the phq-2 is a rapid, effective screening tool for depression in a general ed population. methods: cross sectional survey of a convenience sample of 1012 adult, non-critically ill, english speaking patients with medical and not psychiatric complaints presenting to the ed between 9am and 11pm weekdays. patients were screened for mdd with the phq-9. we used spss v19.0 to analyze the specificity, sensitivity, positive predictive value (ppv), negative predictive value (npv), and kappa of phq-2 scores of 2 and 3 (out of possible total score of 6) compared to a validated cut-off score of 10 or higher of 27 points on the phq-9. the two questions on the phq-2 are: ''over the last two weeks, how often have you had little interest in doing things? how often have you felt down, depressed or hopeless?'' responses are scored from 0-3 based on ''never'',''several days'', ''more than half'', ''nearly every day''. results: 1012 subjects of 1116 approached agreed to participate (90.7% response rate), and 975 (96.3%) completed the phq-9. the phq-9 identified 225 (23.1%) subjects with mdd. table 1 outlines the percent of subjects who were positive and the sensitivity, specificity, positive, and negative predictive values and kappa for each cut-off on the phq-2. conclusion: the phq-2 is a sensitive and specific screening tool for mdd in the ed setting. moreover, the phq-2 is closely correlated with the phq-9, especially if a score of 3 or greater is used. given the simplicity and ease of using a two-item questionnaire and the high rates of undiagnosed depression in the ed, including this brief, self-administered screening tool to ed patients may allow for early awareness of possible mdd and appropriate evaluation and referral. patients. however, much of this self-harm behavior is not discovered clinically and very little is known about the prevalence and predictors of current ed screening practices. attention to this issue is increasing due to the joint commission's patient safety goal 15, which focuses on identification of suicide risk in patients. objectives: to describe the prevalence and predictors of screening for self-harm and of presence of current self-harm in eds. methods: data were obtained from the nimh-funded emergency department safety assessment and followup evaluation (ed-safe). eight u.s. eds reviewed charts in real time for 35-40 hours a week between 8/ 2010 and 11/2011. all patients presenting during enrollment shifts were characterized as to whether a selfharm screening had been performed by ed clinicians. a subset of patients with a positive screening was asked about the presence of self-harm ideation, attempts, or both by trained research staff. we used multivariable logistic regression to identify predictors of screening and of current self-harm. data were clustered by site. in each model we examined day and time of presentation, age < 65 years, sex, race, and ethnicity. results: of the 92,154 patients presenting during research shift, 24,240 (26%) were screened for self-harm. screening rates varied among sites and ranged from 4% to 32%, with one outlier at 93%. of those screened, 2,471 (10%) had current self-harm. among those with selfharm approached by study personnel (n = 1,037), 916 (88%) had thoughts of self-harm (suicidal or non-suicidal), 806 (78%) had thoughts of suicide, 444 (43%) had self-harm behavior, and 316 (31%) had suicide attempt(s) over the preceding week. predictors of being screened were: age < 65 years, male sex, weekend presentation, and night shift presentation (table) . among those screened, predictors of current self-harm were: age < 65 years, white race, and night shift presentation. conclusion: screening for self-harm is uncommon in ed settings, though practices vary dramatically by site. patients presenting at night and on weekends are more likely to be screened, as are those under age 65 and males. current self-harm is more common among those presenting on night shift, those under age 65, and whites. results: there were 1328 out-of-hospital records reviewed, and hospital discharge data were available in 1120 non-cardiac arrest patients. of the 1120 patients, 1084 (96.8%) patients survived to hospital discharge and 36 (3.2%) died during hospitalization. the mean age of those transported was 54 years (sd20), 612 (55%) were male, 128 (11%) were trauma-related, and 112 (10%) were admitted to the icu. average systolic blood pressure (sbp), pulse (p), respiratory rate (rr), oxygen saturation (o 2 sat), and end-tidal carbon dioxide (etco 2 ) were sbp = 141 (sd29), p = 95 (sd25), rr = 24 (sd9), o 2 sat = 95% (sd8), and etco 2 = 34 (sd10 conclusion: of all the initial vital signs recorded in the out-of-hospital setting, etco 2 was the most predictive of mortality. these findings suggest that pre-hospital etco 2 is a useful clinical tool for determining severity of illness and appropriate triage. background: the prehospital use of continuous positive airway pressure (cpap) ventilation is a relatively new management for acute cardiogenic pulmonary edema (acpe) and there is little high quality evidence on the benefits or potential dangers in this setting. objectives: the aim of this study was to determine whether patients in severe respiratory distress treated with cpap in the prehospital setting have a lower mortality than those treated with usual care. methods: randomized, controlled trial comparing usual care versus cpap (whisperflowò) in a prehospital setting, for adults experiencing severe respiratory distress, with falling respiratory efforts, due to a presumed acpe. patients were randomised to receive either usual care, including conventional medications (nitrates, furosemide, and oxygen) plus bag-valve-mask ventilation, versus conventional medications plus cpap. the primary outcome was prehospital or in-hospital mortality. secondary outcomes were need for tracheal intubation, length of hospital stay, change in vital signs, and arterial blood gas results. we calculated relative risk with 95% cis. results: fifty patients were enrolled with mean age 79ae8 (sd 11ae9), male 56ae0%, mortality 20ae0%. the risk of death was significantly reduced in the cpap arm with mortality 34ae6% (9 deaths) in the usual care arm compared to 4ae2% (1 death) in the cpap arm (rr, 0ae12; 95% ci 0ae02 to 0ae88; p = 0ae04). patients who received cpap were significantly less likely to have respiratory acidosis (mean difference in ph 0ae09; 95% ci 0ae01 to 0ae16; p = 0ae02; n = 24) than patients receiving usual care. the length of hospital stay was significantly less in the patients who received cpap (mean difference 2ae3 days; 95% ci )0ae01 to 4ae6, p = 0ae05). conclusion: we found that cpap significantly reduced mortality, respiratory acidosis, and length of hospital stay for patients in severe respiratory distress caused by acpe. this study shows the use of cpap for acpe improves patient outcomes in the prehospital setting. (originally submitted as a ''late-breaker.'') trial reg. anzctr actrn12609000410257; funding fisher and paykal suppliers of the whisperflowò cpap device. background: because emergency service utilization continues to climb, validated methods to safely identify and triage low-acuity patients to either alternate care destinations or a complaint-appropriate level of ems response is of keen interest to ems systems and potentially payers. though the literature generally supports the medical priority dispatch system (mpds) as a tool to predict low-acuity patients by various standards, correlation with initial patient physiologic data and patient age is novel. objectives: to determine whether the six mpds priority determinants for protocol 26 (sick person) can be used to predict initial ems patient acuity assessment or severity of an aggregate physiologic score. our longterm goal is to determine whether mpds priority can be used to predict patient acuity and potentially send only a first responder to do an in-person assessment to confirm this acuity, while reserving als transport resources for higher acuity patients. methods: calls dispatched through the wichita-sedgwick county 9-1-1 center between july 20, 2009 and october 1, 2011 using mpds protocol 26 (sick person) were linked to the ems patient care record for all patients 14 and older. the six mpds priority determinants were evaluated for correlation with initial ems acuity code, initial vital signs, rapid acute physiology score (raps), or patient age. the ems acuity code scores patients from low to severe acuity, based on initial ems assessment. results: there were 9370 calls dispatched using protocol 26 for those 14 years of age and older during the period, representing approximately 13% of all ems calls. there is a significant difference in the first encounter vital signs among different mpds priority levels. based on the logistic regression model, the mpds priority code alone had a sensitivity of 68% and specificity of 55% for identifying low-acuity patients with ems acuity score as the standard. the area under the curve (auc) for roc is 0.62 for mpds priority codes alone, while addition of age increases this value to 0.69. if we use the raps score as the standard to the mpds priority code, auc is 0.528. if we include both mpds and age in the model, the auc is 0.533. conclusion: in our system, mpds priority codes on protocol 26 (sick person) alone, or with age or raps score, are not useful either as predictors of patient acuity on ems arrival or to reconfigure system response or patient destination protocols. alternate ambulance destination program c. nee-kofi mould-millman 1 , tim mcmahan 2 , michael colman 2 , leon h. haley 1 , arthur h. yancey 1 1 emory university, atlanta, ga; 2 grady ems, atlanta, ga background: low-acuity patients calling 9-1-1 are known to utilize a large proportion of ems and ed resources. the national association of ems physicians and acep jointly support ems alternate destination programs (adps) in which low-acuity patients are allocated alternative resources non-emergently. analysis of one year's adp data from our ems system revealed that only 4.5% of eligible patients were transported to alternate destinations (ambulatory clinics). reasons for this low success rate need investigation. objectives: to survey emts and discover the most frequent reasons given by them for transportation of eligible patients to eds instead of to clinics. methods: this study was conducted within a large, urban, hospital-based ems system. upon conducting an adp for 12 months, a paper-based survey was created and pre-tested. all medics with any adp-eligible patient contact were included. emts were asked about personal, patient, and system related factors contributing to ed transport during the last 3 months of the adp. qualitative data were coded, collated, and descriptively reported. results: sixty-three respondents (26 emt-intermediates and 37 emt-paramedics) completed the survey, representing 79% of eligible emts. thirty-one emts (49%) responded that they did not attempt to recruit eligible patients into the adp in the last 3 program months. of those emts, 25 (81%) attributed their motive to multiple, prior, failed recruitment attempts. the 32 emts who actively recruited adp patients were asked reasons given by patients for clinic transport refusals: 19 (60%) cited that patients reported no prior experience of care at the participating clinics, and 23 (72%) reported patients had a strong preference for care in an ed. regarding system-related factors contributing to non-clinic transport, 24 of the 32 emts (75%) reported that clinic-consenting patients were denied clinic visits, mostly because of non-availability of same-day clinic appointments. conclusion: respondents indicated that poor emt enrollment of eligible patients, lack of available clinic time slots, and patient preference for ed care were among the most frequent reasons contributing to the low success rate of the adp. this information can be used to enhance the success of this, and potentially other adp programs, through modifications to adp operations and improved patient education. the effect of a standardized offline pain treatment protocol in the prehospital setting on pediatric pain treatment brent kaziny 1 , maija holsti 1 , nanette dudley 1 , peter taillac 1 , hsin-yi weng 1 , kathleen adelgais 2 1 university of utah, school of medicine, salt lake city, ut; 2 university of colorado, school of medicine, aurora, co background: pain is often under treated in children. barriers include need for iv access, fear of delayed transport, and possible complications. protocols to treat pain in the prehospital setting improve rates of pain treatment in adults. the utah ems for children (emsc) program developed offline pediatric protocol guidelines for ems providers, including one protocol that allows intranasal analgesia delivery to children in the prehospital setting. objectives: to compare the proportion of pediatric patients receiving analgesia for orthopedic injury by prehospital providers before and after implementation of an offline pediatric pain treatment protocol. methods: we conducted a retrospective study of patients entered into the utah prehospital on-line active reporting information system (polaris, a database of statewide ems cases) both before and after initiation of the pain protocol. patients were included if they were age 3-17 years, with a gcs of 14-15, an isolated extremity injury, and were transported by an ems agency that had adopted the protocol. pain treatment was compared for 2 years before and 18 months after protocol implementation with a wash-out period of 12 months for agency training. the difference in treatment proportions between the two groups was analyzed and 95% cis were calculated. results: during the two study periods, 1155 patients met inclusion criteria. patient demographics are outlined in the table. 93/501 (18.6%) patients were treated for pain before compared to 174/654 (26.6%) patients treated after the pain protocol was implemented; a difference of 8.0% (95% ci: 3.2%-12.8%). patients were more likely to receive pain medication if they had a pain score documented (or: 1.16; 95% ci: 1.09-1.22) and if they were treated after the implementation of a pain protocol (or: 1.27; 95% ci: 1.00-1.62). factors not associated with the treatment of pain include age, sex, and mechanism of injury. conclusion: the creation and adoption of statewide emsc pediatric offline protocol guideline for pain management is associated with a significant increase in use of analgesia for pediatric patients in the prehospital setting. background: evidence-based guidelines are needed to determine the appropriate use of air medical transport, as few criteria currently used predict the need for air transport to a trauma center. we previously developed a clinical decision rule (cdr) to predict mortality in injured, helicopter-transported patients. objectives: this study is a prospective validation of the cdr in a new population. methods: a prospective, observational cohort analysis of injured patients ( ‡16 y.o.) transported by helicopter from the scene to one of two level i trauma centers. variables analyzed included patient demographics, diagnoses, and clinical outcomes (in-hospital mortality, emergent surgery w/in 24 hrs, blood transfusion w/in 24 hrs, icu admit greater than 24 hrs, combined outcome of all). prehospital variables were prospectively obtained from air medical providers at the time of transport and included past medical history, mechanism of injury, and clinical factors. descriptive statistics compared those with and without the outcomes of interest. the previous cdr (age ‡ 45, gcs £ 13, sbp < 90, flail chest) was prospectively applied to the new population to determine its accuracy and discriminatory ability. results: 416 patients were transported from october 2010-august 2011. the majority of patients were male (59%), white (79%), with an injury occurring in a rural location (60%). most injuries were blunt (95%) with a median iss of 9. overall mortality was 5%. the most common reasons for air transport were: mvc with high risk mechanism (17%), gcs £ 13 (16%), loc >5 minutes (16%), and mvc >20 mph (14%). of these, only gcs £ 13 was significantly associated with any of the clinical outcomes. when applying the cdr, the model had a sensitivity of 100% (81.2%-100%), a specificity of 51.2% (50.6%-51.6%), a npv of 100% (98.1%-100%), and a ppv of 9.9% (8.0%-9.9%) for mortality. the area under the curve for this model was 0.92, suggesting excellent discriminatory ability. conclusion: the air transport decision rule in this study performed with high sensitivity and acceptable specificity in this validation cohort. further external validation in other systems and with ground transported patients are needed in order to improve decision making for the use of helicopter transport of injured patients. background: acute non-variceal upper gastrointestinal (gi) bleeding is a common indication for hospital admission. to appropriately risk-stratify such patients, endoscopy is recommended within 24 hours. given the possibility to safely manage patients as outpatients after endoscopy, risk stratification as part of an emergency department (ed) observation unit (ou) protocol is proposed. objectives: our objective was to determine the ability of an ou upper gi bleeding protocol to identify a lowrisk population, and to expeditiously obtain endoscopy and disposition patients. we also identified rates of outcomes including changes in hemoglobin, abnormal endoscopy findings, admission, and revisits. background: acute uncomplicated pyelonephritis (pyelo) requires no imaging but a ct flank pain protocol (ctfpp) may be ordered to determine if patients with pyelo and flank pain also have an obstructing stone. the prevalence of kidney stone and the characteristics predictive of kidney stone in pyelo patients is unknown. objectives: to determine elements on presentation that predict ureteral stone, as well as prevalence of stone and interventions in patients undergoing ct for pyelo. methods: retrospective study of patients at an academic ed who received a ctfpp scan between 8/05 and 4/09. 5497 ctfpps were identified and 1899 randomly selected for review. pyelo was defined as: positive urine dip for infection and >5 wbc/hpf on formal urinalysis in addition to flank pain/cva tenderness, chills, fever, nausea, or vomiting. patients were excluded for age < 18 y.o., renal disease, pregnancy, urological anomaly, or recent trauma. clinical data (178 elements) were gathered blinded to ct findings; ct results were abstracted separately and blinded to clinical elements. ct findings of hydronephrosis and hyrdroureter (hydro) were used as a proxy for hydro that could be determined by ultrasound prior to ct. patients were categorized into three groups: ureteral stone, no significant findings, and intervention or follow-up required. classification and regression tree analysis was used to determine which variables could identify ureteral stone in this population of pyelo patients. results: out of the 1899 patients, 105 (7.0%) met criteria for pyelo; subjects had a mean age of 39 ± 15.9 and 82% (n = 87) were female. ct revealed 31 (29%, 95% ci = 0.22-0.39) symptomatic stones, and 72 (68%, 95% ci = 0.59-0.76) exams with no significant findings. two patients needed intervention/ follow-up (1%, 95% ci = 0.0052-0.0667), one for perinephric hemorrhage and the other for pancreatitis. hydro was predictive for ureteral stone with an or = 18.4 (95% ci = 6.4-52, p < 0.0001). eleven (35%) ureteral stone patients were admitted and 9 (8%) of them had procedures. of these patients, 100% had ct signs of obstruction, 8 (88%) had hydronephrosis, and 1 (11%) had hydroureter. conclusion: hydronephrosis was predictive of ureteral stone and in-house procedures. prospective study is needed to determine whether ct scan is warranted in patients with pyelonephritis but without hydronephrosis or hydroureter. curative objectives: the specific aim of this analysis was to describe characteristics of patients presenting to the emergency department (ed) at their index diagnosis, and to determine whether emergency presentation precludes treatment with curative intent. methods: we performed a retrospective cohort analysis on a prospectively maintained institutional tumor registry to identify patients diagnosed with crc from 2008-2010. emrs were reviewed to identify which patients presented to the ed with acute symptoms of crc as the initial sign of their illness. the primary outcome variable was treatment plan (curative vs. palliative). secondary outcome variables included demographics, tumor type and location. descriptive statistics were conducted for major variables. chi-squre and fisher's exact tests were used to detect the association between categorical variables. two-sample t-test was used to identify the association between continuous and categorical variables. results: between jan 1 2008 and dec 31 2010, 376 patients were identified at our institution with crc. 214 (57%) were male and 162 (43%) were female, with mean age 60.6; sd: 13.3. thirty-three patients (8.8%) initially presented to the ed, of whom 5 (15.5%) received palliation. of 339 patients who initially presented elsewhere, 69 (20.5%) received palliation. acute ed presentation with crc symptoms did not preclude treatment with curative intent (p = 0.47). patients who presented emergently were more likely to be female (64% vs male 41%; p = 0.01) and older (65 vs. 60; p = 0.02). there was no statistically significant relationship between age, sex, tumor location, or type and treatment approach. conclusion: patients with crc may present to the ed with acute symptoms, which ultimately leads to the diagnosis. emergent presentation of crc does not preclude patients from receiving therapy with curative intent. cannabinoid (or 2.93, , and white blood cell (wbc) count ‡14,000/mm 3 (or 11.35, 95% ci 3.42-37.72). conclusion: age ‡65 years is not associated with need for admission from an ed observation unit. older adults can successfully be cared for in these units. initial temperature, respiratory rate, and pulse were not predictive of admission, but extremely elevated blood pressure was predictive. other relevant predictor variables included comorbidities and elevated wbc count. advanced age should not be a disqualifying criterion for disposition to an ed observation unit. older adult fallers in the emergency department luna ragsdale, cathleen colon-emeric duke university, durham, nc background: approximately 1/3 of community-dwelling older adults experience a fall each year, and 2.2 million are treated in u.s. emergency departments (ed) annually. the ed offers a potential location for identification of high-risk individuals and initiation of fall-prevention services that may decrease both fall rates and resource utilization. objectives: the goal of this study was to: 1) validate an approach to identifying older adults presenting with falls to the ed using administrative data; and 2) characterize the older adult who falls and presents to the ed and determine the rate of repeat ed visits, both fall-related and all visits, after an index fall-related visit. methods: we identified all older adults presenting to either of the two hospitals serving durham county residents during a six month period. manual chart review was completed for all encounters with icd9 codes that may be fall-related. charts were reviewed 12 months prior and 12 months post index visit. descriptive statistics were used to describe the cohort. results: a total of 4452 older adults were evaluated in the ed during this time period; 1714 (55.7%) had an icd9 code for a potentially fall-related injury. of these, record review identified 534 (12%) with a fall from standing height or less. of the fallers, 65.9% of the patients were discharged, 31% were admitted, and 3% were admitted under observation. of those who fell, 38.2% had an ed visit within the previous year. approximately 1/3 (33.3%) of these were fall related. over half (53.4%) of the patients who fell returned to the ed within one year of their index visit. a large proportion (44.4%) of the return visits was fall-related. follow-up with a primary care provider or specialist was recommended in 46% of the patients who were discharged. overall mortality rate for fallers over the year following the index visit was 18%. conclusion: greater than fifty percent of fallers will return to the ed after an index fall, with a large proportion of the visits related to a fall. a large number of these fallers are discharged home with less than fifty percent having recommended follow-up. the ed represents an important location to identify high-risk older adults to prevent subsequent injuries and resource utilization. objectives: we studied whether falls from a standing position resulted in an increased risk for intracranial or cervical injury verses falling from a seated or lying position. methods: this is a prospective observational study of patients over the age of 65 who presented with a chief complaint of fall to a tertiary care teaching facility. patients were eligible for the study if they were over age 65, were considered to be at baseline mental status, and were not triaged to the trauma bay. at presentation, a questionnaire was filled out by the treating physician regarding mechanism and position of fall, with responses chosen from a closed list of possibilities. radiographic imaging was obtained at the discretion of the treating physician. charts of enrolled patients were subsequently reviewed to determine imaging results, repeat studies done, or recurrent visits. all patients were called in follow-up at 30 days to assess for delayed complications related to the fall. data were entered into a standardized collection sheet by trained abstractors. data were analyzed with fisher's exact test and descriptive statistics. this study was reviewed and approved by the institutional review board. results: two-hundred sixty two patients were enrolled during the study period. one-hundred ninety eight of these had fallen from standing and 64 fell from either sitting or lying positions. the mean age for patients was 84 (sd 7.9) for those who fell from standing and 84 (sd 8.4) for those who fell from sitting or lying. there were 6 patients with injuries who fell from standing: three with subdural hematomas, one with a cerebral contusion, one with an osteophyte fracture at c6, and one with an occipital condyle fracture with a chip fracture of c1. there were 2 patients with injuries who fell from a seated or lying position: one with a traumatic subarachnoid hemorrhage and one with a type ii dens fracture. the overall rate of traumatic intracranial or cervical injury in elders who fell was 3%. no patients required surgical intervention. there was no difference in rate of injury between elders who fell from standing versus those who fell from sitting or lying (p = 1). (table) . conclusion: both instruments identify the majority of patients as high-risk which will not be helpful in allocating scarce resources. neither the isar nor the trst can distinguish geriatric ed patients at high or low risk for 1or 3-month adverse outcomes. these prognostic instruments are not more accurate in dementia or lower literacy subsets. future instruments will need to incorporate different domains related to short-term adverse outcomes. background: for older adults, both inpatient and outpatient care involves not only the patient and physician, but often a family member or informal caregiver. they can assist in medical decision making and in performing the patient's activities of daily living. to date, multiple outpatient studies have examined the positive roles family members play during the physician visit. however, there is very limited information on the involvement of the caregiver in the ed and their relationship with the health outcomes of the patient. objectives: to assess whether the presence of a caregiver influences the overall satisfaction, disposition, and outpatient follow-up of elderly patients. we performed a three-step inquiry of patients over 65 years old who arrived to the upenn ed. patients and care partners were initially given a questionnaire to understand basic demographic data. at the end of the ed stay, patients were given a satisfaction survey and followed through 30 days to assess time to disposition, whether the patient was admitted or discharged, outpatient follow-up, and ed revisit rates. chi-square and t-tests were used to examine the strength of differences in the elderly patients' sociodemographics, self-rated health, receiving aid with their instrumental activities of daily living, and number of health problems by accompaniment status. multivariate regression models were constructed to examine whether the presence or absence of caregivers affected satisfaction, disposition, and follow-up. results: overall satisfaction was higher among patients who had caregivers (2.4 points), among patients who felt they were respected by their physician (3.8 points), and had lower lengths of stay (2 hours). patients with caregivers were also more likely to be discharged home (or 2.4) and to follow-up with their regular physician (or 2.1). there was no evidence to suggest caregivers affected the overall rates of revisits back to an ed. conclusion: for older adults, medical care involves not only the patient and physician, but often a family member or an informal care companion. these results demonstrate the positive influence of caregivers on the patients they accompany, and emergency physicians should define ways to engage these caregivers during their ed stay. this will also allow caregivers to participate when needed and can help to facilitate transitions across care settings. background: shared decision making has been shown to improve patient satisfaction and clinical outcomes for chronic disease management. given the presence of individual variations in the effectiveness and side effects of commonly used analgesics in older adults, shared decision making might also improve clinical outcomes in this setting. objectives: we sought to characterize shared decision making regarding the selection of an outpatient analgesic for older ed patients with acute musculoskeletal pain and to examine associations with outcomes. methods: we conducted a prospective observational study with consecutive enrollment of patients age 65 or older discharged from the ed following evaluation for moderate or severe musculoskeletal pain. two essential components of shared decision making, 1) information provided to the patient and 2) patient participation in the decision, were assessed via patient interview at one week using four-level likert scales. results: of 233 eligible patients, 110 were reached by phone and 87 completed the survey. only 25% (21/87) of patients reported receiving 'a lot' of information about the analgesic, and only 21% (18/87) reported participating 'a lot' in the selection of the analgesic. there were trends towards white patients (p = 0.06) and patients with higher educational attainment (p = 0.07) reporting more participation in the decision. after adjusting for sex, race, education, and initial pain severity, patients who reported receiving 'a lot' of information were more likely to report optimal satisfaction with the analgesic than those receiving less information (78% vs. 47%, p < 0.05). after the same adjustments, patients who reported participating 'a lot' in the decision were also more likely to report optimal satisfaction with the analgesic (82% vs. 47%, p < 0.05) and greater reductions in pain scores (mean reduction in pain 4.6 vs. 2.7, p < 0.05) at one week than those who participated less. background: quality of life (qol) measurements have become increasingly important in outcomes-based research and cost-utility analyses. dementia is a prevalent, often unrecognized, geriatric syndrome that may limit the accuracy of patient self-report in a subset of patients. the relationship between caregiver and geriatric patient qol in the emergency department (ed) is not well understood. objectives: to qualify the relationship between caregiver and geriatric patient qol ratings in ed patients with and without cognitive dysfunction. methods: this was a prospective, consecutive patient, cross-sectional study over two months at one urban academic medical center. trained research assistants screened for cognitive dysfunction using the short blessed test and evaluated health impairment using the quality of life-alzheimer's disease (qol-ad) test. when available in the ed, caregivers were asked to independently complete the qol-ad. consenting subjects were non-critically ill, english-speaking, community-dwelling adults over 65 years of age. responses were compared using wilcoxon signed ranks test to assess the relationships between patient and caregiver scores from the qol-ad stratified by normal or abnormal cognitive screening results. significance was defined by p < 0.05. results: patient qol ratings were obtained from 108 patient-caregiver pairs. patients were 51% female, 52% african-american, with a mean age of 76-years, and 58% had abnormal cognitive screening tests. compared with caregivers, cognitively normal patients had no significant qol assessment differences except for questions of energy level and overall mood. on the other hand, cognitively impaired patients differed significantly on questions of energy level and ability to perform household chores with a trend towards significant differences for living setting (p = 0.097) and financial situation (p = 0.057). in each category, the differences reflected a caregiver underestimation of quality compared with the patient's self-rating. conclusion: discrepancies between qol domains and total scores for patients with cognitive dysfunction and their caregivers highlights the importance of identifying cognitive dysfunction in ed-based outcomes research and cost-utility analyses. further research is needed to quantify the clinical importance of the patient-and caregiver-assessed quality of life. background: age is often a predictor for increased morbidity and mortality. however, it is unclear whether old age is a predictor of adverse outcome in syncope. objectives: to determine whether old age is an independent predictor of adverse outcome in patients presenting to the emergency department following a syncopal episode. methods: a prospective observational study was conducted from june 2003 to july 2006 enrolling consecutive adult ed patients (>18 years) presenting with syncope. syncope was defined as an episode of transient loss of consciousness. adverse outcome or critical intervention were defined as gastrointestinal bleeding or other hemorrhage, myocardial infarction/percutaneous coronary intervention, dysrhythmia, alteration in antidysrhythmics, pacemaker/defibrillator placement, sepsis, stroke, death, pulmonary embolus, or carotid stenosis. outcomes were identified by chart review and 30-day follow-up phone calls. results: of 575 patients who met inclusion criteria, an adverse event occurred in 24% of patients. overall, 35% of patients with risk factors had adverse outcomes compared to 1.6% of patients with no risk factors. in particular, 28/127 (22%; 95% ci 16-30%) of patients <65 with risk factors had adverse outcomes, while 85/196 (43%; 95% ci 36-50%) of the elderly with risk factors had adverse outcomes. in contrast, among young people 2/196 (1%; 95% ci 0.04-3.8%) of patients without risk factors had adverse outcomes while 2/56 (3.6%; 95% ci 0.28-13%) of patients ‡65 without risk factors had adverse outcomes. conclusion: although the elderly are at greater risk for adverse outcomes in syncope, age ‡ 65 or older alone does not appear to be a predictor of adverse outcome following a syncopal event. based on these data, it should be safe to discharge home from the ed patients with syncope, but without risk factors, regardless of age. (originally submitted as a ''late-breaker.'') antibiotics background: adherence to national guidelines for hiv and syphilis screening in eds is not routine. in our ed, hiv and syphilis screening rates among patients tested for gonorrhea and chlamydia (gc/ct) have been reported to be 45% and 30%, respectively. objectives: to determine the effect of a sexually transmitted infection (sti) laboratory order set on hiv and syphilis screening among ed patients tested for gc/ct. we hypothesized that a sti order set would increase screening rates by at least 30%. methods: a 6-month, quasi-experimental study in an urban ed comparing hiv and syphilis screening rates of gc/ct-tested patients before (control phase) and after the implementation of a sti laboratory order set (intervention phase). the order set linked blood-based rapid hiv and syphilis screening with gc/ct testing. consecutive patients completing gc/ct testing were included. the primary outcome was the absolute difference in hiv and syphilis screening rates among gc/ ct-tested patients between phases. we estimated that 550 subjects per phase were needed to provide 90% power (p-value of £0.05) to detect an absolute difference in screening rates of 10%, assuming a baseline hiv screening rate of 45%. results: the ed census was 42,461. characteristics of patients tested for gc/ct were similar between phases: the mean age was 33 years (sd = 12) and most were female (65%), black (49%), hispanic (30%), and unmarried (84% services have recommended the use of immunization programs against influenza disease within hospitals since the 1980s. the emergency department (ed) being the ''safety net'' for most non-insured people is an ideal setting to intervene and provide primary prevention from influenza. objectives: the purpose of this study is to assess whether a pharmacist-based influenza immunization program is feasible in the ed, and successful in increasing the percentage of adult patients receiving the influenza vaccine. methods: implementation of pharmacist-based immunization program was developed in coordination with ed physicians and nursing staff in 2010. the nursing staff, using an embedded electronic questionnaire within their triage activity, screened patients for eligibility for the influenza vaccine. the pharmacist using an electronic alert system within the electronic medical record identified patients who we deemed eligible and if agreed the pharmacist vaccinated the patient. patients who refused to be vaccinated were surveyed to ascertain their perception concerning immunization offered by a pharmacist in the ed. feasibility and safety data for vaccinating patient in the ed were recorded. results: 149 patients were approached and enrolled into the study. of the 149, 41% agreed to receive the influenza vaccine from a pharmacist in the ed. the median screening time was 5 minutes and median vaccination time was 3 minutes for a total of 8 minutes from screening time to vaccination time. 74% were willing to receive the influenza vaccine from a pharmacist, and 78% were willing to receive the vaccine in the ed. the main reason given for refusing to receive the influenza vaccine was ''patient does not feel at risk of getting the disease''; only 14.6% stated they were vaccinated recently. conclusion: a pharmacist-based influenza immunization program is feasible in the ed, and has the potential to successfully increase the percentage of adult patients receiving the vaccine. 1.4 ± 0.1, p < 0.05). ed visits by hiv-infected patients also had longer lengths of ed stay (317 ± 26.0 minutes vs. 222.5 ± 5.6 minutes, p < 0.05) and were more likely to be admitted (29% vs. 15%, p < 0.05), than their non-hiv infected counterparts. conclusion: although ed visits by hiv-infected individuals in the u.s. are relatively infrequent, they occur at rates higher than the general population, and consume significantly more ed resources than the general population. the background: the influence of wound age on the risk of infection in simple lacerations repaired in the emergency department (ed) has not been well studied. it has traditionally been taught that there is a ''golden period'' beyond which lacerations are at higher risk of infection and therefore should not be closed primarily. the proposed cutoff for this golden period has been highly variable (3-24 hours in surgical textbooks). objectives: to answer the following research question: are wounds closed via primary repair after the golden period at increased risk for infection? methods: we searched medline, embase, and other databases as well as bibliographies of relevant articles. we included studies that enrolled ed patients with lacerations repaired by primary closure. exclusion: 1. intentional delayed primary repair or secondary closure, 2. wounds requiring intra-operative repair, skin graft, drains, or extensive debridement, and 3. grossly contaminated or infected at presentation. we compared the outcome of wound infection in two groups of early versus delayed presentations (based on the cut-offs selected by the original articles). we used ''grading of recommendations assessment, development and evaluation'' (grade) criteria to assess the quality of the included trials. frequencies are presented as percentages with 95% confidence intervals. relative risk (rr) of infection is reported when clinically significant. results: 418 studies were identified. four trials enrolling 3724 patients in aggregate met our inclusion/exclusion criteria. two studies used a 6-hour cut-off and the other two used a 12-hour cut-off for defining delayed wounds. the overall quality of evidence was low. the infection rate in the wounds that presented with delay ranged from 1.4% to 32%. one study with the smallest sample size (morgan et al), which only enrolled lacerations to the hand and forearm, showed higher rates of infection in patients with delayed wounds (table). the infection rates in delayed wound groups in the remaining three studies were not significantly different from the early wounds. conclusion: the evidence does not support the existence of a golden period, nor does it support the role of wound age on infection rate in simple lacerations. background: although clinical studies in children have shown that temperature elevation is an independent and significant predictor of bacteremia in children, the relationship in adults is largely unknown or equivocal. objectives: review the incidence of positive blood cultures on critically ill adult septic patients presenting to an emergency department (ed) and determine the association of initial temperature with bacteremia. methods: july 2008 to july 2010 retrospective chart review on all patients admitted from the ed to an urban community hospital with sepsis and subsequently expiring within 4 days of admission. fever was defined as a temperature ‡38°c. sirs criteria were defined as: 1) temperature ‡38°c or £36°c, 2) heart rate ‡90 beats/ minute, 3) respiratory rate ‡20 or mechanical ventilation, 4) wbc ‡ 12,000/mm 3 or <4,000 or bands ‡10%. objectives: we examined the utility of limited genetic sequencing of bacterial isolates using multilocus sequence typing (mlst) to discriminate between known pathogenic blood culture isolates of s. epidermidis and isolates recovered from skin. methods: ten blood culture isolates from patients meeting the centers for disease control and prevention (cdc) criteria for clinically significant s. epidermidis bacteremia and ten isolates from the skin of healthy volunteers were studied. mlst was performed by sequencing 400 bp regions of seven genes (arc, aroe, gtr, muts, pyr, tpia, and yqil) . genetic variability at these sites was compared to an international database (www.sepidermidis.mlst.net) and each strain was then categorized into a genotype on the basis of known genetic variation. the ability of the gene sequences to correctly classify strains was quantified using the support vector machine function in the statistical package r. 1,000 bootstrap resamples were performed to generate confidence bounds around the accuracy estimates. results: between-strain variability was considerable, with yqil being most variable (6 alleles) and tpia being least (1 allele). the muts gene, responsible for dna repair in s. epidermidis, showed almost complete separation between pathogenic and commensal strains. when the seven genes were used in a joint model, they correctly predicted bacterial strain type with 90% accuracy (iqr 85, 95%). conclusion: multilocus sequence typing shows excellent early promise as a means of distinguishing contaminant versus truly pathogenic isolates of s. epidermidis from clinical samples. near-term future goals will involve developing more rapid means of sequencing and enrolling a larger cohort to verify assay performance. conference are presented by influenza scenario in table 1 and background: antiviral medications are recommended for patients with influenza who are hospitalized or at high risk for complications. however, timely diagnosis of influenza in the ed remains challenging. influenza rapid antigen tests have short turn-around times, making them potentially useful in the ed setting, but their sensitivities may be too low to assist with treatment decisions. objectives: to evaluate the test characteristics of the binaxnow influenza a&b rapid antigen test (rat) in ed patients. methods: we prospectively enrolled a systematic sample of patients of all ages presenting to two eds with acute respiratory symptoms or fever during three consecutive influenza seasons (2008) (2009) (2010) (2011) . research personnel collected nasal and throat swabs, which were combined and tested for influenza with rt-pcr using cdc-provided primers and probes. ed clinicians independently decided whether to obtain a rat during clinical care. rats were performed in the clinical laboratory using the binaxnow influenza a&b test on nasal swabs collected by ed staff. the study cohort included subjects who underwent both a research pcr and clinical rat. rat test characteristics were evaluated using pcr as the criterion standard with stratified sub-analyses for age group and influenza subtype (pandemic h1n1 (ph1n1), non-pandemic influenza a, influenza b). results: 561 subjects were enrolled; 131 subjects were pcr positive for influenza (76 ph1n1, 20 non-pandemic influenza a, and 35 influenza b). for all age groups, rat sensitivities were low and specificities were high ( hiv infection with cd4 < 200; and among nursing home residents, inability to independently perform activities of daily living. sources for bacterial cultures included blood, sputum (adults only), bronchoalveolar lavage (bal), tracheal aspirate, and pleural fluid. only sputum specimens with a bartlett score ‡1+ were considered adequate for culturing. results: among 461 children enrolled, 7 (2%) had s. aureus cultured from ‡1 specimen, including 5 with methicillin-resistant s. aureus (mrsa) and 2 with methicillin-susceptible s. aureus (mssa). specimens positive for s. aureus included 3 pleural fluid, 2 blood, 2 tracheal aspirates, and 1 bal. two children with s. aureus had evidence of co-infection: 1 influenza a, and 1 streptococcus pneumoniae. among 673 adults enrolled, 17 (3%) grew s. aureus from ‡1 specimen, including 9 with mrsa and 8 with mssa. specimens positive for s. aureus included 5 blood, 11 sputum, and 3 bal. five adults with s. aureus had evidence of co-infections: 2 coronavirus, 1 respiratory syncytial virus, 1 s. pneumoniae, and 1 pseudomonas aeruginosa. presenting clinical characteristics and outcomes of subjects with staphylococcal cap are summarized in tables 1-2. conclusion: these preliminary findings suggest s. aureus is an uncommon cause of cap. although the small number of staphylococcal cases limits conclusions that can be drawn, in our analysis staphylococcal cap appears to be associated with co-infections, pleural effusions, and severe disease. future work will focus on continued enrollment and developing clinical prediction models to aid in diagnosing staphylococcal cap in the ed. background: emergency care has been a neglected public health challenge in sub-saharan africa. the goal of global emergency care collaborative (gecc) is to develop a sustainable model for emergency care delivery in low-resource settings. gecc is developing a training program for emergency care practitioners (ecps). objectives: to analyze the first 500 patient visits at karoli lwanga ''nyakibale'' hospital ed in rural uganda to determine the knowledge and skills needed in training ecps. methods: a descriptive cross-sectional analysis of the first 500 consecutive patient visits in the ed's patient care log was reviewed by an unblinded abstractor. data on demographics, procedures, laboratory testing, bedside ultrasounds (us) performed, radiographs (xrs) ordered, and diagnoses were collated. all authors discussed uncertainties and formed a consensus. descriptive statistics were performed. results: of the first 500 patient visits, procedures were performed in 367 (73.4%) patients, including 244 (48.8%) who had ivs placed, 47 (9.4%) who received wound care, and 42 (8.4%) who received sutures. complex procedures, such as procedural sedations, lumbar punctures, orthopedic reductions, nerve blocks, and tube thoracostomies, occurred in 49 (9.8%) patients. laboratory testing, xrs, and uss were performed in 188,(37.6%), 99 (19.8%), and 45 (7%) patients, respectively. infectious diseases were diagnosed in 217 (43.4%) patients; 78 (15.6 %) with malaria and 57 (11.4%) with pneumonia. traumatic injuries were present in 140 (28%) patients; 77 (15.4%) needing wound care and 31 (6.2%) with fractures. gastrointestinal and neurological diagnoses affected 58 (11.6%) and 27 (5.4%) patients, respectively. conclusion: ecps providing emergency care in sub-saharan africa will be required to treat a wide variety of patient complaints and effectively use laboratory testing, xrs, and uss. this demands training in a broad range of clinical, diagnostic, and procedural skills, specifically in infectious disease and trauma, the two most prevalent conditions seen in this rural sub-saharan africa ed. assessment of point-of-care ultrasound in tanzania background: current chinese ems is faced with many challenges due to a lack of systematic planning, national standards in training, and standardized protocols for prehospital patient evaluation and management. objectives: to estimate the frequency with which prehospital care providers perform critical actions for selected chief complaints in a county-level ems system in hunan province, china. methods: in collaboration with xiangya hospital (xyh), central south university in hunan, china, we collected data pertaining to prehospital evaluation of patients on ems dispatches from a ''1-2-0'' call center over a 2-month period. this call center services an area of just under 5000 km 2 with a total population of 1.36 million. each ems team consists of a driver, a nurse, and a physician. this was a cross-sectional study where a single trained observer accompanied ems teams on transports of patients with a chief complaint of chest pain, dyspnea, trauma, or altered mental status. in this convenience sample, data were collected daily between 8 am and 6 pm. critical actions were pre-determined by a panel of emergency medicine faculty from xyh and the university of maryland school of medicine. simple statistical analysis was performed to determine the frequency of critical actions performed by ems providers. results: during the study period, 1170 patients were transported, 452 of whom met the inclusion criteria. 218 (48.2%) evaluations were observed directly for critical actions. the table shows the frequency of critical actions performed by chief complaint. none of the patients with chest pain received an ecg even though the equipment was available. rapid glucose was checked in only 2.1% of patients presenting with altered mental status. a lung exam was performed in 22.7% of patients with dyspnea, and the respiratory rate was measured in 9.1%. among patients transported for trauma, blood pressure, and heart rate were only measured in 1% and 4.1%, respectively. conclusion: in this observation study of prehospital patient assessments in a county-level ems system, critical actions were performed infrequently for the chief complaints of interest. performance frequencies for critical actions ranged from 0 to 22.7%, depending on the chief complaint. standardized prehospital patient care protocols should be established in china and further training is needed to optimize patient assessment. trends little is known about the comparative effectiveness of noninvasive ventilation (niv) versus invasive mechanical ventilation (imv) in chronic obstructive pulmonary disease (copd) patients with acute respiratory failure. objectives: to characterize the use of niv and imv in copd patients presenting to the emergency department (ed) with acute respiratory failure and to compare the effectiveness of niv vs. imv. methods: we analyzed the 2006-2008 nationwide emergency department sample (neds), the largest, all-payer, us ed and inpatient database. ed visits for copd with acute respiratory failure were identified with a combination of copd exacerbation and respiratory failure icd-9-cm codes. patients were divided into three treatment groups: niv use, imv use, and combined use of niv and imv. the outcome measures were inpatient mortality, hospital length of stay (los), hospital charges, and complications. propensity score analysis was performed using 42 patient and hospital characteristics and selected interaction terms. results: there were an estimated 101,000 visits annually for copd exacerbation and respiratory failure from approximately 4,700 eds. ninety-six percent were admitted to the hospital. of these, niv use increased slightly from 14% in 2006 to 16% in 2008 (p = 0.049), while imv use decreased from 28% in 2006 to 19% in 2008 (p < 0.001); the combined use remained stable (4%). inpatient mortality decreased from 10% in 2006 to 7% in 2008 (p < 0.001). niv use varied widely between hospitals, ranging from 0% to 100% with median of 11%. in a propensity score analysis, niv use (compared to imv) significantly reduced inpatient mortality (risk ratio 0.57; 95% confidence interval [ci] 0.48-0.56), shortened hospital los (difference )3 days; 95%ci )4 to )3), and reduced hospital charges 044; 855) . niv use was associated with a lower rate of iatrogenic pneumothorax compared with imv use (0.04% vs. 0.6%, p < 0.001). an instrumental analysis confirmed the benefits of niv use, with a 5% reduction in inpatient mortality in the niv-preferring hospitals. conclusion: niv use is increasing in us hospitals for copd with acute respiratory failure; however, its adoption remains low and varies widely between hospitals. niv appears to be more effective and safer than imv in the real-world setting. background: dyspnea is a common ed complaint with a broad differential diagnosis and disease-specific treatment. bronchospasm alters capnographic waveforms, but the effect of other causes of dyspnea on waveform morphology is unclear. objectives: we evaluated the utility of capnographic waveforms in distinguishing dyspnea caused by reactive airway disease (rad) from non-rad in adult ed patients. methods: this was a prospective, observational, pilot study of a convenience sample of adult patients presenting to the ed with dyspnea. waveforms, demographics, past medical history, and visit data were collected. waveforms were independently interpreted by two blinded reviewers. when the interpreters disagreed, the waveform was re-reviewed by both reviewers and an agreement was reached. treating physician diagnosis was considered the criterion standard. descriptive statistics were used to characterize the study population. diagnostic test characteristics and inter-rater reliability are given. results: fifty subjects were enrolled. median age was 52 years (range 21-82), 50% were female, 34% were caucasian. 29/50 (58%) had a history of asthma or chronic obstructive pulmonary disease. rad was diagnosed by the treating physician in 19/50 (38%) and 32/50 (64%) had received treatment for dyspnea prior to waveform acquisition. the interpreters agreed on waveform analysis in 47/50 (94%) cases (kappa = 0.88). test characteristics for presence of acute rad, including 95%ci, were: overall accuracy 70% (55.2%-81.7%), sensitivity 69% (43.5%-86.4%), specificity 71% (51.8%-85.1%), positive predictive value 59% (36.7%-78.5%), negative predictive value 79% (58.5%-91.0%), positive likelihood ratio 2.25 (1.36-3.72) , negative likelihood ratio 0.42 (0.23-0.74). conclusion: inter-rater agreement is high for capnographic waveform interpretation, and shows promise for helping to distinguish between dyspnea caused by rad and dyspnea from other causes in the ed. treatments received prior to waveform acquisition may affect agreement between waveform interpretation and physician diagnosis, affecting the observed test characteristics. asthma background: asthma and chronic obstructive pulmonary disease (copd) patients who present to the emergency department (ed) usually lack adequate ambulatory disease control. while evidence-based care in the ed is now well defined, there is limited inform-ation regarding the pharmacologic or non-pharmacologic needs of these patients at discharge. objectives: this study evaluated patients' needs with regard to the ambulatory management of their respiratory conditions after ed treatment and discharge. methods: over 6 months, 94 adult patients with acute asthma or copd, presenting to a tertiary care alberta hospital ed and discharged after being treated for exacerbations, were enrolled. using results from standardized in-person questionnaires, charts were reviewed by respiratory researchers to identify care gaps. results: overall, 58 asthmatic and 36 copd patients were enrolled. more patients with asthma required education on spacer devices (52% vs 31%). few asthma (9%) and no copd patients had written action plans; asthma patients were more likely to need adherence counseling (53% vs 36%) for preventer medications. more patients with asthma required influenza vaccination (72% vs 39%; p = 0.003); pneumococcal immunization was low (36%) in copd patients. only 22% of asthmatics reported ever being referred to an asthma education program and 19% of the copd patients reported ever being referred to pulmonary rehabilitation. at ed presentation, 28% of the asthmatics required the addition of inhaled corticosteroids (ics) and 16% required the addition of ics/long acting beta-agonist (ics/laba) combination agents. on the other hand, 36% of copd patients required the addition of long-acting anticholinergics while most (83%) were receiving preventer medications. finally, 31% of copd and 29% of asthma patients who smoked required smoking cessation counseling. conclusion: overall, we identified various care gaps for patients presenting to the ed with asthma and copd. there is an urgent need for high-quality research on interventions to reduce these gaps. methods: this is an interim, sub-analysis of an interventional, double-blinded study performed in an academic urban-based adult ed. subjects with acute exacerbation of asthma with fev1 < 50% predicted within 30 minutes following initiation of ''standard care'' (including a minimum of 5 mg nebulized albuterol, 0.5 mg nebulized ipratropium, and 50 mg corticosteroid) who consented to be in a trial were included. all treatment was administered by emergency physicians unaware of the study objectives. patients were randomly assigned to treatment with placebo or an intravenous beta agonist. all subjects had fev1 and ds obtained at baseline, 1, 2, and 3 hours after treatment. fev1 was measured using a bedside nspire spirometer, and ds was calculated using a modified borg dyspnea score. results: thirty-eight patients were included for analysis. spearman's rho test (rho) was used to measure correlations between fev1 and ds at 1, 2, and 3 hours post study entry and subsequent hospitalization. rho is negative for fev1 (higher fev1 correlates to lower rate of hospitalization) and positive for ds (higher ds correlates to higher rate of hospitalization). at each time point, ds were more highly correlated to hospitalization than were fev1 (see table) . conclusion: dyspnea score at 1, 2, and 3 hours were significantly correlated with hospital admission, whereas fev1 was not. in this set of subjects with moderate to severe asthma exacerbations, a standardized subjective tool was superior to fev1 for predicting subsequent hospitalization. methods: this is an interim, subgroup analysis of a prospective, interventional, double-blind study performed in an academic urban ed. subjects who were consented for this trial presented with acute asthma exacerbations with fev1 £ 50% predicted within 30 minutes following initiation of ''standard care'' (includes a minimum of 2.5 mg nebulized albuterol, 0.5 mg nebulized ipratropium, and 50 mg of a corticosteroid). ed physicians who were unaware of the study objectives administered all treatments. subjects were randomized in a 1:1 ratio to either placebo or investigational intravenous beta agonist arms. blood was obtained at 1 and 1.25 hours after the start of the hour long infusion. blood was centrifuged and serum stored at )80°c, and then shipped on dry ice for albuterol and lactate measurements at a central lab. the treatment lactate and d lactate were correlated with 1 hr serum albuterol concentrations and hospital admission using partial pearson correlations to adjust for ds. results: 38 subjects were enrolled to date, 20 with complete data. the mean baseline serum lactate level was 18.1 mg/dl (sd ± 8.6). this increased to 32.7 mg/ dl (sd ± 15.0) at 1.25 hrs. the mean 1 hr ds was 3.85 (sd ± 2.0). the correlations between treatment lactate, d lactate, 1 hr serum albuterol concentrations (r, s and total) and admission to hospital are shown (see table) . both treatment and d lactate were highly conrrelated with total serum albuterol, r albuterol, and s albuterol. there was no correlation between treatment lactate or d lactate and hospital admission. conclusion: lactate and d lactate concentrations correlate with albuterol concentrations in patients presenting had asthma. fifty one percent were <21 years old and 54% were female. we found a decline of 27% (95% ci: 23%-30%, p < 0.0001; r 2 = 0.73, p < 0.0001) in the overall yearly asthma visits to total ed visits from 1996 to 2010. when we analyzed sex and age groups separately, we found no statistically significant changes for females or for males <21 years old (r 2 £ 0.016, p ‡ 0.65). for females and males >21 years old, yearly asthma visits to total ed visits from 1996 to 2010 decreased 39% (95% ci: 33%-43%, p < 0.0001; r 2 = 0.90, p < 0.0001) and 20% (95% ci: 14%-26%, p < 0.0001; r 2 = 0.80, p < 0.0001), respectively. conclusion: we found an overall decrease in yearly asthma visits to total ed visits from 1996 to 2010. we speculate that this decrease is due to greater corticosteroid use despite the increasing prevalence of asthma. it is unclear why this decrease was seen in adults and not in children and why it was greater for adult females than males. objectives: our objectives were to describe the use of a unique data collection system that leveraged emr technology and to compare its data entry error rate to traditional paper data collection. methods: this is a retrospective review of data collection methods during the first 12 months of a multicenter study of ed, anti-coagulated, head injury patients. on-shift ed physicians at five centers enrolled eligible patients and prospectively completed a data form. enrolling ed physicians had the option of completing a one-page paper data form or an electronic ''dotphrase'' (dp) data form. our hospital system uses an epicòbased emr. a feature of this system is the ability to use dps to assist in medical information entry. a dp is a preset template that may be inserted into the emr when the physician types a period followed by a code phrase (in this case ''.ichstudy''). once the study dp was inserted at the bottom of the electronic ed note, it prompted enrolling physicians to answer study questions. investigators then extracted data directly from the emr. our primary outcomes of interest were the prevalence of dp data form use and rates of data entry errors. results: from 7/2009 through 8/2010, 883 patients were enrolled. dp data forms were used in 288 (32.6%; 95% ci 29.5, 35.7%) cases and paper data forms in 595 (67.4%; 95% ci 64.3, 70.5%). the prevalence of dp data form use at the respective study centers was 11%, 16%, 18%, 31%, and 85%. sixty-six (43.7 %; 95% ci 35.8, 51.6%) of 151 physicians enrolling patients used dp data entry at least once. using multivariate analysis, we found no significant association between physician age, sex, or tenure and dp use. data entry errors were more likely on paper forms (234/595, 39.3%; 95% ci 35.4, 43.3%) than dp data forms (19/288, 6.6%; 95% ci 3.7, 9.5%), difference in error rates 32.7% (95% ci 27.9, 37.6%, p < 0.001). conclusion: dp data collection is a feasible means of study data collection. dp data forms maintain all study data within the secure emr environment obviating the need to maintain and collect paper data forms. this innovation was embraced by many of our emergency physicians. we found lower data entry error rates with dp data forms compared to paper forms. background: inadequate randomization, allocation concealment, and blinding can inflate effect sizes in both human and animal studies. these methodological limitations might in part explain some of the discrepancy between promising results in animal models and non-significant results in human trials. whereas blinding is not always possible, in clinical or animal studies, true randomization with allocation concealment is always possible, and may be as important in minimizing bias. objectives: to determine the frequency with which published emergency medicine (em) animal research studies report randomization, specific randomization methods, allocation concealment, and blinding of interventions and measurements, and to estimate whether these have changed over time. methods: all em animal research publications from 1/ 2000 through 12/2009 in ann emerg med and acad emerg med were reviewed by two trained investigators for a statement regarding randomization, and specific descriptions of randomization methods, allocation concealment, blinding of intervention, and blinding of measurements, when possible. raw initial agreement was calculated and differences were settled by consensus. the first (period 1 = 2000-2004) and second (period 2 = 2005-2009) 5-year periods were compared with 95% confidence intervals. results: of 117 em animal research studies, 109 were appropriate for review because they involved intervention in at least two groups. blinding of interventions and measurements were not considered possible in 37% and 3%, respectively. significant differences between period 1 and 2 were absent, although there was a trend towards less blinding of interventions and more blinding of measurements. raw agreement was 91%. conclusion: although randomization is mentioned in the majority of studies, allocation concealment and blinding remain underutilized in em animal research. we did not compare outcomes between blinded and non-blinded, randomized and non-randomized studies, because of small sample size. this review fails to demonstrate significant improvement over time in these methodological limitations in em animal research publications. journals might consider requiring authors to explicitly describe their randomization, allocation, and blinding methods. background: cluster randomized trials (crts) are increasingly utilized to evaluate quality improvement interventions aimed at health care providers. in trials testing ed interventions, migration of eps between hospitals is an important concern, as contamination may affect both internal and external validity. objectives: we hypothesized geographically isolating emergency departments would prevent migratory contamination in a crt designed to increase ed delivery of tpa in stroke (the instinct trial). methods: instinct was a prospective, cluster-randomized, controlled trial. twenty-four michigan community hospitals were randomly selected in matched pairs for study. following selection of a single hospital, all hospitals within 15 miles were excluded from the sample pool. individual emergency physicians staffing each site were identified at baseline (2007) and 18 months later. contamination was defined at the cluster level, with substantial contamination defined a priori as >10% of eps affected. non-adherence, total crossover (contamination + non-adherence), migration distance and characteristics were determined. results: 307 emergency physicians were identified at all sites. overall, 7 (2.3%) changed study sites. one moved between control sites, leaving 6 (2.0%) total crossovers. of these, 2 (0.7%) moved from intervention to control (contamination) and 4 (1.3%) moved from control to intervention (non-adherence). contamination was observed in 2 of 24 sites, with 17% and 9% contamination of the total site ep workforce at follow-up, respectively. two of 6 crossovers occurred between hospitals within the same health system. average migration distance was 42 miles for all eps in the study and 35 miles for eps moving from intervention to control sites. conclusion: the mobile nature of emergency physicians should be considered in the design of quality improvement crts. use of a 15-mile exclusion zone in hospital selection for this crt was associated with very low levels of substantial cluster contamination (1 of 24) and total crossover. assignment of hospitals from a single health system to a single study group and/or an exclusion zone of 45 miles would have further reduced crossovers. increased reporting of contamination in cluster randomized controlled trials is encouraged to clarify thresholds and facilitate crt design. objectives: an extension of the lr, the average absolute likelihood ratio (aalr), was developed to assess the average change in the odds of disease that can be expected from a test, or series of tests, and an example of its use to diagnose wide qrs complex tachycardia (wct) is provided. methods: results from two retrospective multicenter case series were used to assess the utility of qrs duration and axis to assess for ventricular tachycardia (vt) in patients with undifferentiated regular sustained wct. serial patients with heart rate (hr) >120 beats per minute and qrs duration >120 milliseconds (msec) were included. the final tachydysrhythmia diagnosis was determined by a number of methods independent of the ecg. the aalr is defined as: aalr = 1/n total [r (n i *lr i ) (for lr > 1) + r (n k /lr k ) (for lr < 1)], where lr i and lr k are the interval lrs, and n i and n k are the number of patients with test results within the corresponding intervals. roc curves were constructed, and interval lrs and aalrs were calculated for the qrs duration and axis tests individually, and when applied together. confidence intervals were bootstrapped with 10,000 replications using the r boot package. results: 187 patients were included: 95 with supraventricular tachycardia (svt) and 92 with vt. optimal qrs intervals (msec) for distinguishing vt from svt were: qrs £ 130, 130 < qrs < 160, and qrs ‡ 160. qrs axis results were dichotomized to upward right axis (181-270 degrees) or not ()89 to 180 degrees). results are listed in the table. conclusion: application of the qrs interval and axis tests together for patients with wide qrs complex tachycardia changes the odds of ventricular tachycardia, on average, by a factor of 3.5 (95% ci 2.4 to 6.2), and this is mildly improved over the qrs duration test alone. both a strength and weakness of the aalr is its dependence on the pretest probability of disease. the aalr may be helpful for clinicians and researchers to evaluate and compare diagnostic testing approaches, particularly when strategies with serial non-independent tests are considered. consultation for adults with metastatic solid tumors at an urban, academic ed located within a tertiary care referral center. field notes were grouped into barrier categories and then quantified when possible. patient demographics for those who did and did not enroll were extracted from the medical record and quantified. patients who did not meet inclusion criteria for the study (e.g., cognitive impairment) were excluded from the analysis. results: attempts were made to enroll 42 eligible patients in the study, and 23 were successfully enrolled (55% enrollment rate). barriers to enrollment were deduced from the field notes and placed into the following categories from most to least common: patient refusal (6); diagnostic uncertainty regarding cancer stage (4); severity of symptoms preclude participation (4); patient unaware of illness or stage (3); and family refusal (2). conclusion: patients, families, and diagnostic uncertainty are barriers to enrolling ed patients with advanced illness in clinical trials. it is unclear whether these barriers are generalizable to other study sites and disease processes other than cancer. objectives: the purpose of this study was to evaluate the use of a high-fidelity mannequin bedside simulation scenario followed by a debriefing session as a tool to improve medical student knowledge of palliative care techniques. methods: third year medical students participating in a 12-week simulation curriculum during a surgery/ emergency medicine/anesthesia clerkship were eligible for the study. all students were administered a pretest to evaluate their baseline knowledge of palliative care and randomized to a control or intervention group. during week 3 or 4, students in the intervention group participated in and observed two end-of-life scenarios. following the scenarios, a faculty debriefer trained in palliative care addressed critical actions in each scenario. during week 10, all students received a posttest to evaluate for improvement in knowledge. the pre-test and post-test consisted of 12 questions addressing prognostication, symptom control, and the medicare hospice benefit. students were de-identified and pre-and post-tests were graded by a blinded scorer. results: from jan-dec 2011, 70 students were included in the study and 5 were excluded due to incomplete data. the mean score on the pre-test for the intervention group was 3.16, and for the control group was 3.45 (p = 0.90 the results indicate that educators identify the most important scenarios as protocol-based simulations. respondents also suggested that scenarios of very common emergency department presentations bear a great deal of importance. emergency medicine educators assign priority to simulations involving professionalism and communication. finally, many respondents noted that they use simulation to teach the presentation and management of rare or less frequent, but important disease processes. the identification of these scenarios would suggest that educators find simulation useful for filling in ''gaps'' in resident education. background: prescription drug misuse is a growing problem among adolescent and young adult populations. objectives: to determine factors associated with past year prescription drug misuse defined as using prescription sedatives, stimulants, or opioids to get high, taking them when they were prescribed to someone else or taking more than was prescribed among patients seeking care in an academic ed. methods: adolescents and young adults (14-20) presenting for ed care at a large, academic teaching hospital were approached to complete a computerized screening questionnaire regarding demographics, prescription drug misuse, illicit drug use, alcohol use, and violence in the past 12 months. logistic regression was used to predict past year prescription drug misuse. results: over the study time period, there were 2156 participants (86% response rate) of whom 300 (13.9%) endorsed past year prescription drug misuse. specifically, rates of past year misuse for opioids was 8.7%, sedatives was 5.4%, and stimulants was 8.0%. significant overlap exists among classes with over 40% misusing more than one class of medications. in the multivariate analysis significant predictors of past year prescription drug misuse included female gender (or conclusion: approximately one in seven adolescents or young adults seeking ed care have misused prescription drugs in the past year. while opioids are the most common drug misused, significant overlap exists among this population. given the correlation of prescription drug misuse with the use and misuse of other substances (i.e. alcohol, cough medicine, marijuana) more research is needed to further understand these relationships and inform interventions. additionally, future research should focus on understanding the differences in demographics and risk factors associated with misuse of each separate class of prescription drugs. prospective 10 objectives: this study aims to examine the association of depression with high ed utilization in patients with non-specific abdominal pain. methods: this single-center, prospective, cross-sectional study was conducted in an urban academic ed located in washington, dc as part of a larger study to evaluate the interaction between depression and frequency of ed visits and chronic pain. as part of this study, we screened patients using the phq-9, a nineitem questionnaire that is a validated, reliable predictor of major depressive disorder. we analyzed the subset of respondents with a non-specific abdominal pain diagnosis (icd-9 code of 789.xx). our principal outcome of interest was the rate of a positive depression screen in patients with non-specific abdominal pain. we analyzed the prevalence of a positive depression screen among this group and also conducted a chi-square analysis to compare high ed use among abdominal pain patients with a positive depression screen versus those without a positive depression screen. we defined high ed utilization as >3 visits in a 364-day period prior to the enrollment visit. background: numerous studies have found high rates of co-morbid mental illness and chronic pain in emergent care settings. one psychiatric diagnosis frequently associated with chronic pain is major depressive disorder (mdd). objectives: we conducted a study to characterize the relationship between mdd and chronic pain in the emergency department (ed) population. we hypothesized that patients who present to the ed with selfreported chronic pain will have higher rates of mdd. methods: this was a single-center, prospective, crosssectional study. we used a convenience sample of noncritically ill, english speaking adult patients presenting with non-psychiatric complaints to an urban academic ed over 6 months in 2011. we oversampled patients presenting with pain-related complaints (musculoskeletal pain or headache). subjects were surveyed about their demographic and other health and health care characteristics and were screened with the phq 9, a nine-item questionnaire that is a validated, reliable predictor of mdd. we conducted bivariate (chi-square) and multivariate analysis controlling for demographic characteristics (race, income, sex, age) using stata v. 10.0. our principal dependent variable of interest was a positive depression screen (phq 9 score ‡10). our principal independent variable of interest was the presence of self-reported chronic pain (greater than 3 months). results: of 77 patients enrolled, 2 did not meet all inclusion criteria. 50 had two or more assessments for comparison. their average age was 39 (range 21-59), 70% were male, and 74% were in police custody. 38% used methadone alone; 16% heroin alone; 4% oxycodone alone; and the rest used multiple opioids. the average dose of im methadone was 10.3 mg (range 5-20 mg); all but 3 patients received 10 mg. the mean cows score before receiving im methadone was 11.19 (range 3-23), compared to 4.83 (range 0-20) 30 minutes after methadone (p < 0.001; mean difference = )6.36; 95% ci = )4.57 to )8.15). the mean wss before and after methadone was )1.54 (range )1 to )2) and )0.755 (range )2 to 2), respectively (p < 0.001; 95% ci = )1.0 to )0.57). the mean physician-assessed wss was significantly lower than the patient's own assessment by 0.78 (p < 0.001). adverse events included an asthmatic patient with bronchospasm whose oxygen saturation decreased from 95% to 88% after receiving methadone, a patient whose oxygen saturation decreased from 95% to 93%, and two patients whose amss decreased from )1 to )2 (indicating moderate sedation). background: as the us population ages, the coexistence of copd and acute coronary syndrome (acs) is expected to be more frequent. very few studies have examined the effect of copd on outcomes in acs patients, and, to our knowledge, there has been no report on biomarkers that possibly mediate between copd and long-term acs patient outcomes. objectives: to determine the effect of copd on longterm outcomes in patients presenting to the emergency department (ed) with acs and to identify prognostic inflammatory biomarkers. methods: we performed a prospective cohort study enrolling acs patients from a single large tertiary center. hospitalized patients aged 18 years or older with acs were interviewed and their blood samples were obtained. seven inflammatory biomarkers were measured, including interleukin-6 (il-6), c-reactive protein (crp), tumor necrosis factor-alpha (tnf-alpha), vascular cell adhesion molecule (vcam), e-selectin, lipoprotein-a (lp-a), and monocyte chemoattractant protein-1 (mcp-1). the diagnoses of acs and copd were verified by medical record review. annual telephone follow-up was conducted to assess health status and major adverse cardiovascular events (mace) outcomes, a composite endpoint including myocardial infarction, revascularization procedure, stroke, and death. background: aortic dissection (ad) is an uncommon life-threatening condition requiring prompt diagnosis and management. thirty-eight percent of cases are missed upon initial evaluation. the cornerstone of accurate diagnosis hinges on maintaining a high index of clinical suspicion for the various patterns of presentation. quality documentation that reflects consideration for ad in the history, exam, and radiographic interpretation is essential for both securing the diagnosis and for protecting the clinician in missed cases. objectives: we sought to evaluate the quality of documentation in patients presenting to the emergency department with subsequently diagnosed acute ad. methods: irb-approved, structured, retrospective review of consecutive patients with newly diagnosed non-traumatic ad from 2004 to 2010. inclusion criteria: new ad diagnosis via ed. exclusion criteria: ad diagnosed at another facility; chronic, traumatic, or iatrogenic ad. trained/monitored abstractors used a standardized data tool to review ed and hospital medical records. descriptive statistics were calculated as appropriate. inter-rater reliability was measured. our primary performance measure was the prevalence of a composite of all three key historical elements (1. any back pain, 2. neurologic symptoms including syncope, and 3. sudden onset of pain.) in the attending emergency physician's documentation. secondary outcomes included documentation of: ad risk factors, pain quality, back pain at multiple locations, presence/absence of pulse symmetry, mediastinal widening on chest radiograph, and migratory nature of the pain. results: 65/203 met our inclusion/exclusion criteria. the mean age was 58.4 years; 65% were male, 23 (35.4%) were stanford a. 32 (60%) presented with a chief complaint of chest pain. primary outcome measure: 6/65 (9.2%; 95%ci = 3.5,19.0) documented the presence/ absence of all three key historical elements. [back pain = 42/65; 64.6% (51.8, 76.1); neuro symptoms = 39/ 65; 60% (47.1, 72.0); sudden onset = 12/65; 18.5% (9.9, 30.0).] limitations: small number of confirmed ad cases. conclusion: in our cohort, emergency physician documentation of key historical, physical exam, and radiographic clues of ad is suboptimal. although our ed miss rate is lower than that which has been reported by previous authors, there is an opportunity to improve documentation of these pivotal elements at our institution. objectives: this study assessed the opinions of iem and gh fellowship program directors, in addition to recent and current fellows regarding streamlining the application process and timeline in an attempt to implement change and improve this process for program directors and fellows alike. methods: a total of 34 current iem and gh fellowship programs were found through an internet search. an electronic survey was administered to current iem and gh fellowship directors, current fellows, and recent graduates of these 34 programs. results: response rates were 88% (n = 30) for program directors and 53% (n = 17) for current and recent fellows. the great majority of current and recent fellows (77%) and program directors (83%) support transitioning to a common application service. similarly, 88% of current and recent fellows and 83% of program directors support instituting a uniform deadline date for applications. however, only 47% of recent/current fellows and 33% of program directors would support a formalized match process like nrmp. conclusion: the majority of fellows and program directors support streamlining the application for all iem and gh fellowship programs. this could improve the application process for both fellows and program directors, and ensure the best fit for the candidates and for the fellowship programs. in order to establish effective emergency care in rural sub-saharan africa, the unique practice demographics and patient dispositions must be understood. objectives: the objectives of this study are to determine the demographics of the first 500 patients seen at nyakibale hospital's ed and assess the feasibility of treating patients in a rural district hospital ed in sub-saharan africa. methods: a descriptive cross-sectional analysis of the first 500 consecutive patient visits in the ed's patient care log was reviewed by an unblinded abstractor. data collected included age, sex, condition upon discharge, and disposition. all authors discussed uncertainties and formed a consensus. descriptive statistics were performed. results: of the first 500 patient visits, 254 (50.8%) occurred when the outpatient clinic was open. there were 275 (55%) male visits. the average age was 25.2 years (sd ± 22.2). pediatric visits accounted for 218 (43.6%) patients, and 132 (26.4%) visits were for children under five years old. only one patient expired in the ed, and 401 (80.2%) were in good condition after treatment, as subjectively defined by the ed physicians. one person was transferred to another hospital. after treatment, 180 (36%) patients were discharged home. of those admitted to an inpatient ward, 126 (25.2%) patients were admitted to medical wards, 97 (19.4%) to pediatrics, and 60 (12%) to surgical. only six (1.2 %) patients went directly to the operating theatre. conclusion: this consecutive sample of patient visits from a novel rural district hospital ed in sub-saharan africa included a broad demographic range. after treatment, most patients were judged to be in ''good condition'', and over one third of patients could be discharged after ed management. this sample suggests that it is possible to treat patients in an ed in rural sub-saharan africa, even in cases where surgical backup and transfers to higher level of care are limited or unavailable. background: communication failures in clinical handoffs have been identified as a major preventable cause of patient harm. in italy, advanced prehospital care is provided predominantly by physicians who work on ambulances in teams with either nurses or basic rescuers. the hand-offs from prehospital physicians to hospital emergency physicians (eps) is especially susceptible to error with serious consequences. there are no studies in italy evaluating the communication at this transition in patient care. studying this, however, requires a tool that measures the quality of this communication. objectives: the purpose of this study is to develop and validate a tool for the evaluation of communication during the clinical handoff from prehospital to emergency physicians in critically ill patients. methods: several previously validated tools for evaluating communication in hand-offs were identified through a literature search. these were reviewed by a focus group consisting of eps, nurses, and rescuers, who then adapted and translated the australian isbar (identification, situation, background, assessment, recommendation), the tool most relevant to local practice. the italian isbar tool consists of the following elements: patient and provider identification; patient's chief complaint; patient's past medical history, medications, and allergies; prehospital clinical assessment (primary survey, illness severity, vital signs, diagnosis); treatment initiated and anticipated treatment plan. we conducted and video-taped the hand-offs of care from the prehospital physicians to the eps in 12 pediatric critical care simulations. four physician raters were trained in the italian isbar tool and used it to independently assess communication in each simulation. to assess agreement we calculated the proportion of agreement among raters for each isbar question, fleiss' kappas for each simulation, as well as mean agreement and mean kappas with standard deviations. results: there was 100% agreement among the four physicians on 70% of the items. the mean level of agreement was 91% (sd 0.15). the overall mean kappa was 0.67 (sd 0.10). conclusion: the standardized tool resulted in good agreement by physician raters. this validated tool may be helpful in studying and improving hand-offs in the prehospital to emergency department setting. objectives: we hypothesized that residents who were provided with vps prior to hfs would perform more thoroughly and efficiently than residents who had not been exposed to the online simulation. methods: we randomized a group of 30 residents from an academic, pgy 1-4 emergency medicine program to complete an online vps case, either prior to (vps group, n = 14 residents) or after (n = 16) their hfs case. the vps group had access to the online case (which reviewed asthma management) 3 days prior to the hfs session. all residents individually participated in their regularly scheduled hfs and were blinded to the content of the case -a patient in moderate asthma exacerbation. the authors developed a dichotomous checklist consisting of 33 items recorded as done/not done along with time completed. a two sample proportion test was used to evaluate differences in the individual items completed between groups. a wilcoxon rank sum test was used to determine the differences in overall and subcategory performance between the two groups. median time to completion was analyzed using the log-rank test. results: the vps group had better overall checklist performance than the control group (p-value 0.046). in addition, the vps group was more thorough in obtaining an hpi (p-value 0.009). specific actions (related to asthma management) were performed better by the vps group: inquiring about last/prior ed visits (0.038), total number of hospitalizations in the prior year (0.029), prior intubations (0.001), and obtaining peak flow measurements (0.030). overall there was no difference in time to event completion between the two groups. conclusion: we found that when hfs is primed with educational modalities such as vps there was an improvement in performance by trainees. however, the improved completeness of the vps group may have served as a barrier to efficiency, inhibiting our ability to identify a statistical significant efficiency overall. vps may aid in priming the learners and maximize the efficiency of training using high-fidelity simulations. training using an animal model helped develop residents' skills and confidence in performing ptv. retention was found to be good at 2 months post-training. this study underscores the need for hands-on training in rare but critical procedures in emergency medicine. methods: in this cross-sectional study at an urban community hospital, 15 residents in their second or third year of training from a 3-year em residency program performed us-guided catheterizations of the ij on a simulator manufactured by blue phantom. two board-certified em physicians observed for the completion of pre-defined procedural steps using a checklist and rated the residents' overall performance of the procedure. overall performance ratings were provided on a likert scale of 1 to 10, with 1 being poor and 10 being excellent. residents were given credit for performing a procedural step if at least one rater marked its completion. agreement between raters was calculated using intraclass correlation coefficients for domain and summary scores. the same protocol was then repeated on an unembalmed cadaver using two different board-certified em physician raters. criterion validity of the residents' proficiency on the simulator was evaluated by comparing their median overall performance rating on the simulator to that on the cadaver and by comparing the proportion of residents completing each procedural step between modalities with descriptive statistics. results: em residents' overall performance rating on the simulator was 7.4 (95% ci: 6.0 to 8.8) and on the cadaver was 6.1 (95% ci: 4.7 to 7.5). the results for each procedural step are summarized in the attached figure. inter-rater agreement was high for assessments on both the simulator and cadaver with overall kappa scores of 0.89 and 0.96 respectively. background: the environment in the emergency department (ed) is chaotic. physicians must learn how to multi-task effectively and manage interruptions. noise becomes an inherent byproduct of this environment. previous studies in the surgical and anesthesiology literature examined the effect of noise levels and cognitive interruptions on resident performance during simulated procedures; however, the effect of noise distraction on resident performance during an ed procedure has not yet been studied. objectives: our aim was to prospectively determine the effects of various levels of noise distraction on the time to successful intubation of a high-fidelity simulator. methods: a total of 45 emergency medicine, emergency medicine/internal medicine, and emergency medicine/family medicine residents were studied in a background noise environments of less than 50 decibels (noise level 1), 60-70 decibels (noise level 2), and of greater than 70 decibels (noise level 3). noise levels were standardized by a dosimeter (ex tech instruments, heavy duty 600). each resident was randomized to the order in which he or she was exposed to the various noise levels and had a total of 2 minutes to complete each of the intubation attempts, which were performed in succession. time, in seconds, to successful intubation was measured in each of these scenarios with the start time defined as the time the resident picked up the storz c-mac video laryngoscope blade and the finish time defined as the time the tube passed through the vocal cords as visualized by an observer on the storz c-mac video screen. analytic methods included analysis of variance, student's t-test, and pearson's chi-square. results: no significant differences were found between time to intubation and noise level nor did the order of noise level exposure affect the time to intubation (see table) . there were no significant differences in success rate between the three noise levels (p = 0.178). a significant difference in time to intubation was found between the residents' second and third intubation attempts with decreased time to intubation for the third attempt (p = 0.001). conclusion: noise level did not have an effect on time to intubation or intubation success rate. time to intubation decreased between the second and third intubations regardless of noise level. background: growing use of the emergency department (ed) is cited as a cause of rising health care costs and a target of health care reform. eds provide approximately one quarter of all acute care outpatient visits in the us. eds are a diagnostic center and a portal for rapid inpatient admission. the changing role of eds in hospital admissions has not been described. objectives: to compare if admission through the ed has increased compared to direct hospital admission. we hypothesized that the use of the ed as the admitting portal increased for all frequently admitted conditions. methods: we analyzed the nationwide inpatient sample (nis), the largest us all-payer inpatient care database, from 1993-2006. nis contains data from approximately 8 million hospital stays each year, and is weighted to produce national estimates. we used an interactive, webbased data tool (hcupnet) to query the nis. clinical classification software (ccs) was used to group discharge diagnoses into clinically meaningful categories. we calculated the number of annual admissions and proportion admitted from the ed for the 20 most frequently admitted conditions. we excluded ccs codes that are rarely admitted through the ed (<10%) as well as obstetbackground: the optimal dose of opioids for patients in acute pain is not well defined, although 0.1 mg/kg of iv morphine is commonly recommended. patient-controlled analgesia (pca) provides an opportunity to assess the adequacy of this recommendation as use of the pca pump is a behavioral indication of insufficient analgesia. objectives: to assess the need for additional analgesia following a 0.1 mg/kg dose of iv morphine by measuring additional self-dosing via a pca pump. methods: a three-arm randomized controlled trial was performed in an urban ed with 75,000 annual adult visits. a convenience sample of ed patients ages 18 to 65 with abdominal pain of <7 days duration requiring iv opioids was enrolled between 4/2009 and 6/2010. all patients received an initial dose of 0.1 mg/kg iv morphine. patients in the pca arms could request additional doses of 1 mg or 1.5 mg iv morphine by pressing a button attached to the pump with a 6-minute lock-out period. for this analysis, data from both pca arms were combined. software on the pump recorded times when the patient pressed the button (activation) and when he/she received a dose of morphine (successful activation). results: 137 patients were enrolled in the pca arms. median baseline nrs pain score was 9. mean amount of supplementary morphine self-administered over the 2 hour study period subsequent to the loading dose was 5.7 mg and 6.7 mg for the 1 and 1.5 mg pca groups respectively. 124 patients activated the pump at least once (91%, 95% ci: 84 to 94%). figure 1 shows the frequency distribution of the number of times the pump was activated. of those who activated the pump, the median number of activations per person was 5 (iqr: 3 to 12). there were 1124 activations of the pump. 60% of activations were successful (followed by administration of morphine), while 40% were unsuccessful as they occurred during the 6-minute lock-out periods. 19% of the activations occurred in the first 30 minutes, 29% in the second 30 minutes, 25% in the third 30 minutes, and 27% in the last 30 minutes after the initial loading dose. conclusion: almost all patients requested supplementary doses of pca morphine, half of whom activated the pump five times or more over a course of 2 hours. this frequency of pca activations suggests that the commonly recommended dose of 0.1 mg/kg morphine may constitute initial oligoanalgesia in most patients. marie-pier desjardins, benoit bailey, fanny alie-cusson, serge gouin, jocelyn gravel chu sainte-justine, montreal, qc, canada background: administration of corticosteroid at triage has been suggested to decrease the time to corticosteroid administration in the ed. objectives: to compare the time between arrival and corticosteroid administration in patients treated with an asthma pathway (ap) or with standard management (sm) in a pediatric ed. methods: chart review of children aged 1 to 17 years diagnosed with asthma, bronchospasm, or reactive airways disease seen in the ed of a tertiary care pediatric hospital. for a one year period, 20% of all visits were randomly selected for review. from these, we reviewed patients who were eligible to be treated with the ap ( ‡18 months with previous history of asthma and no other pulmonary condition) and who had received at least one inhaled bronchodilator treatment. charts were evaluated by a data abstractor blinded to the study hypothesis using a standardized datasheet. various variables were evaluated such as age, respiratory rate and 0 2 saturation at triage, type of physician who saw patient first, treatment prior to visit, in ed, and at discharge, time between arrival and corticosteroid administration, and length of stay (los background: return visits comprise 3.5% of pediatric emergency department (ped) visits, at a cost of >$500 million/year nationally. these visits are typically triaged with higher acuity and admission rates and raise concern for lapses in quality of care and patient education during the first visit. objectives: the aim of this qualitative study was to describe parents' reasons for return visits to the ped. methods: we prospectively recruited a convenience sample of parents of patients under the age of 18 years who returned to the ped within 72 hours of their previous visit. we excluded patients who were instructed to return, had previously left without being seen, arrived without a parent, were wards of the state, or did not speak english. after obtaining consent, the principal investigator (ce) conducted confidential, in-person, tape-recorded interviews with parents during ped return visits. parents answered 12 open-ended questions and 9 closed-ended questions using a five-point likert scale. responses to open-ended questions were analyzed using thematic analysis techniques. the scaled responses were grouped into three categories of agree, disagree, or neutral. results: from the 49 closed-ended responses, 86% of parents agreed that their children were getting sicker, and 92% agreed that their children were not getting better. 80% agreed that they were unsure how to treat the illness, however only 41% agreed they did not feel figure 1 : frequency distribution of number of pca activations comfortable taking care of the illness. only 29% agreed that the medical condition and/or the instructions were not clearly explained in the first visit. some common themes from the open-ended questions included worsening or lack of improvement of symptoms. many parents reported having unanswered questions about the cause of the illness and hoped to find out the cause during the return visit. conclusion: most parents brought their children back to the ped because they believed the symptoms had worsened or were not improving. although a large proportion of parents believed that the medical condition was clearly explained at the first visit, many parents still had unanswered questions about the cause of their child's illness. while worsening symptoms seemed to drive most return visits, it is possible that some visits related to failure to improve might be prevented during the first ped visit through a more detailed discussion of disease prognosis and expected time to recover. pediatric background: experience indicates that it is difficult to effectively quell many parents' anxiety toward pediatric fevers, making this a common emergency department (ed) complaint. the question remains as to whether athome treatment has any effect on the course of emergency department treatment or length of stay in this population. objectives: to determine whether anti-pyretic treatment prior to arrival in the emergency department affects the evaluation or emergency department length of stay of febrile pediatric patients. methods: a convenience sample of children, ages 0-12 years, who presented to a tertiary care ed with chief complaint of fever were enrolled. parents were asked to participate in an eight-question survey. questions related to demographic information, pre-treatment of the fever, contact with primary care providers prior to ed arrival, and immunization status. upon admission or discharge, investigators recorded information regarding length of stay, laboratory tests and imaging ordered, and medications given. results: eighty-one patients were enrolled in the study. seventy-six percent of the patients were pre-treated with some form of anti-pyretic by the caregiver prior to ed arrival. there was no significant effect of pre-treatment on whether laboratory tests or medications were ordered in the ed or whether the patient was admitted or discharged. the length of ed stay was found to be significantly shorter among those who received anti-pyretics prior to arrival (184 ± 11 vs. 247 ± 36 minutes; p = 0.03). conclusion: among febrile children, those who receive anti-pyretics prior to their ed visit had statistically significant shorter length of stays. this also supports implementation of triage or nursing protocols to administer an anti-pyretic as soon as possible in the hope of decreasing ed throughput times. background: during the past two decades, the prevalence of overweight (bmi percentile >95) in children has more than doubled, reaching epidemic proportions both nationally and globally. the public health burden is enormous given the increased risk of adult obesity as well as the adverse consequences on cardiovascular, metabolic, and psychological health. despite the overwhelming prevalence, the effect of obesity on emergency care has received little attention. objectives: the goal of this study is to determine the relation of weight on reported emergency department visits in children from a nationally representative sample. methods: weight (as reported by parents) and height along with frequency of and reason for emergency department (ed) use in the last 12 months were obtained from children aged 10-17 y (n = 46,707) in the cross-sectional, telephone-administered, national survey of children's health (nsch). bmi percentiles were calculated using sex-specific bmi for age growth charts from the cdc (2000). children were categorized as: underweight (bmi percentile£5), normal weight (>5 to <85), at-risk for overweight (85 to <95), and overweight ( ‡95). prevalence of ed use was estimated and compared across bmi percentile categories using chisquare analysis and multivariable logistic regression. taylor-series expansion was used for variance estimation of the complex survey design. results: the prevalence of at least one ed use in the past 12 months increased with increasing bmi percentiles (figure 1, p < 0.001). additionally, overweight children were more likely to have more than one visit. overweight children were also less likely to report an injury, poisoning, or accident as the reason for ed visit compared to other bmi categories (47, 55, 59, 54% in overweight, at-risk, normal, and underweight respectively, p < 0.05). conclusion: as rates of childhood obesity continue to grow in the u.s., we can expect greater demands on the ed. this will likely translate into an increased emphasis on the care of chronic conditions rather than injuries and accidents in the pediatric ed setting. results: mean pediatric satisfaction score was 84.1 (sd 3.9) compared with 81.4 (3.2) for adult patients (p < 0.001); monthly sample sizes ranged from 14-74 and from 30-125 for the two populations, respectively. both populations showed an increase in satisfaction after opening of the ped-ed. for both populations there was no significant trend in patient satisfaction from the beginning of the study period to the opening of the ped-ed, but after the opening the models of the populations differed. the pediatric satisfaction model was an interrupted two-slope model, with an immediate jump of 3.5 points in november and an increase of 0.2 points per month thereafter. in contrast, adult satisfaction scores did not show a jump but increased linearly (two slope model) after 11/2011 at a rate of 0.3 per month. prior to the opening of the ped-ed, mean monthly pediatric and adult satisfaction scores were 81.5 (2.4) and 79.5 (2.8), respectively (difference 2.0 95% ci 0.1-3.8, p = 0.04). after the opening the mean scores were 86.8 (3.1) and 83.2 (2.4), respectively (difference 3.6, 95% ci 2.1-5.0, p < 0.001). conclusion: opening of a dedicated ped-ed was associated with a significant increase in patient satisfaction scores both for children and adults. patient satisfaction for children, as compared to adults, was higher before and after opening a ped-ed. the background: there are racial disparities in outcomes among injured children. in particular, black race appears to be an independent predictor of mortality. objectives: to evaluate disparities among ed visits for unintentional injuries among children ages 0-9. methods: five years of data (2004) (2005) (2006) (2007) (2008) from the national hospital ambulatory cares survey were combined. inclusion criteria were defined as unintentional injury visits (e-code 800.0 to 869.9 or 888.0 to 929.9) and age 0-9 years. visit rates per 100 population (defined by the us census) were calculated by race and age group. weighted multivariate logistic regression analysis was performed to describe associations between race and specific outcome variables and related covariates. primary statistical analyses were performed using sas version 9.1.3. results: 21,524,000 of 585,294,000 weighted ed visits met our inclusion criteria (3.7%). per 100 persons, black children had 1.5 times as many ed visits for unintentional injuries as whites (table) . there were no racial differences in the sex ratio (1.4 boy visits: 1 girl), proportion of visits by age, ed disposition, immediacy with which they needed to be seen, whether or not they were evaluated by an attending physician, metropolitan vs. rural hospital, admission length of stay, mode of transportation for ed arrival, number of procedures, diagnostic services, or ed medications. background: sudden cardiac arrests in schools are infrequent, but emotionally charged events. little data exist that describes aed use in these events. objectives: the purpose of our study was to 1) describe characteristics and outcomes of school cardiac arrests (ca), and 2) assess the feasibility of conducting bystander interviews to describe the events surrounding school ca. methods: we performed a telephone survey of bystanders to ca occurring in k-12 schools in communities participating in the cardiac arrest registry to enhance survival (cares) database. the study period was from 8/2005-12/2010 and continued in one community through 2011. utstein style data and outcomes were collected from the cares database. a structured telephone interview of a bystander or administrative personnel was conducted for each ca. a descriptive summary was used to assess for the presence of an aed, provision of bystander cpr (bcpr), and information regarding aed deployment, training, and use and perceived barriers to aed use. descriptive data are reported. results: during the study period there were 30,603 ca identified at cares communities, of which 73 were identified as educational institutions. of these, 46 (0.15%) events were at k-12 schools with 21 (45.7%) being high schools. of the 46 arrests, a minority were children (15 (32.6%) < age 19), most (32, 84.8%) were witnessed, a majority (36, 76.1%) received bcpr, and 26 (56.5%) were initially in ventricular fibrillation (vf). most arrests 28/40 (70%) occurred during the school day (7a-5p). overall, 14 (30.4%) survived to hospital discharge. interviews were completed for 29 of 46 (63.0%) k-12 events. eighteen schools had an aed on site. most schools (84.2%) with aeds reported that they had a training program and personnel identified for its use. an aed was applied in 10 of 18 patients, and of these 8 were in vf and 4 survived to hospital discharge. multiple reasons for aed non-use (n = 8) were identified. conclusion: cardiac arrests in schools are rare events; most patients are adults and received bcpr. aed use was infrequent, even when available, but resulted in excellent (4/10) survival. further work is needed to understand aed non-use. post-event interviews are feasible and provide useful information regarding cardiac arrest care. physician background: gastroenteritis is a common childhood disease accounting for 1-2 million annual pediatric emergency visits. current literature supports the use of anti-emetics reporting improved oral re-hydration, cessation of vomiting, and reduced need for iv re-hydration. however, there remains concern that using these agents may mask alternative diagnoses. objectives: to assess outcomes associated with use of a discharge action plan using ed-dispensed ondansetron at home in the treatment of gastroenteritis. methods: a prospective, controlled, observational trial of patients presenting to an urban pediatric emergency department (census 22,400) over a 12-month period for acute gastroenteritis. fifty patients received ondansetron in the ed. twenty-nine patients were enrolled in the pediatric emergency department discharge action plan (ped-dap) where ondansetron for home use was dispensed by the treating clinician. twenty-one patients were controls. control patients did not receive home ondansetron. ped-dap patients were given instructions to administer the ondansetron for ongoing symptoms any time 6 hours post ed discharge. all patients were followed by phone at 7-14 days to assess for the following: time of emesis resolution, alternative diagnoses, unscheduled visits, and adverse events. results: all 50 patients were followed by phone. 24/29 ped-dap patients received home ondansetron. 21/29 patients had resolution of emesis in the ed. 7/29 had resolution of their emesis between time of discharge and 24 hours. 1/29 of ped-dap patients reported emesis after 24 hours from ed discharge. five patients reported an unscheduled visit. all five return visits returned to the ed (1/5 returned for emesis, 4/5 for diarrhea). 17/21 controls reported resolution of symptoms within the ed. 2/21 of controls had resolution between time of discharge and 24 hours. 1/21 of the control patients had resolution with between 24 and 48 hours post discharge. 1/21 had an unscheduled appointment with the pmd at 72 hours post-discharge for ongoing fever and nausea. in follow-up there were no alternative diagnoses identified. the effect of the ped-dap on resolution of emesis between discharge and 24 hours appears to be statistically significant (p value < 0.04). conclusion: ondansetron given in schedule with a discharge action plan appears to provide a modest benefit in resolution of symptoms relative to a control population. objectives: to determine the repeatability coefficient of a 100 mm vas in children aged 8 to 17 years in different circumstances: assessments done either at 3 or 1 minute interval, when asked to recall their score or to reproduce it. methods: a prospective cohort study was conducted using a convenience sample of patients aged 8 to 17 years presenting to a pediatric ed. patients were asked to indicate, on a 100 mm paper vas, how much they liked a variety of food with four different sets of three questions: (set 1) questions at 3 minute interval with no specific instruction other than how to complete the vas and no access to previous scores, (set 2) same format as set 1 except for questions at 1 minute interval, (set 3) same as set 1 except patients were asked to remember their answers, and (set 4) same as set 1 except patients were shown their previous answers. for each set, the repeatability coefficient of the vas was determined according to the bland-altman method for measuring agreement using repeated measures: 1.96 x ö 2 x s w where s w is the within-subject standard deviation by anova. the sample size required to estimate s w to 10% of the fraction value as recommended was 96 patients if we obtained three measurements for each patient. results: a total of 100 patients aged 12.1 ± 2.4 years were enrolled. the repeatability coefficient for the questions asked at 3 minute intervals was 12 mm, and 8 mm when asked at 1 minute interval. when asked to remember their previous answers or to reproduce them, the repeatability coefficient for the questions was 7 mm and 6 mm, respectively. conclusion: the condition of the assessments (variation in intervals or patients asked to remember or to reproduce their previous answers) influence the testretest reliability of the vas. depending on circumstances, the theoretical test-retest reliability in children aged 8 to 17 years varies from 6 to 12 mm on a 100 mm paper vas. background: skull radiographs are a useful tool in the evaluation of pediatric head trauma patients. however, there is no consensus on the ideal number of views that should be obtained as part of a standard skull series in the evaluation of pediatric head trauma patients. objectives: to compare the sensitivity and specificity of a two-and four-film x-ray series in the diagnosis of skull fracture in children, when interpreted by pediatric emergency medicine physicians. methods: a prospective, crossover experimental study was performed in a tertiary care pediatric hospital. the skull radiographs of 100 children were reviewed. these were composed of the 50 most recent cases of skull fracture for which a four-film radiography series was available at the primary setting and 50 controls, matched for age. two modules, containing a random sequence of two-and four-film series of each child, were constructed in order to have all children evaluated twice (once with two films and once with four films). board-certified or -eligible pediatric emergency physicians evaluated both modules two to four weeks apart. the interpretation of the four-film series by a radiologist, or when available, the findings on ct scan, served as the gold standard. accuracy of interpretation was evaluated for each patient. the sensitivity and specificity of the two-film versus the four-film skull xray series, in the identification of fracture, were compared. this was a non-inferiority cross-over study evaluating the null hypothesis that a series with two views would have a sensitivity (specificity) that is inferior by no more than 0.055 compared to a series with four views. a total of 50 controls and 50 cases were needed to establish non-inferiority of the two-film series versus the four-film series, with a power of 80% and a significance level of 5%. results: ten pediatric emergency physicians participated in the study. for each radiological series, the proportion of accurate interpretation varied between 0.20 to 1.00. the four-film series was found to be more sensitive in the detection of skull fracture than a two-film series (difference: 0.084, 95%ci 0.030 to 0.139). however, there was no difference in the specificity (difference: 0.004, 95%ci )0.024 to 0.033). conclusion: for children sustaining a head trauma, a four-film skull radiography series is more sensitive than a two-film series, when interpreted by pediatric emergency physicians. the objectives: we developed a free online video-based instrument to identify knowledge and clinical reasoning deficits of medical students and residents for pediatric respiratory emergencies. we hypothesized that it would be a feasible and valid method of differentiating educational needs of different levels of learners. methods: this was an observational study of a free, web-based needs assessment instrument that was tested on 44 third and fourth year medical students (ms3-4) and 29 pediatric and emergency medicine residents (r1-3). the instrument uses youtube video triggers of children in respiratory distress. a series of cased-based questions then prompts learners to distinguish between upper and lower airway obstruction, classify disease severity, and manage uncomplicated croup and bronchiolitis. face validity of the instrument was established by piloting and revision among a group of experienced educators and small groups of targeted learners. final scores were compared across groups using t-tests to determine the ability of the instrument to differentiate between different levels of learners (concurrent validity). cronbach's alpha was calculated as a measure of internal consistency. results: response rates were 19% among medical students and 43% among residents. the instrument was able to differentiate between junior (ms3, ms4, and r1) and senior (r2, r3) learners for both overall mean score (61% vs.78%, p < 0.01) and mean video portion score (74 vs. 84%, p = 0.02). table 1 compares results of several management questions between junior and senior learners. cronbach's alpha for the test questions was 0.47. conclusion: this free online video-based needs assessment instrument is feasible to implement and able to identify knowledge gaps in trainees' recognition and management of pediatric respiratory emergencies. it demonstrates a significant performance difference between the junior and senior learners, preliminary evidence of concurrent validity, and identifies target groups of trainees for educational interventions. future revisions will aim to improve internal consistency. results: the survey response rate was 87% (60/69). among responding programs, 40 (67%) reside within a children's hospital (vs. general ed); 51 (85%) are designated level i pediatric trauma centers. forty-three (72%) programs accept 1-2 pem fellows per year; 53 (88%) provided at least some eus training to fellows, and 42 (70%) offer a formal eus rotation. on average this training has existed for 3 ± 1 years and the mean duration of eus rotations is 4 ± 2 weeks. twenty-eight (67%) programs with eus rotations provide fellow training in both a general ed and a pediatric ed. there were no hospital or program level factors associated with having a structured training program for pem fellows. conclusion: as of 2011, the majority of pem fellowship programs provide eus training to their fellows, with a structured rotation being offered by most of these programs. background: ed visits are an opportunity for clinicians to identify children with poor asthma control and intervene. children with asthma who use eds are more likely than other children to have poor control, not be using controller medications, and have less access to traditional sources of primary care. one significant barrier to ed-based interventions is recognizing which children have uncontrolled asthma. objectives: to determine whether the pacci, a 12item parent-administered questionnaire, can help ed clinicians better recognize patients with the most uncontrolled asthma and differentiate between intermittent and persistent asthma. methods: this was a randomized controlled trial performed at an urban pediatric ed. parents were asked to answer questions about their child's asthma including drug adherence and history of exacerbations, as well as answer demographic questions. using a convenience sample of children 1-18 years presenting with an asthma exacerbation, attending physicians in the study were asked to complete an assessment of asthma control. physicians were randomized to receive a completed pacci (intervention) or not (control group). using an intent-to-treat approach, clinicians' ability to accurately identify 1) four categories of control used by the national heart, lung, and blood institute (nhlbi) asthma guidelines, 2) intermittent vs. persistent level asthma, and 3) controlled / mildly uncontrolled vs. moderate/severely uncontrolled asthma were compared for both groups using chi-square analysis. results: between january and august 2011, 57 patients were enrolled. there were no statistically significant differences between the intervention and control groups for child's sex, age, race and parents' education. conclusion: the pacci improves ed clinicians' ability to categorize children's asthma control according to nhlbi guidelines, and the ability to determine when a child's control has been worsening. ed clinicians may use the pacci to identify those children in greatest need for intervention, to guide prescription of controller medications, and communicate with primary care providers about those children failing to meet the goals of asthma therapy. figure) . fewer than half of physicians reported the parent of a 2-year-old being discharged from their ed following an mvc-related visit would receive either child passenger safety information or referrals (table) . conclusion: emergency physician report of child passenger safety resource availability is associated with trauma center designation. even when resources are available, referrals from the ed are infrequent. efforts to increase referrals to community child passenger safety resources must extend to the community ed settings where the majority of children receive injury care. background: pediatric subspecialists are often difficult to access following ed care especially for patients living far from providers. telemedicine (tm) can potentially eliminate barriers to access related to distance, and cost. objectives: to evaluate the overall resource savings and access that a tm program brings to patients and families. methods: this study took place at a large, tertiary care regional pediatric health care system. data were collected from 1/2011-10/2011. metrics included travel distance saved (round trip between tm presenting sites and the location of the receiving sites), time savings, direct cost savings (based on $0.55/mile) and potential work and school days saved. indirect costs were calculated as travel hrs saved/encounter (based on an average speed of 55 miles/hr). demographics and services provided were included. results: 690 tm consults were completed by 13 separate pediatric subspecialty services. most patients were school aged (86% >/= 5yrs old objectives: to analyze test characteristics of the pathway and its effects on ed length of stay, imaging rates, and admission rate before versus after implementation. methods: children ages 3-18 presenting to one academic pediatric ed with suspicion for appendicitis from october 2010 -august 2011 were prospectively enrolled to a pathway using previously validated lowand high-risk scoring systems. the attending physician recorded his or her suspicion of appendicitis and then used one of two scoring systems incorporating history, physical exam, and cbc. low-risk patients were to be discharged or observed in the ed. high-risk patients were to be admitted to pediatric surgery. those meeting neither low-nor high-risk criteria were evaluated in the ed by pediatric surgery, with imaging at their discretion. chart review and telephone follow-up were conducted two weeks after the visit. charts of a random sample of patients with diagnoses of acute appendicitis or chief complaint of abdominal pain and undergoing a workup for appendicitis in the eight months before and after institution of the pathway were retrospectively reviewed by one or two trained abstractors. results: appendicitis was diagnosed in 65 of 178 patients prospectively enrolled to the pathway (37%). mean age was 9.6 years. of those with appendicitis, 63 were not low-risk (sensitivity 96.9%, specificity 48.7%). the high-risk criteria had a sensitivity of 73.8% and specificity of 77.0%. a priori attending physician assessment of low risk had a sensitivity of 100% and specificity of 49.6%. a priori assessment of high risk had a sensitivity of 58.5% and specificity of 90.2%. we reviewed 232 visits prior to the pathway and 290 after. mean ed length of stay was similar (256 minutes before versus 257 after). ct was used in 12.1% of visits before and 7.3% after (p = 0.07). use of ultrasound increased (44.8% before versus 55.9% after, p < 0.02). admission rates were not significantly different (48.3% before versus 42.7% after, p = 0.2). conclusion: the low-risk criteria had good sensitivity in ruling out appendicitis and can be used to guide physician judgment. institution of this pathway was not associated with significant changes in length of stay, utilization of ct, or admission rate in an academic pediatric ed. computer-delivered alcohol and driver safety behavior screening and intervention program initiated during an emergency department visit mary k. murphy 1 , lucia l. smith 2 , anton palma 2 , david w. lounsbury 2 , polly e. bijur 2 , paul chambers 2 1 yale university, new haven, ct; 2 albert einstein college of medicine, bronx, ny background: alcohol use is involved in 32 percent of all fatal motor vehicle crashes and recent estimates show that at least 448,000 people were injured due to distracted driving last year. patients who visit the emergency department (ed) are not routinely screened for driver safety behavior; however, large numbers of patients are treated in the ed every day creating an opportunity for screening and intervention on important public health behaviors. objectives: to evaluate patient acceptance and response to a computer-based traffic safety educational intervention during an ed visit and one month follow-up. methods: design. pre /post educational intervention. setting. large urban academic ed serving over 100,000 patients annually. participants. medically stable adult ed patients. intervention. patients completed a self-administered, computer-based program that queried patients on alcohol use and risky driving behaviors (texting, talking, and other forms of distracted driving). the computer provided patients with educational information on the dangers of these behaviors and collected data on patient satisfaction with the program. staff called patients one month post ed visit for a repeat query. results: 150 patients participated; average age 39 (21-70), 58% hispanic, 52% male. 96% of patients reported the program was easy to use and were comfortable receiving this education via computer during their ed visit. self-reported driver safety behaviors pre, post intervention (% change): driving while talking on the phone 45%,16% ()29%, p = 0.001), aggressive driving 44%,15% ()29%, p = 0.001), texting while driving 28%,9% ()19%, p = 0.001), driving while drowsy 18%,4% ()14%, p = 0.002), drinking in excess of nih safe drinking guidelines15%,%7 ()8%, p = 0.039), drinking and driving 10%,1% ()9%, p = 0.006). conclusion: we found a high prevalence of selfreported risky driving behaviors in our ed population. at 1 month follow-up, patients reported a significant decrease in these behaviors. overall patients were very satisfied receiving educational information about these behaviors via computer during their ed visit. this study indicates that a low-intensity, computer-based educational intervention during an ed visit may be a useful approach to educate patients about safe driving behaviors and promote behavior change. prevalence of depression among emergency department visitors with chronic illness janice c. blanchard, benjamin l. bregman, jeffrey smith, mohammad salimian, qasem al jabr george washington university, washington, dc background: persons with chronic illnesses have been shown to have higher rates of depression than the general population. the effect of depression on frequent emergency department (ed) use among this population has not been studied. objectives: this study evaluated the prevalence of major depressive disorder (mdd) among persons presenting with depression to the george washington university ed. we hypothesized that patients with chronic illnesses would be more likely to have mdd than those without. methods: this was a single center, prospective, crosssectional study. we used a convenience sample of noncritically ill, english-speaking adult patients presenting with non-psychiatric complaints to an urban academic ed over 6 months in 2011. subjects were screened with the phq 9, a nine-item questionnaire that is a validated, reliable predictor of mdd. we also queried respondents about demographic characteristics as well as the presence of at least one chronic disease (heart disease, hypertension, asthma, diabetes, hiv, cancer, kidney disease, or cerebrovascular disease). we evaluated the association between mdd and chronic illnesses with both bivariate analysis and multivariate logistic regression controlling for demographic characteristics (age, race, sex, income, and insurance coverage). results: our response rate was 90.7% with a final sample size of 1012. of our total sample, 525 (51.9%) had at least one of the chronic illnesses defined above. of this group, 162 (30.9%) screened positive for mdd as compared to 82 (16.6%) of the group without chronic illnesses (p < 0.0001). in multivariate analysis, persons with chronic illnesses had an odds ratio for a positive depression screen of 1.80 (1.31, 2.50) as compared to persons without illness. among the subset of persons with chronic illnesses (n = 525), 46.9% had ‡3 visits in the prior 364 days as compared to 34.4% of persons with chronic illnesses without mdd (p = 0.007). conclusion: our study found a high prevalence of untreated mdd among persons with chronic illnesses who present to the ed. depression is associated with more frequent emergency department use among this population. initial blood alcohol level aids ciwa in predicting admission for alcohol withdrawal craig hullett, douglas rappaport, mary teeple, daniel butler, arthur sanders university of arizona, tucson, az background: assessment of alcohol withdrawal symptoms is difficult in the emergency department. the clinical institute withdrawal assessment (ciwa) is commonly used, but other factors may also be important predictors of withdrawal symptom severity. objectives: the purpose of this study is to determine whether ciwa score at presentation to triage was predictive of later admission to the hospital. methods: a retrospective study of patients presenting to an acute alcohol and drug detoxification hospital was performed from july 2010 through january 2011. patients were excluded if other drug withdrawal was present in addition to alcohol. initial assessment included age, sex, vital signs, and blood alcohol level (bal) in addition to hourly ciwa score. admission is indicated for a ciwa score of 10 or higher. data were analyzed by selecting all patients not immediately admitted at initial presentation. logistic regression using wald's criteria for stepwise inclusion was used to determine the utility of the initially gathered ciwa, bal, longest sobriety, liver cirrhosis, and vital signs in predicting subsequent admission. results: there were 123 patients who fit the inclusion criteria, with 9 admitted for treatment at initial intake and another 27 admitted during the following 10 hours. logistic regression indicated that presenting bal was a strong predictor (p = 0.01) of admission for treatment after initial presentation, as was presenting ciwa (p = 0.03). thus, presenting bal provided a substantial addition above initial ciwa in predicting later admission. no other variables added significantly to the prediction of later admission. to determine the interaction between presenting bal and ciwa scores, we ran a repeated measures analysis of the first five ciwa scores (from presentation to 4 hours later), using bal split into low (bal < 0.10) and high (bal > 0.10) groups (see figure) . their interaction was significant, f (1, 93) = 11.86, p < 0.001, g 2 = 0.11. those presenting with higher initial bal had suppressed ciwa scores that rose precipitously as the alcohol cleared. those with low presenting bal showed a decline in ciwa over time conclusion: initial assessment using the common assessment tool ciwa is aided significantly by bal assessment. patients with higher presenting bal are at higher risk for progression to serious alcohol withdrawal symptom. objectives: to describe patient and visitor characteristics and perspectives on the role of visitors in the ed and determine the effect of visitors on ed and hospital outcome measures. methods: this cross-sectional study was done in an 81,000-visit urban ed, and data were attempted to be collected from all patients over a consecutive 96-hour period from august 25 to 28, 2011. trained data collectors were assigned to the ed continuously for the study period. patients assigned to a rapid care section of the ed (24%) were excluded. a visitor was defined as a person other than a health care provider (hcp) or hospital staff present in a patient's room at any time. patient perspectives on visitors were assessed in the following domains: transportation, emotional support, physical care, communication, and advocating for the patient. ed and hospital outcome measures pertaining to ed length of stay (los) and charges, hospital admission rate, hospital los and charges were obtained from patient medical records and hospital billing. data analyses included frequencies, student's t-tests for continuous variables, and chi-square tests of association for categorical variables. all tests for significance were two-sided. objectives: to examine the effect of sunday alcohol availability on ethanol-related visits and alcohol withdrawal visits to the ed. methods: study design was a retrospective beforeafter study using electronically archived hospital data at an urban, safety net hospital. all adult non-prisoner ed visits from 1/1/2005 to 12/31/2009 were analyzed. an ethanol-related ed visit was defined by icd-9 codes related to alcohol (291.x, 303.x, 305.0, 980.0 ). an alcohol withdrawal visit was defined by icd-9 codes of delirium tremens (291.0), alcohol psychosis with hallucination (291.3), and ethanol withdrawal (291.81). we generated a ratio of ethanol-related ed visits to total ed visits (ethanol/total) and ratio of alcohol withdrawal ed visits to total ed visits (withdrawal/total). a day was redefined as 8 am to 8 am. the ratios were averaged within the four seasons to account for seasonal variations. data from summer 2008 were dropped as it spanned the law change. we stratified data into sunday and non-sunday days prior to analysis to isolate the effects of the law change. we used multivariable linear regression to estimate the association of the ratio with the law change while adjusting for time and the seasons. each ratio was modeled separately. the interaction between time and the law change was assessed using p < 0.05. results: during the study there were a total of 212,189 ed visits including 12,042 (6% of total) ethanol-related visits and 5,496 (3% of total) alcohol withdrawal visits. unadjusted ratios in seasonal blocks are plotted in the figure with associated 95% ci and best fit regression line for before and after law change, respectively. after adjusting for time and season in the multivariable linear regression, we found no significant association of either ethanol/total or withdrawal/total with the law change. this remained true for both sunday and non-sunday data. all interactions assessed were not significant. conclusion: the change in colorado law to allow the sale of full-strength alcoholic beverages on sundays did not significantly affect ethanol-related or alcohol withdrawal ed visits. background: olanzapine is a second-generation antipsychotic (sga) with actions at the serotonin/histamine receptors. post-marketing reports and a case report have documented dangerous lowering of blood pressure when this antipsychotic is paired with benzodiazepines, but a recent small study found no bigger decreases in blood pressure compared to another antipsychotic like haloperidol. decreases in oxygen saturations, however, were larger when olanzapine was combined with benzodiazepines in alcohol-intoxicated patients. it is unclear whether these vital sign changes are associated with the intramuscular (im) route only. objectives: the assessment of vital signs following administration of either oral (po) or im olanzapine, either with or without benzodiazepines (benzos) and with or without concurrent alcohol intoxication. methods: this is a structured retrospective chart review of all patients who received olanzapine in an academic medical center ed from 2004-2010 who had vital signs documented both before medication administration and within four hours afterwards. vital signs were calculated as pre-dose minus lowest post-dose vital sign within 4 hours, and were analyzed in an anova with route (im/po), benzo use (+/)), and alcohol use (+/)) as factors. significance level was set to <0.05. results: there were 482 patients who received olanzapine over the study period. a total of 275 patients (225 po, 50 im) met inclusion criteria. systolic blood pressures decreased across all groups as patients reduced their agitation. neither the route of administration, concurrent use of benzos, nor the use of alcohol were associated with significant changes in systolic bp (p = ns for all comparisons; see figure 1 ). decreases in oxygen saturations, however, were significantly larger for alcoholintoxicated patients who subsequently received im olanzapine + benzos compared to other groups (route: p < 0.001; alcohol: p < 0.01; route x alcohol: p < 0.001; route x benzos x alcohol: p < 0.05; see figure 2 ). conclusion: alcohol and benzos are not associated with significant decreases in blood pressure after po olanzapine, but im olanzapine + benzos is associated with potentially significant oxygen desaturations in patients who are intoxicated. intoxicated patients may have differential effects with the use of im sgas such as olanzapine when combined with benzos, and should be studied separately in drug trials. patients with a psychiatric diagnosis rasha buhumaid, jessica riley, janice blanchard george washington university, washington, dc background: literature suggests that frequent emergency department (ed) use is common among persons with a mental health diagnosis. few studies have documented risk factors associated with increased utilization among this population. objectives: to understand demographic characteristics of frequent users of the emergency department and describe characteristics associated with their visits. it was hypothesized that frequent visitors would have a higher rate of medical comorbidities than infrequent visitors. methods: this was a retrospective study of patients presenting to an urban, academic emergency department in 2009. a cohort of all patients with a mental health-related final icd-9 coded diagnosis (axis i or axis ii) was extracted from the electronic medical record. using a standard abstraction form, a medical chart review collected information about medical comorbidities, substance abuse, race, age, sex, and insurance coverage, as well as diagnosis, disposition, and time of each visit. results: our sample consisted of 109 frequent users ( ‡4 visits in a 365 day period) and 442 infrequent users (£3 visits in a 365 day period). frequent users were more likely to be male (68% vs. 54.5% p = 0.01), black (86% vs. 59% p < 0.0001), and had a higher average number of comorbid conditions (2.0, 95%ci 1.73,2.26) as compared to infrequent users (1.0, 95%ci 0.90,1.10). a higher percentage of visits in the infrequent user group occurred during the day (49% vs. 38.3% p < 0.0001) while a higher number of visits in the frequent users occurred after midnight (24.3% vs. 16.6% p = 0.0003). visits in the frequent user group were less likely to be for a psychiatric complaint (34.3% vs. 81.2%) and less likely to result in a psychiatric admission (18.3% versus 56.7%) as compared to the infrequent user group (p < 0.0001). conclusion: our data indicate that among patients with psychiatric diagnoses, those who make frequent ed visits have a higher rate of comorbid conditions than infrequent visitors. despite their increased use of the ed, frequent visitors have a significantly lower psychiatric admission rate. many of the visits by frequent users are for non-psychiatric complaints and may reflect poor access to outpatient medical and mental health services. emergency departments should consider interventions to help address social and medical issues among mental health patients who frequently use ed services. background: the world health organization estimates that one million people die annually by suicide. in the u.s., suicide is the fourth leading cause of death between the ages of 10 and 65. many of these patients are seen in ed, while outpatient visits for depression are also high. no recent analysis has compared these groups in the recent years. objectives: to determine if there is a relationship between the incidence of suicidal and depressed patients presenting to emergency departments and the incidence of depressed patients presenting to outpatient clinics from 2002-2008. the secondary objective is to analyze trends in suicidal patients in the ed. methods: we used nhamcs (national hospital ambulatory medical care survey) and namcs (national ambulatory medical care survey), national surveys completed by the centers for disease control, which provide a sampling of emergency department and outpatient visits respectively. for both groups, we used mental-health-related icd-9-cm, e codes and reasons for visit. we compared suicidal and depressed patients who presented to the ed, to those who presented to outpatient clinics. our subgroup analyses included age, sex, race/ethnicity, method of payment, regional variation, and urban verses rural distribution. results: ed visits for depression (1.14%) and suicide attempts (0.49%) remained stable over the years, with no significant linear trend. however, office visits for depression significantly decreased from 3.14% of visits in 2002 to 2.65% of visits in 2008. non-latino whites had a higher percentage of ed visits for depression (1.25%) and suicide attempt (0.57%) (p < 0.0001), and a higher percentage of office visits for depression than all other groups. among patients age 50-69 years, ed visits for suicide attempt significantly increased from 0.12% in 2002 to 0.44% in 2008. homeless patients had a higher percent of ed visits for depression (6.5%) and suicide attempt ( background: for potentially high-risk ed patients with psychiatric complaints, efficient ed throughput is key to delivering high-quality care and minimizing time spent in an unsecured waiting room. objectives: we hypothesized that adding a physician in triage would improve ed throughput for psychiatric patients. we evaluated the relationship between the presence of an ed triage physician and waiting room (wr) time, time to first physician order, time to ed bed assignment, and time spent in an ed bed. methods: the study was conducted from 11/2009-2/ 2011 at an academic ed with 55000 annual visits and a dedicated on-site emergency psychiatric unit. we performed a pre/post retrospective observational cohort study using administrative data, including weekend visits from noon-10pm, 8 months pre and post addition of weekend triage physicians. after adjusting for patient age, sex, insurance status, emergency severity index score, mode of arrival, ed occupancy rate, wr count, boarding count, and average wr los, multiple linear regression evaluated the relationship between the presence of a triage physician and four ed throughput outcomes: time spent in the wr, time to first order, time spent in an ed bed, and the total ed los. results: 565 visits met inclusion criteria, 280 in the 8 months before and 285 in the 8 months after physicians were assigned to triage on weekends. table 1 reports demographic data; multivariate analysis results are found in table 2 . the presence of a triage physician was associated with an 8 (95% ci 0.6-15.2) minute increase in wr time and no associated change in time to first order, time spent in an ed bed, or in the overall ed los. conclusion: use of triage physicians has been reported to decrease the time patients spend in an ed bed and improve ed throughput. however, for patients with psychiatric complaints, our analysis revealed a slight increase in wr time without evident change in the time to first order, time spent in an ed bed, or total ed los. improvements in ed throughput for psychiatric patients will likely require system-level changes, such as reducing ed boarding and improving lab efficiency to speed the process of medical clearance and reduce time spent in the unsecured wr. these findings may not be generalizable to eds without a dedicated ed psychiatric unit with full-time social workers to assist with disposition. initial assessment included ciwa scoring, repeated hourly, as well as other variables (see table 1 ). treatment and admission to the inpatient hospital was indicated for a ciwa score of 10 or higher. statistical analysis was performed utilizing repeated measures general linear modeling for ciwa scores and anova for all other variables. results: there were 123 patients who fit the inclusion criteria, with 9 admitted for treatment at initial intake and another 27 admitted during the following 10 hours. the table below compares the three most prevalent ethnic populations seen at our hospital. native americans presented at a significantly younger age (p < 0.05) than the other two ethnicities. initial ciwa scores taken on admission were significantly lower in the native american group than the other two groups (p < 0.05) and at 1 hour a difference existed but failed to reach significance. repeated measures analysis indicate that ciwa scores progressed in a u-shaped curvilinear fashion (see figure 1 ) conclusion: initial assessment utilizing ciwa scores appears to be affected by ethnicity. care must be taken when assessing and making decisions on a single initial ciwa score. further research is needed in this area as our numbers are small and differences might be seen in subsequent scoring. in addition, our study consists of primarily male patients and does not include african-american patients. background: age is a risk factor for adverse outcomes in trauma, yet evidence supporting the use of specific age cut-points to identify seriously injured patients for field triage is limited. objectives: to evaluate under-triage by age, empirically examine the association between age and serious injury for field triage, and assess the potential effect of mandatory age criteria. methods: this was a retrospective cohort study of injured children and adults transported by 48 ems agencies to 105 hospitals in 6 regions of the western u.s. from 2006-2008. hospital records were probabilistically linked to ems records using trauma registries, emergency department data, and state discharge databases. serious injury was defined as an injury severity score (iss) ‡16 (the primary outcome). we assessed under-triage (triage-negative patients with iss ‡16) by age decile, different mandatory age criteria, and used multivariable logistic regression models to test the association (linear and non-linear) between age and iss ‡ 16, adjusted for important confounders. results: 260,027 injured patients were evaluated and transported by ems over the 3-year period. under-triage increased markedly for patients over 60 years, reaching 58% for those over 90 years ( figure 1 ). mandatory age triage criteria decreased under-triage, while substantially increasing over-triage: one iss ‡ 16 patient identified for every 65 additional patients triaged to major trauma centers. among patients not identified by other criteria, age had a strong non-linear association with iss ‡ 16 (p < 0.01); the probability of serious injury steadily increased after 30 years, becoming more notable after 60 years ( figure 2 ). conclusion: under-triage in trauma increases in patients over 60 years, which may be reduced with mandatory age criteria at the expense of system efficiency. among patients not identified by other criteria, serious injury steadily increased after 30 years, though there was no age at which risk abruptly increased. background: although limited resuscitation with hemoglobin-based oxygen carriers (hbocs) improves survival in several polytrauma models, including those of traumatic brain injury (tbi) with uncontrolled hemorrhage (uh) via liver injury, their use remains controversial. objectives: we examine the effect of hboc resuscitation in a swine polytrauma model with uh by aortic tear +/) tbi. we hypothesize that limited resuscitation with hboc would offer no survival benefit and would have similar effects in a model of uh via aortic tear +/) tbi. methods: anesthetized swine subjected to uh inflicted via aortic tear +/) fluid percussion tbi underwent equivalent limited resuscitation with hboc, lr, or hboc+nitroglycerin (ntg) (vasoattenuated hboc) and were observed for 6 hours. comparisons were between tbi and no-tbi groups with adjustment for resuscitation fluid type using two-way anova with interaction and tukey kramer adjustment for individual comparisons. results: there was no independent effect of tbi on survival time after adjustment for fluid type (anova, tbi term p = 0.59) and there was no interaction between tbi and resuscitation fluid type (anova interaction term p = 0.12). there was a significant independent effect of fluid type on survival time (anova p = 0.005 background: intracranial hemorrhage (ich) after a head trauma is a problem frequently encountered in the ed. an elevated inr is recognized as a risk of bleeding. however, in a patient with an inr in normal range, a level associated with a lower risk of ich is not known. objectives: the aim of this study was to identify an inr threshold that could predict a decreased risk of an ich after a head trauma in patients with a normal inr. it is hypothesized that there is a threshold at which the likelihood of bleeding decreases significantly. methods: we did a study using data from a registry of patients with mild to severe head trauma (n = 3356) evaluated in a level i trauma center in canada between march 2008 and february 2011. all the patients with a documented scan interpreted by a radiologist and a normal inr, defined as a value less then 1.6, were included. we determined the correlation between inr value binned by 0.1 and the proportion of patients with an ich. threshold was defined by consensus as an abrupt change of more than 10% in the percentage of patients with ich. univariate frequency distribution was tested with pearson's chisquare test. logistic regression analysis was then used to study the effects of inr on ich with the following confounding factors: age, sex, and intake of warfarin, clopidogrel, or aspirin. results are presented with 95% confidence intervals. results: 751 patients met the inclusion criteria. the mean age was 55.3 years ± 29.9 and 65% were men. 267 patients (35.6%) had an ich on brain scan. we found a significantly lower risk of ich at a threshold of inr less than 1.0 (p < 0.001, univariate or = 0.37, 95%ci 0.25-0.54) and a strong correlation between the risk of bleeding for every increase of the inr (r 2 = 0.8987). in fact, after adjustment for confounding variables, every 0.1 inr increase was associated with an increased risk of having an ich (or 1.50; 95% ci 1.31-1.72). conclusion: we were able to demonstrate an inr threshold under which the probability of ich was significantly lower. we also found a strong association between the risk of bleeding and the increase in inr within a normal range, suggesting that clinicians should not be falsely reassured by a normal inr. our results are limited by the fact that this is a retrospective study and a small proportion of traumatic brain injured patients in our database had no scan or inr at their ed visit. a prospective cohort study would be needed to confirm our results. background: increasingly, patients with tbi are being seen and managed in the emergency neurology setting. knowing which early signs are associated with prognosis can be helpful in directing the acute management. objectives: to determine whether any factors early in the course of head trauma are associated with shortterm outcomes including inpatient admission, in-hospital mortality, and return to the hospital within 30 days. methods: this irb-approved study is a retrospective review of patients head injury presenting to our tertiary care academic medical center during a 9-month period. the dataset was created using redcap, a data management solution hosted by our medical school's center for translational science institute. results: the median age of the cohort (n = 500) was 26, iqr = 15-48yrs, with 62% being male. 84% had a gcs of 13-15 (mild tbi), 3% 9-13 (moderate tbi), and 13% gcs < 8 (severe tbi). 39% of patients were admitted to the hospital. the median length of hospital stay was 2 days, with an iqr of 1-5 days. of those admitted, 53% had an icu stay as well. the median icu los was also 2 days, with an iqr of 1-6days. twenty nine (6%) patients died during their hospital stay. lower gcs was predictive of inpatient admission (p = 0.0003) as well as icu days (p < 0.0001). significant predictors of re-admission to the hospital within 30 days included hypotension (p = 0.002) upon initial presentation. the prehospital and ed gcs scores were not statistically significant. significant predictors of in-hospital death in a model controlling for age included bradycardia (p = 0.0042), hyperglycemia (p = 0.0040), and lower gcs (p = 0.0003). the incidence of bradycardia (hr < 60) was 4.4%. conclusion: early hypotension, hyperglycemia, and bradycardia along with lower initial gcs are associated with significantly higher likelihood of hospital admission, including icu admission, as well as intrahospital death and re-admission. background: over 23,000 people per day require treatment for ankle sprains, resulting in lost workdays and training for athletes. platelet rich plasma (prp) is an autologous concentration of platelets which, when injected into the site of injury, is thought to improve healing by promoting inflammation through growth factor and cytokine release. studies to date have shown mixed results, with few randomized or placebo-controlled trials. the lower extremity functional scale (lefs) is a previously validated objective measure of lower extremity function. objectives: is prp helpful in acute ankle sprains in the the emergency department? methods: prospective, randomized, double-blinded, placebo-controlled trial. patients with severe ankle sprains and negative x-rays were randomized to trial or placebo. severe was defined as marked swelling and ecchymosis and inability to bear weight. both groups had 50 cc of blood drawn. trial group blood was centrifuged with a magellan autologous platelet separator (arteriocyte, cleveland) to yield 3-4 cc of prp. prp along with 0.5 cc of 1% lidocaine and 0.5 cc of 0.25% bupivicaine was injected at the point of maximum tenderness by a blinded physician under ultrasound guidance. control group blood was discarded and participants were injected in a similar fashion substituting sterile 0.9% saline for prp. both groups had visual analog scale (vas) pain scores and lefs on days 0, 3, 8, and 30. all participants had a posterior splint and were made non weight bearing for 3 days after which they were reexamined, had their splint removed, and were asked to bear weight as tolerated. participants were instructed not to use nsaids during the trial. results: 1156 patients were screened and 37 were enrolled. four withdrew before prp injection was complete. eighteen were randomized to prp and 15 to placebo. see tables for results. vas and lefs are presented as means with sd in parentheses. demographics were not statistically different between groups. conclusion: in this small study, prp did not appear to offer benefit in either pain control or healing. both groups had improvement in their pain and functionality and did not differ significantly during the study period. limitations include small study size and large number of participant refusals. methods: a structured chart review of all icd-9 radius fracture coded charts spanning march 18, 2010 to july 17, 2011 was conducted. specific variable data were collected and categorized as follows: age, moi, body mass index, and fracture location. the charts were reviewed by two medical students, with 10% of the charts reviewed by both students to confirm inter-rater reliability. frequencies and inter-quartile ranges were determined. comparisons were made with fisher's exact test and multiple logistic regression. results: 187 charts met inclusion criteria. 46 charts were excluded due to one of the following reasons: no fracture or no x-ray (14), isolated ulnar fracture (19), or undocumented or penetrating moi (13). of the analyzed patients (n = 141), distal radius fractures were most common (66%), followed by proximal (32%) and midshaft (2%). chart reviewers were found to be reliable (j = 1). age and moi were significantly associated with fracture location (see table) . ages 18-54 and bike accidents were more strongly associated with proximal radius fractures (odds ratio: 12 [2-94] and 5 [2-13], respectively). conclusion: patients presenting to our inner city ed with a radius fracture are more likely to have a distal fracture. adults 18-54 and bike accidents had a significantly higher incidence of proximal fractures than other ages or mois. background: trauma centers use guidelines to determine the need for a trauma surgeon in the ed on patient arrival. a decision rule from loma linda university that includes penetrating injury and tachycardia was developed to predict which pediatric trauma patients require emergent intervention, and thus are most likely to benefit from surgical presence in the ed. objectives: our goal was to validate the loma linda rule (llr) in a heterogeneous pediatric trauma population and to compare it to the american college of surgeons' major resuscitation criteria (mrc). we hypothesized that the llr would be more sensitive than the mrc for identifying the need for emergent operative or procedural intervention. methods: we performed a secondary analysis of prospectively collected trauma registry data from two urban level i pediatric trauma centers with a combined annual census of approximately 115,000 visits. consecutive patients <15 years old with blunt or penetrating trauma from 1993 through 2010 were included. patient demographics, injury severity scores (iss), times of ed arrival and surgical intervention, and all variables of both rules were obtained. the outcome (emergent operative intervention within 1 hour of ed arrival or ed cricothyroidotomy or thoracotomy) was confirmed by trained, blinded abstractors. sensitivities, specificities, and 95% confidence intervals (cis) were calculated for both rules. results: 8,079 patients were included with a median age of 5.9 years and a median iss of 9. emergent intervention was required in 51 patients (0.6%). the llr had a sensitivity ranging from 59.4%-59.7% (95% ci: 25.9%-93.5%) and specificity ranging from 49.5%-86.5% (95% ci: 21.6%-82.1%) between both institutions. the mrc had a sensitivity ranging from 73.6%-81.6% (95% ci: 54.7%-95.1%) and specificity ranging from 69.4%-84.7% (95% ci: 54.7%-90.1%) between institutions. conclusion: emergent intervention is rare in pediatric trauma patients. the mrc was more sensitive for predicting the need for emergent intervention than the llr. neither set of criteria was sufficiently accurate to recommend their routine use for pediatric trauma patients. droperidol for sedation of acute behavioural disturbance leonie a. calver 1 , colin page 2 , michael downes 3 , betty chan 4 , geoffrey k. isbister 1 1 calvary mater newcastle and university of newcastle, newcastle, australia; 2 princess alexandra hospital, brisbane, australia; 3 calvary mater newcastle, newcastle, australia; 4 prince of wales hospital, sydney, australia background: acute behavioural disturbance (abd) is a common occurrence in the emergency department (ed) and is a risk to staff and patients. there remains little consensus on the most effective drug for sedation of violent and aggressive patients. prior to the food and drug administration's black box warning, droperidol was commonly used and was considered safe and effective. objectives: this study aimed to investigate the effectiveness of parenteral droperidol for sedation of abd. methods: as part of a prospective observational study, a standardised protocol using droperidol for the seda-acute and delayed behavioral deficits were demonstrated in this rat model of co toxicity, which parallels the neurocognitive deficit pattern observed in humans (see figure) . similar to prior studies, pathologic analysis of brain tissue demonstrated the highest percentage of necrotic cells in the cortex, pyramidal cells, and cerebellum. the collected data are summarized in the table. we have developed an animal model of severe co toxicity evidenced by behavioral deficits and neuronal necrosis. future efforts will compare neurologic outcomes in severely co poisoned rats treated with hypothermia and 100% inspired o2 versus hbo to normothermic controls treated with 100% inspired o2. increasing in popularity, attracting more than 70,000 annual participants worldwide. prior studies have consistently documented renal function impairment, but only after race completion. the incidence of renal injury during these multi-day ultramarathons is currently unknown. this is the first prospective cohort study to evaluate the incidence of acute kidney injury (aki) in runners during a multi-day ultramarathon foot race. objectives: to assess the effect of inter-stage recovery versus cumulative damage on resulting renal function during a multi-day ultramarathon. methods: demographic and biochemical data gathered via phlebotomy and analyzed by istatò (abbott, nj) were collected at the start and finish of day 1 (25 miles), 3 (75 miles), and 5 (140 miles) during racing the planet'sò150-mile, 7-day self-supported desert ultramarathons. pre-established rifle criteria using creatinine (cr) and glomerular filtration rate (gfr) defined aki as ''no injury'' (cr <1.5x normal, decrease of gfr <25%), ''risk'' (cr 1.5x normal, decrease of gfr by 25-49%), and ''injury'' (cr 2x normal, decrease of gfr by 50-75%). results: thirty racers (76% male) with a mean (+/) sd) age of 39 + /-10 years were studied during the 2008 sahara (n = 7, 23.3%), 2008 gobi (n = 10, 33%), and 2009 namibia (n = 13, 43.3%) events. the average decrease in gfr from day 1 start to day 1 finish was 28 + /-25 (p < 0.001, 95% ci 18.5-37.6); day 1 start to day 3 finish was 29.6 + /-20.1 (p < 0.001, 95% ci 18.4-40.7); and day 1 start to day 5 finish was 30.9 ± 17.5 (p < 0.001, 95% ci 20.8-41). runners categorized as risk and injury for aki after stage 1 was 44.8 % and 10%; after stage 3 was 67% and 13%, and after stage 5 was 57.1% and 7.1% conclusion: the majority of participants developed significant levels of renal impairment despite recovery intervals. given the changes in renal function, potentially harmful non-steroidal anti-inflammatory drugs should be minimized to prevent exacerbating acute kidney injury. background: more than 10% of the elderly abuse prescription drugs, and emergency medicine providers frequently struggle to identify features of opioid addiction in this population. the prescription drug use questionnaire (pduqp) is a validated, 42-item, patient-administered tool developed to help health care providers better identify problematic opioid use, or dependence, in patients who receive opioids for the treatment of chronic pain. objectives: to identify the prevalence of prescription drug misuse features in elderly ed patients. methods: this cross-sectional, observational study was conducted between 07/2011 and 08/2011 in the ed of an urban, university-affiliated community hospi-tal that serves a large geriatric population. all patients aged 65 to 89 inclusive were eligible, and were recruited on a convenience basis. exclusion criteria included known dementia, and critical illness. outcomes of interest included self-reported history of prior prescription opioid use, substance abuse history, aberrant medication-taking behaviors, and pduqp results. results: one hundred patients were approached for participation. two were excluded for inability to read english, three were receiving analgesia for metastatic cancer, 28 had never taken a prescription opioid, and seven refused to participate beyond pre-screening. sixty patients completed the study (see table 1 ). of those, 13.3% reported four or more visits within 12 months; chronic pain was reported by 56.7%; debilitating pain by 55.9%; prior pain management referral by 18.3%; and storing opioids for future use by 30%. seventeen patients reported current prescription opioid use, and were administered the pduqp (see figure) . in this population, 47.1% thought their pain was not adequately being treated; 41.2% reported having to increase the amount of pain medication they were taking over the prior 6 months; 35.3% saved up future pain medication; 11.8% had doctors refuse to give them pain medication for fear that the patient would abuse the prescription opioids; and 29.4% reported having a previous drug or alcohol problem. conclusion: screening instruments, such as the pduqp, facilitate identification of geriatric patients with features of opioid misuse. a high proportion of patients in this study save opioids for further use. interventions for safe medication disposal may decrease access to opioids and subsequent morbidity. age extremes, male sex, and several chronic health conditions were associated with increased odds of heat stroke, hospital admission, and death in the ed by a factor of 2-3. chronic hematologic disease (e.g. anemia) was associated with a 10-12 fold increase in adjusted odds of each of these outcomes. conclusion: hri imposes a substantial public health burden, and a wider range of chronic conditions confer susceptibility than previously thought. males, older adults, and patients with chronic conditions, particularly anemia, are likely to have more severe hri, be admitted, or die in the ed. background: carbon monoxide (co) poisoning is a remarkable cause of death worldwide. co, produced by the incomplete combustion of hydrocarbons, has many toxic effects on especially the heart and brain. co binds strongly to cytochrome oxidase, hemoglobin, and myoglobin causing hypoxia of organs and issues. co converts hemoglobin to carboxyhemoglobin and makes transport of oxygen through the body impossible and causes severe hypoxia. objectives: the aim of this study is to investigate the levels of s100b and neuron specific enolase (nse) measured both during admittance and at the sixth hour of hyperbaric and normobaric oxygen therapy carried out on patients with a diagnosis of co poisoning. methods: the study is designed as a prospective observational laboratory study. forty patients were enrolled in the study: 20 underwent normobaric oxygen therapy (nbot) and the other 20 underwent hyperbaric oxygen therapy (hbot). levels of s100b and nse were measured both during admittance and at the sixth hour of admittance of all patients. demographic data, clinical characteristics, and outcome measures were recorded. all data were statistically analyzed. results: in both treatment groups, mean levels of nse after therapy were significantly lower than admittance levels. although levels of nse measured before and 6 hours after treatment in hbot group were high, the difference between groups was not statistically significant (p > 0.05). in both treatment groups, mean levels of s100b after therapy were significantly lower than admittance levels; likewise nse. although levels of s100b measured before and 6 hours after treatment in hbot group were high, the difference between groups was not statistically significant (p > 0.05). additionally, while levels of s100b measured after treatment in the hbot group were lower compared to the nbot group, the difference between groups was also not statistically significant (p > 0.05). conclusion: levels of s100b and nse as evidence for brain injury elevation in case of co poisoining and decrease by therapy according to our study as well as previous studies. decrease in levels of s100b is more significant. according to our results, s100b and nse may be useful markers in case of co poisoning; however, we did not meet any data providing more value in determining hbot indications and determining levels of cohb in the management of patients with a diagnosis of co poisoining. neurons objectives: this study was conducted to determine if neurons in the dmh, and its neighbor the paraventricular hypothalamus (pvn), were likewise involved in mdma-mediated neuroendocrine responses, and if serotonin 1a receptors (5-ht1a) play a role in this regional response. methods: in both experiments, male sprague dawley rats (n = 5-12/group) were implanted with bilateral cannulas targeting specific regions of the brain, i.v. catheters for drug delivery, and i.a. catheters for blood withdrawal. experiments were conducted in raturn cages, which allow blood withdrawal and drug administration in free moving animals while recording their locomotion. in the first experiment, rats were microinjected into the dmh, the pvn, or a region between, with the gabaa agonist muscimol (80 pmol/100nl/side) or pbs (100nl) and 5 min later were injected with either mdma (7.5 mg/kg i.v.) or an equal volume of saline. blood was withdrawn prior to microinjections and 15 minutes after mdma for ria measurement of plasma acth. locomotion was recorded throughout the experiment. in a separate experiment of identical design, either the 5-ht1a antagonist way 100635 (way, 5 nmol/100 nl/side) or saline was microinjected followed by i.v. injection of mdma or saline. in both experiments, increases in acth and distance traveled were compared between groups using an anova analysis. results: when compared to controls, microinjections of muscimol into the dmh, pvn, or the area in between attenuated plasma increases in acth and locomotion evoked by mdma. when microinjected into the dmh or pvn, way had no effect on acth, but when injected into the region of the dmh it significantly increased locomotion. background: poor hand-offs between physicians when admitting patients have been shown to be a major source of medical errors. objectives: we propose that training in a standardized admissions protocol by emergency medicine (em) to internal medicine (im) residents would improve the quality of and quantity of communication of vital patient information. methods: em and im residents at a large academic center developed an evidence-based admission handover protocol termed the '7ps' (table 1) . em and im residents received '7ps' protocol training. im residents recorded prospectively how well each of the seven ps were communicated during each admission pre-and post-intervention. im residents also assessed the overall quality of the handover using a likert scale. the primary outcome was the change in the number of 'ps' conveyed by the em resident to the accepting im resident. data were collected for six weeks before and then for six weeks starting two weeks after the educational intervention. results: there were 78 observations recorded in the preintervention (control) group and 48 observations in the post-intervention group. for each of the seven 'ps' the percentage of observation where all of the information was communicated is shown in table 2 . the communication of 'ps' increased following the intervention. this rise was statistically significant for patient information and pending tests. in the control group the mean of total communicated ps was 5 and in the intervention group, the mean increased to 6 (p < 0.005). the quality of the handover communication had a mean rating of 3.9 in the control group and 4.3 in the intervention group (p < 0.05). conclusion: this educational intervention in a cohort of em and im residents improved the quality and quantity of vital information communicated during patient handovers. the intervention was statistically significant for patient information transfer and tests pending. the results are limited by study size. based on our preliminary data, an agreed-upon handover protocol with training improved the amount and quality of communication during patients' hospital admission on simple items that were likely had been taken for granted as routinely transmitted. we recruited a convenience sample of residents and students rotating in the pediatric emergency department. a two-sided form had the same seven clinical decisions on each side: whether to perform blood, urine, spinal fluid tests, imaging, iv fluids, antibiotics, or a consult. the rating choices were: definitely not, probably not, probably would, and definitely would. trainees rated each decision after seeing a patient, but before presenting to the preceptor, who, after evaluating the patient, rated the same seven decisions on the second side of the form. the preceptor also indicated the most relevant decision (mrd) for that patient. we examined the validity of the technique using hypothesis testing; we posited that residents would have a higher degree of concordance with the preceptor than would medical students. this was tested using dichotomized analyses (accuracy, kappa) and roc curves with the preceptor decision as the gold standard. results: thirty-one students completed 130 forms (median 4 forms; iqr 2,6) and 23 residents completed 206 (6; iqr 3,12). preceptors included 24 attending physicians and 3 fellows (9; iqr 4, 21). students were concordant with preceptors in 70% (k = 0.38) of mrd while residents agreed in 79.6% (p = 0.045), k = 0.59. roc analysis revealed significant differences between students and residents in the auc for the mrd (0.84 vs 0.72; p = 0.03). conclusion: this measure of trainee-preceptor concordance requires further research but may eventually allow for assessment of trainee clinical decision-making. it also has the pedagogical advantage of promoting independent trainee decision-making. background: basic life support (bls) and advanced cardiac life support (acls) are integral parts of emergency cardiac care. this training is usually reserved in most institutions for residents and faculty. the argument can be made to introduce bls and acls training earlier in the medical student curriculum to enhance acquisition of these skills. objectives: the goal of the survey was to characterize the perceptions and needs of graduating medical students in regards to bls and acls training. methods: this was a survey-based study of graduating fourth year medical students at a u.s. medical school. the students were surveyed before voluntarily participating in a student-led acls course in march of their final year. the surveys were distributed before starting the training course. both bls and acls training, comfort levels, and perceptions were assessed in the survey. results: of the 182 students in the graduating class, 152 participated in the training class with 109 (72%) completing the survey. 50% of students entered medical school without any prior training and 49% started clinics without training. 83.5% of students reported witnessing an average of 3.0 in-hospital cardiac arrests during training (range of 0-20). overall, students rated their preparedness 2.0 (sd 1.0) for adult resuscitations on a 1-5 likert scale with 1 being the unprepared. 98% and 92% of students believe that bls and acls should be included in the medical student curriculum respectively with a preference for teaching before starting clerkships. 36% of students avoided participating in resuscitations due to lack of training. of those, 95% said they would have participated had they been trained. conclusion: to our knowledge, this is one of the first studies to address the perceptions and needs for bls and acls training in u.s. medical schools. students feel that bls and acls training is needed in their curriculum and would possibly enhance perceived comfort levels and willingness to participate in resuscitations. background: professionalism is one of six core competency requirements of the acgme, yet defining and teaching its principles remains a challenge. the ''social contract'' between physician and community is clearly central to professionalism so determining the patient's understanding of the physician's role in the relationship is important. because specialization has created more narrowly focused and often quite different interactions in different medical environments, the patient concept of professionalism in different settings may vary as well. objectives: we hoped to determine if patients have different conceptions of professionalism when considering physicians in different clinical environments. methods: patients were surveyed in the waiting room of an emergency department, an outpatient internal medicine clinic, and a pre-operative/anesthesia clinic. the survey contained 18 examples of attributes, derived from the american board of internal medicine's eight characteristics of professionalism. participants were asked to rate, on a 10-point scale, the importance that a physician possess each attribute. an anova analysis was used to compare the sites for each question. results: of 604 who took the survey, 200 were in the emergency department, 202 were in the medicine clinic, and 202 were in the pre-operative clinic. females comprised 56% of the study group and the average age was 49 with a range from 18 to 94. there was a significant difference on the attribute of ''providing a portion of work for those who cannot pay;'' this was rated higher in the emergency department (p = 0.003). there was near-significance (p = 0.05) on the attribute of ''being able to make difficult decisions under pressure,'' which was rated higher in the pre-op clinic. there was no difference for any of the other questions. the top four professional attributes at each clinical site were the same -''honesty,'' ''excellence in communication and listening,'' ''taking full responsibility for mistakes,'' and ''technical competence/ skill;'' the bottom two were ''being an active leader in the community'' and ''patient concerns should come before a doctor's family commitments.'' conclusion: very few differences between clinical sites were found when surveying patient perception of the important elements of medical professionalism. this may suggests a core set of values desired by patients for physicians across specialties. emergency medicine faculty knowledge of and confidence in giving feedback on the acgme core competencies todd guth, jeff druck, jason hoppe, britney anderson university of colorado, aurora, co background: the acgme mandates that residency programs assess residents based upon six core competencies. although the core competencies have been in place for a number of years, many faculty are not familiar with the intricacies of the competencies and have difficulty giving competency-specific feedback to residents. objectives: the purpose of the study is to determine the extent to which emergency medicine (em) faculty can identify the acgme core competencies correctly and to determine faculty confidence with giving general feedback and core competency focused feedback to em residents. methods: design and participants: at a single department of em, a survey of twenty-eight faculty members, their knowledge of the acgme core competencies, and their confidence in providing feedback to residents was conducted. confidence levels in giving feedback were scored on a likert scale from 1 to 5. observations: descriptive statistics of faculty confidence in giving feedback, identification of professional areas of interest, and identification of the acgme core competencies were determined. mann-whitney u tests were used to make comparisons between groups of faculty given the small sample size of the respondents. results: there was a 100% response rate of the 28 faculty members surveyed. eight faculty members identified themselves as primarily focused on education. although those faculty members identifying themselves as focused on education scored higher than non-education focused faculty for all type of feedback (general feedback, constructive feedback, negative feedback), there was only a statistical difference in confidence levels 4.57 versus 2.65 (p < 0.002) for acgme core competency specific feedback when compared to noneducation focused faculty. while education focused faculty correctly identified all six of acgme core competencies 94% of the time, not one of the non-education focused faculty identified all six of the core competencies correctly. non-education focused faculty only correctly identified three or more competencies 25% of the time. conclusion: if residency programs are to assess residents using the six acgme core competencies, additional faculty development specific to the core competencies will be needed to train all faculty on the core competencies and on how to give core competency specific feedback to em residents. there is no clear consensus as to the most effective tool to measure resident competency in emergency ultrasound. objectives: to determine the relationship between the number of scans and scores on image recognition, image acquisition, and cognitive skills as measured by an objective structured clinical exam (osce) and written exam. secondarily, to determine whether image acquisition, image recognition, and cognitive knowledge require separate evaluation methodologies. methods: this was a prospective observational study in an urban level i ed with a 3-year acgme-accredited residency program. all residents underwent an ultrasound introductory course and a one-month ultrasound rotation during their first and second years. each resident received a written exam and osce to assess psychomotor and cognitive skills. the osce had two components: (1) recognition of 22 images, and (2) acquisition of images. a registered diagnostic medical sonographer (rdms)-certified physician observed each bedside examination. a pre-existing residency ultrasound database was used to collect data about number of scans. pearson correlation coefficients were calculated for number of scans, written exam score, image recognition, and image acquisition scores on the osce. results: twenty-nine residents were enrolled from march 2010 to february 2011 who performed an average of 247 scans (range 118-617). there was no significant correlation between number of scans and written exam scores. an analysis of the number of scans and the ocse found a moderate correlation with image acquisition (r = 0.42, p = 0.029) and image recognition (r = 0.61, p = <0.01)). pearson correlation analysis between the image acquisition score and image recognition score found that there was no correlation (r = 0.175, p = 0.383). there was a moderate correlation with image acquisition scores to written scores (r = 0.541, p = 0.025) and image recognition scores to written scores (r = 0.596, p = 0.019). conclusion: the number of scans does not correlate with written tests but has a moderate correlation with image acquisition and image recognition. this suggests that resident education should include cognitive instruction in addition to scan numbers. we conclude that multiple methods are necessary to examine resident ultrasound competency. background: although emergency physicians must often make rapid decisions that incorporate their interpretation of an ecg, there is no evidence-based description of ecg interpretation competencies for emergency medicine (em) trainees. the first step in defining these competencies is to develop a prioritized list of ecg findings relevant to em contexts. objectives: the purpose of this study was to categorize the importance of various ecg diagnoses and/or findings for the em trainee. methods: we developed an extensive list of potentially important ecg diagnoses identified through a detailed review of the cardiology and em literature. we then conducted a three-round delphi expert opinion-soliciting process where participants used a five-point likert scale to rate the importance of each diagnosis for em trainees. consensus was defined as a minimum of 75 percent agreement on any particular diagnosis at the second round or later. in the absence of consensus, stability was defined as a shift of 20 percent or less after successive rounds. results: twenty-two em experts participated in the delphi process, sixteen (72%) of whom completed the process. of those, fifteen were experts from eleven different em training programs across canada and one was a recognized expert in em electrocardiography. overall, 77 diagnoses reached consensus, 42 achieved stability, and one diagnosis achieved neither consensus nor stability. out of 120 potentially important ecg diagnoses, 53 (43%) were considered ''must know'' diagnoses, 62 (51%) ''should know'' diagnoses, and 7 (6%) ''nice to know'' diagnoses. conclusion: we have categorized ecg diagnoses within an em training context, knowledge of which may allow clinical em teachers to establish educational priorities. this categorization will also facilitate the development of an educational framework to establish em trainee competency in ecg interpretation. ''rolling refreshers background: cardiac arrest survival rates are low despite advances in cardiopulmonary resuscitation. high quality cpr has been shown to impart greater cardiac arrest survival; however, retention of basic cpr skills by health care providers has been shown to be poor. objectives: to evaluate practitioner acceptance of an in-service cpr skills refresher program, and to assess for operator response to real-time feedback during refreshers. methods: we prospectively evaluated a ''rolling refresher'' in-service program at an academic medical center. this program is a proctored cpr practice session using a mannequin and cpr-sensing defibrillator that provides real-time cpr quality feedback. subjects were basic life support-trained providers who were engaged in clinical care at the time of enrollment. subjects were asked to perform two minutes of chest compressions (ccs) using the feedback system. ccs could be terminated when the subject had completed approximately 30 seconds of compressions with <3 corrective prompts. a survey was then completed by to obtain feedback regarding the perceived efficacy of this training model. cpr quality was then evaluated using custom analysis software to determine the percent of cc adequacy in 30-second intervals. results: enrollment included 88 subjects from the emergency department and critical care units (55 nurses, 17 physicians, 16 students and allied health professionals). all participants completed a survey and 61 cpr performance data logs were obtained. positive impressions of the in-service program were registered by 81% (71/88) and 74% (65/88) reported a self-perceived improvement in skills confidence. eighty-three percent (73/88) of respondents felt comfortable performing this refresher during a clinical shift. thirtynine percent (24/61) of episodes exhibited adequate cc performance with approximately 30 seconds of cc. of the remaining 37 episodes, 71.1 ± 29.2% of cc were adequate in the first 30 seconds with 80.1 ± 28.6% of cc adequate during the last 30 second interval (p = 0.1847). of these 37 individuals, 30 improved or had no change in their cpr skills, and 7 individuals skills declined during cc performance (p = 0.007). conclusion: implementation of a bedside cpr skill refresher program is feasible and is well received by hospital staff. real time cpr feedback improved upon cpr skill performance during the in-service session. teaching emergency medicine skills: is a self-directed, independent, online curriculum the way of the future? tighe crombie, jason r. frank, stephen noseworthy, richard gerein, a. curtis lee university of ottawa, ottawa, on, canada background: procedural competence is critical to emergency medicine, but the ideal instructional method to acquire these skills is not clear. previous studies have demonstrated that online tutorials have the potential to be as effective as didactic sessions at teaching specific procedural skills. objectives: we studied whether a novel online curriculum teaching pediatric intraosseus (io) line insertion to novice learners is as effective as a traditional classroom curriculum in imparting procedural competence. methods: we conducted a randomized controlled educational trial of two methods of teaching io skills. preclinical medical students with no past io experience completed a written test and were randomized to either an online or classroom curriculum. the online group (og) were given password-protected access to a website and instructed to spend 30 minutes with the material while the didactic group (dg) attended a lecture of similar duration. participants then attended a 30-minute unsupervised manikin practice session on a separate day without any further instruction. a videotaped objective structured clinical examination (osce) and post-course written test were completed immediately following this practice session. finally, participants were crossed over into the alternate curriculum and were asked to complete a satisfaction survey that compared the two curricula. results were compared with a paired t-test for written scores and an independent t-test for osce scores. results: sixteen students completed the study. pre-course test scores of the two groups were not significantly different prior to accessing their respective curricula (mean scores of 32% for og and 34% for dg, respectively; p > 0.05). post-course written scores were also not significantly different (both with means of 76%; p > 0.05); however, for the post-treatment osce scores, the og group scored significantly higher than the dg group (mean scores of 92.6% and 88.1%; t(14) = 1.76, p < 0.05.) conclusion: this novel online curriculum was superior to a traditional didactic approach to teaching pediatric io line insertion. novice learners assigned to a selfdirected online curriculum were able to perform an emergency procedural skill to a high level of performance. em educators should consider adopting online teaching of procedural skills. background: applicants to em residency programs obtain information largely from the internet. curricular information is available from a program's website (pw) or the saem residency directory (sd). we hypothesize that there is variation between these key sources. objectives: to identify discrepancies between each pw and sd. to describe components of pgy1-3 em residency programs' curricula as advertised on the internet. methods: pgy1-3 residencies were identified through the sd. data were abstracted from individual sd and pw pages identifying pre-determined elements of interest regarding rotations in icu, pediatrics, inpatient (medicine, pediatrics, general surgery), electives, orthopedics, toxicology, and anesthesia. agreement between the sd and pw was calculated using a cohen's unweighted kappa calculation. curricula posted on pws were considered the gold standard for the programs' current curricula. results: a total of 117 pgy1-3 programs were identified through the sd and confirmed on the pw. ninetyone of 117 programs (78%) had complete curricular information on both sites. only these programs were included in the kappa analysis for sd and pw comparisons. of programs with complete listings, 66 of 91 programs (73%) had at least one discrepancy. the agreement of information between pw and sd revealed a kappa value of 0.26 (95% ci 0.19-0.33). analysis of pw revealed that pgy1-3 programs have an average of 4.15 (range, 2-9), 3.1 (range, 1-6), 1.7 (range, 0-4), and 1.0 (range, 0-4) blocks of icu, pediatrics, elective, and inpatient, respectively. common but not rrc-mandated rotations in orthopedics, toxicology, and anesthesiology are present in 77, 80, and 93 percent of programs, respectively. conclusion: publicly accessible curricular information through the sd and pw for pgy1-3 em programs only has fair agreement (using commonly accepted kappa value guides). applicants may be confused by the variability of data and draw inaccurate conclusions about program curricula. from the gravid uterus and improves cardiac output; however, this theory has never been proven. objectives: we set out to determine the difference in inferior vena cava (ivc) filling when third trimester patients were placed in supine, llt, and right lateral tilt (rlt) positions using ivc ultrasound. methods: healthy pregnant women in their third trimester presenting to the labor and delivery suite were enrolled. patients were placed in three different positions (supine, rlt, and llt) and ivc maximum (max) and minimum (min) measurements were obtained using the intercostal window in short axis approximately two centimeters below the entry of the hepatic veins. ivc collapse index (ci) was calculated for each measurement using the formula (max-min)/max. in addition, blood pressure, heart rate, and fetal heart rate were monitored. patients stayed in each position for at least 3 minutes prior to taking measurements. we compared ivc measurements using a one-way analysis of variance for repeated measures. results: twenty patients were enrolled. the average age was 25 years (sd 5.7) with a mean estimated gestational age of 39.5 weeks (sd 1.4). there were no significant differences seen in ivc filling in each of the positions (see table 1 ). in addition, there were no differences in hemodynamic parameters between positions.ten (50%) patients had the largest ivc measurement in the llt position, 7 (35%) patients in the rlt position, and 3 (15%) in the supine position. conclusion: there were no significant differences in ivc filling between patient positions. for some third trimester patients llt may not be the optimal position for ivc filling. background: although the acgme and rrc require competency assessment in ed bedside ultrasound (us), there are no standardized assessment tools for us training in em. objectives: using published us guidelines, we developed four observed structured competency evalua-tions (osce) for four common em us exams: fast, aortic, cardiac, and pelvic. inter-rater reliability was calculated for overall performance and for the individual components of each osce. methods: this prospective observational study derived four osces that evaluated overall study competency, image quality for each required view, technical factors (probe placement, orientation, angle, gain, and depth), and identification of key anatomic structures. em residents with varying levels of training completed an osce under direct observation of two em-trained us experts. each expert was blinded to the other's assessment. overall study competency and image quality of each required views were rated on a five-point scale (1poor, 2-fair, 3-adequate, 4-good, 5-excellent), with explicit definitions for each rating. each study had technical factors (correct/incorrect) and anatomic structures (identified/not identified) assessed as binary variables. data were analyzed using cohen's and weighted k, descriptive statistics, and 95% ci. results: a total of 185 us exams were observed, including 33 fast, 53 cardiac, 53 aorta, and 46 pelvic. total assessments included 185 ratings of overall study competency, 691 ratings of required view image quality, 2998 ratings of technical factors, and 2978 ratings of anatomic structures. inter-rater assessment of overall study competency showed excellent agreement, raw agreement 0.84 (0.77, 0.89), weighted k 0.87 (0.82, 0.91). ratings of required view image quality showed excellent agreement: raw agreement 0.75 (0.72, 0.79), weighted k 0.82 (0.79, 0.84). inter-rater assessment of technical factors showed substantial agreement: raw agreement 0.96 (0.95, 0.97), cohen's k 0.78 (0.74, 0.82). ratings of identification of anatomic structures showed substantial agreement: raw agreement 0.86 (0.85, 0.88), cohen's k 0.64 (0.60, 0.67). conclusion: inter-rater reliability is substantial to excellent using the derived ultrasound osces to rate em resident competency in fast, aortic, cardiac, and pelvic ultrasound. validation of this tool is ongoing. a objectives: the objective of this study was to identify which transducer orientation, longitudinal or transverse, is the best method of imaging the axillary vein with ultrasound, as defined by successful placement in the vein with one needle stick, no redirections, and no complications. methods: emergency medicine resident and attending physicians at an academic medical center were asked to cannulate the axillary vein in a torso phantom model. the participants were randomized to start with either the longitudinal or transverse approach and completed both sequentially, after viewing a teaching presentation. participants completed pre-and post-attempt questionnaires. measurements of each attempt were taken regarding time to completion, success, skin punctures, needle redirections, and complications. we compared proportions using a normal binomial approximation and continuous data using the t-distribution, as appropriate. a sample size of 57 was chosen based on the following assumptions: power, 0.8; significance, 0.05; effect size, 50% versus 75%. results: fifty-seven operators with a median experience of 85 prior ultrasounds (26 to 120 iqr) participated. first-attempt success frequency was 39/57 (0.69) for the longitudinal method and 21/57 (0.37) for the transverse method (difference 0.32, 95% ci 0.12-0.51); this difference was similar regardless of operator experience. the longitudinal method had fewer redirections (mean difference 1.8, 95% ci 0.8-2.8) and skin punctures (mean difference 0.3, 95% ci )2 to 0.18). arterial puncture occurred in 2/57 longitudinal attempts and 7/ 57 transverse attempts, with no pleural punctures in either group. among successful attempts, the time spent was 24 seconds less for longitudinal method (95% ci 3-45). though 93% of participants had more experience with the transverse method prior to the training session, 58% indicated after the session that they preferred the longitudinal method. methods: a prospective single-center study was conducted to assess the compressibility of the basilic vein with ultrasound. healthy study participants were recruited. the compressibility was assessed at baseline, and then further assessed with one proximal tourniquet, two tourniquets (one distal and one proximal), and a proximal blood pressure cuff inflated to 150 mmhg. compressibility was defined as the vessel's resistance to collapse to external pressure and rated as completely compressible, moderately compressible, or mildly compressible after mild pressure was applied with the ultrasound probe. results: one-hundred patients were recruited into the study. ninety-eight subjects were found to have a completely compressible basilic vein at baseline. when one tourniquet and two tourniquets were applied 64 and 58 participants, respectively, continued to have completely compressible veins. a fisher's exact test comparing one versus two tourniquets revealed no difference between these two techniques (p = 0.46). only two participants continued to have completely compressible veins following application of the blood pressure cuff. the compressibility of this group was found to be statistically significant by fisher's exact test compared to both tourniquet groups (p < 0.0001). furthermore, 24 participants with the blood pressure cuff applied were found to have moderately compressible veins and 72 participants were found to have mildly compressible veins. conclusion: tourniquets and blood pressure cuffs can both decrease the compressibility of peripheral veins. while there was no difference identified between using one and two tourniquets, utilization of a blood pressure cuff was significantly more effective to decrease compressibility. the findings of this study may be utilized in the emergency department when attempting to obtain peripheral venous access, specifically supporting the use of blood pressure cuffs to decrease compressibility. background: electroencephalography (eeg) is an underused test that can provide valuable information in the evaluation of emergency department (ed) patients with altered mental status (ams). in ams patients with nonconvulsive seizure (ncs), eeg is necessary to make the diagnosis and to initiate proper treatment. yet, most cases of ncs are diagnosed >24 h after ed presentation. obstacles to routine use of eeg in the ed include space limitations, absence of 24/7 availability of eeg technologists and interpreters, and the electrically hostile ed environment. a novel miniature portable wireless device (microeeg) is designed to overcome these obstacles. objectives: to examine the diagnostic utility of micro-eeg in identifying eeg abnormalities in ed patients with ams. methods: an ongoing prospective study conducted at two academic urban eds. inclusion: patients ‡13 years old with ams. exclusion: an easily correctable cause of ams (e.g. hypoglycemia, opioid overdose). three 30-minute eegs were obtained in random order from each subject beginning within one hour of presentation: 1) a standard eeg, 2) a microeeg obtained simultaneously with conventional cup electrodes using a signal splitter, and 3) a microeeg using an electrocap. outcome: operative characteristics of micro-eeg in identifying any eeg abnormality. all eegs were interpreted in a blinded fashion by two board-certified epileptologists. within each reader-patient pairing, the accuracy of eegs 2 and 3 were each assessed relative to eeg 1. sensitivity, specificity, and likelihood ratios (lr) are reported for microeeg by standard electrodes and electrocap (eegs 2 and 3). inter-rater variability for eeg interpretations is reported with kappa. results: the interim analysis was performed on 130 consecutive patients (target sample size: 260) enrolled from may to october 2011 (median age: 61, range: 13-100, 40% male). overall, 82% (95% confidence interval [ci], 76-88%) of interpretations were abnormal (based on eeg1). kappa values representing the agreement of neurologists in interpretation of eeg 1-3 were 0.54 (0.36-0.73), 0.57 (0.39-0.75), and 0.55 (0.37-0.74), respectively. conclusion: the diagnostic accuracy and concordance of microeeg are comparable to those of standard eeg but the unique ed-friendly characteristics of the device could help overcome the existing barriers for more frequent use of eeg in the ed. (originally submitted as a ''late-breaker.'') a background: patients who use an ed for acute migraine are characterized by higher migraine disability scores, lower socio-economic status, and are unlikely to have used a migraine-specific medication prior to ed presentation. objectives: to determine if a comprehensive migraine intervention, delivered just prior to ed discharge, could improve migraine impact scores one month after the ed visit. methods: this was a randomized controlled trial of a comprehensive migraine intervention versus typical care among patients who presented to an ed for management of acute migraine. at the time of discharge, for patients randomized to comprehensive care, we reinforced their diagnosis, shared a migraine education presentation from the national library of medicine, provided them with six tablets of sumatriptan 100 mg and 14 tablets of naproxen 500 mg, and if they wished, provided them with an expedited free appointment to our institution's headache clinic. patients randomized to typical care received the care their attending emergency physician felt was appropriate. the primary outcome was a between-group comparison of the hit6 score, a validated headache assessment instrument, one month after ed discharge. secondary outcomes included an assessment of satisfaction with headache care and frequency of use of migraine-specific medication within that one month period. the outcome assessor was blinded to assignment. results: over a 19 month period, 50 migraine patients were enrolled. one month follow-up was successfully obtained in 92% of patients. baseline characteristics were comparable. one month hit6 scores in the two groups were nearly identical (59 vs 56, 95%ci for difference of 3: )5, 11), as was dissatisfaction with overall headache care (17% versus 18%, 95%ci for difference of 1%: )22, 24%). not surprisingly, patients randomized to the comprehensive intervention were more likely to be using triptans or migraine-preventive therapy (43% versus 0%, 95%ci for difference of 43%: 20, 63%) one month later. conclusion: a comprehensive migraine intervention, when compared to typical care, did not improve hit6 scores one month after ed discharge. future work is needed to define a migraine intervention that is practical and useful in an ed. background: lumbar puncture (lp) is the standard of care for excluding non-traumatic subarachnoid hemorrhage (sah), and is usually performed following head ct (hct). however, in the setting of a non-diagnostic hct, lp demonstrates a low overall diagnostic yield for sah (<1% positive rate). objectives: to describe a series of ed patients diagnosed with sah by lp following a non-diagnostic hct, and, when compared to a set of matched controls, determine if clinical variables can reliably identify these ''ct-negative/lp-positive'' patients. methods: retrospective case-control chart review of ed patients in an integrated health system between the years 2000-2011 (estimated 5-6 million visits among 18 eds). patients with a final diagnosis of non-traumatic sah were screened for case inclusion, defined as an initial hct without sah by final radiologist interpretation and a lp with >5 red blood cells/mm 3 , along with either 1) xanthochromic cerebrospinal fluid, 2) angiographic evidence of cerebral aneurysm or arteriovenous malformation, or 3) head imaging showing sah within 48 hours following lp. control patients were randomly selected among ed patients diagnosed with headache following a negative sah evaluation with hct and lp. controls were matched to cases by year and presenting ed in a 3:1 ratio. stepwise logistic regression and classification and regression tree analysis (cart) were employed to identify predictive variables. inter-rater reliability (kappa) was determined by independent chart review. results: fifty-five cases were identified. all cases were hunt-hess grade 1 or 2. demographics are shown in table 1 . thirty-four cases (62%) had angiographic evidence of sah. five variables were identified that positively predicted sah following a normal hct with 98% sensitivity (95% ci, 90-100%) and 25% specificity (95% ci, 19-32%): age > 50 years, neck pain or stiffness, onset of headache with exertion, vomiting with headache, or loss of consciousness at headache onset. kappa values for selected variables ranged from 0.75-1.0 (18% sample). the c-statistic (auc) and hosmer-lemeshow test p-value for the logistic regression model are 0.87 and 0.74, respectively (table 2) . conclusion: several clinical variables can help safely limit the amount of invasive testing for sah following a non-diagnostic hct. prospective validation of this model is needed prior to practice implementation. background: post-thrombolysis intracerebral hemorrhage (ich) is associated with poor outcomes. previous investigations have attempted to determine the relationship between pre-existing anti-platelet (ap) use and the safety of intravenous thrombolysis, but have been limited by low event rates thus decreasing the precision of estimates. objectives: our objective was to determine whether pre-existing ap therapy increases the risk of ich following thrombolysis. methods: consecutive cases of ed-treated thrombolysis patients were identified using multiple methods, including active and passive surveillance. retrospective data were collected from four hospitals from 1996-2005, and 24 distinct hospitals from 2007-2010 as part of a cluster randomized trial. the same chart abstraction tool was used during both time periods and data were subjected to numerous quality control checks. hemorrhages were classified using a pre-specified methodology: ich was defined as presence of hemorrhage in radiographic interpretations of follow up imaging (primary outcome). symptomatic ich (secondary outcome) was defined as radiographic ich with associated clinical worsening. a multivariable logistic regression model was constructed to adjust for clinical factors previously identified to be related to postthrombolysis ich. as there were fewer sich events, the multivariable model was constructed similarly, except that variables divided into quartiles in the primary analysis were dichotomized at the median. results: there were 830 patients included, with 47% having documented pre-existing ap treatment. the mean age was 69 years, the cohort was 53% male, and the median nihss was 12. the unadjusted proportion of patients with any ich was 15.1% without ap and 19.3% with ap (difference 4.2%, 95% ci )1.2% to 9.6%); for sich this was 6.1% without ap and 9% with ap (difference 3.1%, 95%ci )1 to 6.7%). no significant association between pre-existing ap treatment with radiographic or symptomatic ich was observed (table) . conclusion: we did not find that ap treatment was associated with post-thrombolysis ich or sich in this cohort of community treated patients. pre-existing tobacco use, younger age, and lower severity were associated with lower odds of sich. an association between ap therapy and sich may still exist -further research with larger sample sizes is warranted in order to detect smaller effect sizes. background: post-cardiac arrest therapeutic hypothermia (th) improves survival and neurologic outcome after cardiac arrest, but the parameters required for optimal neuroprotection remain uncertain. our laboratory recently reported that 48-hour th was superior to 24-hour th in protecting hippocampal ca1 pyramidal neurons after asphyxial cardiac arrest in rats. cerebellar purkinje cells are also highly sensitive to ischemic injury caused by cardiac arrest, but the effect of th on this neuron population has not been previously studied. objectives: we examined the effect of post-cardiac arrest th onset time and duration on purkinje neuron survival in cerebella collected during our previous study. methods: adult male long evans rats were subjected to 10-minute asphyxial cardiac arrest followed by cpr. rats that achieved return of spontaneous circulation (rosc) were block randomized to normothermia (37.0 deg c) or th (33.0 deg c) initiated 0, 1, 4, or 8 hours after rosc and maintained for 24 or 48 hours (n = 21 per group). sham injured rats underwent anesthesia and instrumentation only. seven days post-cardiac arrest or sham injury, rats were euthanized and brain tissue was processed for histology. surviving purkinje cells with normal morphology were quantified in the primary fissure in nissl stained sagittal sections of the cerebellar vermis. purkinje cell density was calculated for each rat, and group means were compared by anova with bonferroni analysis. results: purkinje cell density averaged (+/) sd) 35.9 (2.4) cells/mm in sham-injured rats. neuronal survival in normothermic post-cardiac arrest rats was significantly reduced compared to sham (10.7% (5.0%)). overall, th resulted in significant neuroprotection compared to normothermia (38.9% (15.7%) of sham). purkinje cell density with 24-hour duration th was 35.0% (11.2%) of sham and 48-hour duration th was 43.3% (15.6%), both significantly improved from sham (p = 0.245 between durations). th initiated 0, 1, 4, and 8 hours post-rosc provided similar benefit: 44.6% (21.6%), 33.2% (8.1%), 36.6% (12.9%), and 41.1% (9.3%) of sham, respectively. conclusion: overall, these results indicate that postcardiac arrest th protects cerebellar purkinje cells with a broad therapeutic window. our results underscore the importance of considering multiple brain regions when optimizing the neuroprotective effect of post-cardiac arrest th. the effect of compressor-administered defibrillation on peri-shock pauses in a simulated cardiac arrest scenario joshua glick, evan leibner, thomas terndrup penn state hershey medical center, hershey, pa background: longer pauses in chest compressions during cardiac arrest are associated with a decreased probability of successful defibrillation and patient survival. having multiple personnel share the tasks of performing chest compressions and shock delivery can lead to communication complications that may prolong time spent off the chest. objectives: the purpose of this study was to determine whether compressor-administered defibrillation led to a decrease in pre-shock and peri-shock pauses as compared to bystander-administered defibrillation in a simulated in-hospital cardiac arrest scenario. we hypothesized that combining the responsibilities of shock delivery and chest-compression performance may lower no-flow periods. methods: this was a randomized, controlled study measuring pauses in chest compressions for defibrillation in a simulated cardiac arrest. medical students and ed personnel with current cpr certification were surveyed for participation between july 2011 and october 2011. participants were randomized to either a control (facilitator-administered shock) or variable (participantadministered shock) group. all participants completed one minute of chest compressions on a mannequin in a shockable rhythm prior to initiation of prompt and safe defibrillation. pauses for defibrillation were measured and compared in both study groups. results: out of 200 total enrollments, the data from 197 defibrillations were analyzed. subject-initiated defibrillation resulted in a significantly lower pre-shock handsoff time (0.57 s; 95% ci: 0.47-0.67) compared to facilitator-initiated defibrillation (1.49 s; 95% ci: 1.35-1.64). furthermore, subject-initiated defibrillation resulted in a significantly lower peri-shock hands-off time (2.77 s; 95% ci: 2.58-2.95) compared to facilitator-initiated defibrillation (4.25 s; 95% ci: 4.08-4.43). conclusion: assigning the responsibility for shock delivery to the provider performing compressions encourages continuous compressions throughout the charging period and decreases total time spent off the chest. this modification may also decrease the risk of accidental shock and improve patient survival. however, as this was a simulation-based study, clinical implementation is necessary to further evaluate these potential benefits. objectives: to determine the sensitivity and specificity of peripheral venous oxygen (po 2 ) to predict abnormal central venous oxygen saturation in septic shock patients in the ed. methods: secondary analysis of an ed-based randomized controlled trial of early sepsis resuscitation targeting three physiological variables: cvp, map, and either scvo 2 or lactate clearance. inclusion criteria: suspected infection, two or more sirs criteria, and either systolic blood pressure <90 mmhg after a fluid bolus or lactate >4 mm. peripheral venous po 2 was measured prior to enrollment as part of routine care, and scvo 2 was measured as part of the protocol. we analyzed for agreement between venous po 2 and scvo 2 using spearman's rank. sensitivity and specificity to predict an abnormal scvo 2 (<70%) were calculated for each incremental value of po 2 . results: a total of 175 were analyzed. median po 2 was 43 mmhg (iqr 32, 55). median initial scvo 2 was 79% (iqr 70, 88). thirty-nine patients (23%) had an initial scvo 2 < 70%. spearman's rank demonstrated fair correlation between initial po 2 and scvo 2 (q = 0.26). a cutoff of venous po 2 < 57 was 90% sensitive and 20% specific for detecting an initial scvo 2 < 70%. twenty-seven patients (20%) demonstrated an initial po 2 of >56. conclusion: in ed septic shock patients, venous po 2 demonstrated only fair correlation with scvo 2, though a cutoff value of 56 was sensitive for predicting an abnormal scvo 2 . twenty percent of patients demonstrated an initial value above the cutoff, potentially representing a group in whom scvo 2 measurement could be avoided. future studies aiming to decrease central line utilization could consider the use of peripheral o 2 measurements in these patients. sessions. ninety-two percent were rns, median clinical experience was 11-15 years, and 56% were from an intensive care unit. provider confidence increased significantly with a single session despite the highly experienced sample (figure 1 ). there was a trend for further increased confidence with an additional session and the increased confidence was maintained for at least 3-6 months given the normal sensitivity analysis. conclusion: high fidelity simulation significantly increases provider confidence even among experienced providers. this study was limited by its small sample size and recent changes in acls guidelines. background: recent data suggest alarming delays and deviations in major components of pediatric resuscitation during simulated scenarios by pediatric housestaff. objectives: to identify the most common errors of pediatric residents during multiple simulated pediatric resuscitation scenarios. methods: a retrospective observational study conducted in an academic tertiary care hospital. pediatric residents (pgy1 and pgy3) were videotaped performing a series of five pediatric resuscitation scenarios using a high-fidelity simulator (simbaby, laerdal): pulseless non-shockable arrest, pulseless shockable arrest, dysrhythmia, respiratory arrest, and shock. the primary outcome was the presence of significant errors prospectively defined using a validated scoring instrument designed to assess sequence, timing, and quality of specific actions during resuscitations based on the 2005 aha pals guidelines. residents' clinical performances were measured by a single video reviewer. the primary analysis was the proportion of errors for each critical task for each scenario. we estimated that the evaluation of each resident would provide a confidence interval less than 0.20 for the proportion of errors. results: twenty-four of 25 residents completed the study. across all scenarios, pulse check was delayed by more than 30 seconds in 56% (95%ci: 46%-66%). for non-shockable arrest, cpr was started more than 30 seconds after recognizing arrest in 21% (95%ci 7-42%) and inappropriate defibrillation was performed in 29% (95%ci 13-51%). for shockable arrest, participants failed to identify the rhythm in 58% (95%ci 37-78%), cpr was not performed in 25% (95%ci 10-47%), while defibrillation was delayed by more than 90 seconds in 33% (95%ci 16-51%) and not performed in one case. for shock, participants failed to ask for a dextrose check in 71% (95%ci 51-86%), and it was delayed by more than 60 seconds for all others. conclusion: the most common error across all scenarios was delay in pulse check. delays in starting cpr and inappropriate defibrillation were common errors in non-shockable arrests, while failure to identify rhythm, cpr omission, and delaying defibrillation were noted for shockable arrests. for shock, omission of rapid dextrose check was the most common error, while delaying the test when ordered was also significant. future training in pediatric resuscitation should target these errors. background: many scoring instruments have been described to measure clinical performance during resuscitation; however, the validity of these tools has yet to be proven in pediatric resuscitation. objectives: to determine the external validity of published scoring instruments to evaluate clinical performance during simulated pediatric resuscitations using pals algorithms and to determine if inter-rater reliability could be assessed. methods: this was a prospective quasi-experimental design performed in a simulation lab of a pediatric tertiary care facility. participants were residents from a single pediatric program distinct from where the instrument was originally developed. a total of 13 pgy1s and 11 pgy3s were videotaped during five simulated pediatric resuscitation scenarios. pediatric emergency physicians rated resident performances before and after a pals course using standardized scoring. each video recording was viewed and scored by two raters blinded to one another. a priori, it was determined that, for the scoring instrument to be valid, participants should improve their scores after participating in the pals course. differences in means between pre-pals and post-pals and pgy1 and pgy3 were compared using an anova test. to investigate differences in the scores of the two groups over the five scenarios, a two-factor anova was used. reliability was assessed by calculating an interclass correlation coefficient for each scenario. results: following the pals course, scores improved by 8.6% (3.8 to 13.3), 15.7% (8.6 to 22.7), 6.3% ()1.8 to 14.3), 18.2% (9.3 to 27), and 4.1% ()3.0 to 11.2) for the pulseless non-shockable arrest, pulseless shockable arrest, dysrhythmia, respiratory, and shock scenarios respectively. there were no differences in scores between pgy1s and pgy3s before and after the pals course. there was an excellent reliability for each scoring instrument with iccs varying between 0.85 and 0.98. conclusion: the scoring instrument was able to demonstrate significant improvements in scores following a pals course for pgy1 and pgy3 pediatric residents for the pulseless non-shockable arrest, pulseless shockable, and respiratory arrest scenarios only. however, it was unable to discriminate between pgy1s and pgy3s both before and after the pals course for any scenarios. the scoring instrument showed excellent inter-reliability for all scenarios. a background: medical simulation is a common and frequently studied component of emergency medicine (em) residency curricula. its utility in the context of em medical student clerkships is not well defined. objectives: the objective was to measure the effect of simulation instruction on medical students' em clerkship oral exam performance. we hypothesized that students randomized to the simulation group would score higher. we predicted that simulation instruction would promote better clinical reasoning skills and knowledge expression. methods: this was a randomized observational study conducted from 7/2009 to 5/2010. participants were fourth year medical students in their em clerkship. students were randomly assigned on their first day to one of two groups. the study group received simulation instruction in place of one of the lectures, while the control group was assigned to the standard curriculum. the standard clerkship curriculum includes lectures, case studies, procedure labs, and clinical shifts without simulation. at the end of the clerkship, all students participated in written and oral exams. graders were not blinded to group allocation. grades were assigned based on a pre-defined set of criteria. the final course composite score was computed based on clinical evaluations and the results of both written and oral exams. oral exam scores between the groups were compared using a two-sample t-test. we used the spearman rank correlation to measure the association between group assignment and the overall course grade. the study was approved by our institutional irb. results: sixty-one students participated in the study and were randomly assigned to one of two groups. twenty-nine (47.5%) were assigned to simulation and the remaining 32 (52.5%) students were assigned to the standard curriculum. students assigned to the simulation group scored 5.34% (95% ci 2.78-7.91%) higher on the oral exam than the non-simulation group. additionally, simulation was associated with a higher final course grade (p < 0.05). limitations of this pilot study include lack of blinding and interexaminer variability. conclusion: simulation training as part of an em clerkship is associated with higher oral exam scores and higher overall course grade compared to the standard curriculum. the results from this pilot study are encouraging and support a larger, more rigorous study. initial approaches to common complaints are taught using a standard curriculum of lecture and small group case-based discussion. we added a simulation exercise to the traditional altered mental status (ams) curriculum with the hypothesis that this would positively affect student knowledge, attitudes, and level of clinical confidence caring for patients with ams. methods: ams simulation sessions were conducted in june 2010 and 2011; student participation was voluntary. the simulation exercises included two ams cases using a full-body simulator and a faculty debriefing after each case. both students who did and did not participate in the simulations completed a written post-test and a survey related to confidence in their approach to ams. results: 154 students completed the post-test and survey. 65 (42%) attended the simulation session. 48 (31%) attended all three sessions. 58 (38%) participated in the lecture and small group. 15 (10%) did not attend any session. post-test scores were higher in students who attended the simulations versus those who did not: 7 (iqr, 6-8) vs. 6 (iqr, 4-7); p < 0.001. students who attended the simulations felt more confident about assessing an ams patient (58% vs. 42%; p = 0.05), articulating a differential diagnosis (66% vs. 47%; p = 0.03), and knowing initial diagnostic tests (74% vs. 53%; p = 0.01) and initial interventions (79% vs. 56%; p = 0.003) for an ams patient. students who attended the simulations were more likely to rate the overall ams curriculum as useful (94% vs. 61%; p < 0.001). conclusion: addition of a simulation session to a standard ams curriculum had a positive effect on student performance on a knowledge-based exam and increased confidence in clinical approach. the study's major limitations were that student participation in the simulation exercise was voluntary and that effect on applied skills was not measured. future research will determine whether simulation is effective for other chief complaints and if it improves actual clinical performance. background: the acgme has defined six core competencies for residents including ''professionalism'' and ''interpersonal and communication skills.'' integral to these two competencies is empathy. prior studies suggest that self-reported empathy declines during medical training; no reported study has yet integrated simulation into the evaluation of empathy in medical training. objectives: to determine if there is a relation between level of training and empathy in patient interactions as rated during simulation. methods: this is a prospective observational study at a tertiary care center comparing participants at four different levels of training: first (ms1) and third year (ms3) medical students, incoming em interns (pgy1), and em senior residents (pgy3/4). trainees participated in two simulation scenarios (ectopic pregnancy and status asthmaticus) in which they were responsible for clinical management (cm) and patient interactions (pi). this was the first simulation exposure during an established simulation curriculum for ms1, ms3, and pgy1. two independent raters reviewed videotaped simulation scenarios using checklists of critical actions for clinical management (cm: 0-11 points) and patient interactions (pi: 0-17 points). inter-rater reliability was assessed by intra-class correlation coefficients (iccs objectives: we explored attitudes and beliefs about the handoff, using qualitative methods, from a diverse group of stakeholders within the ems community. we also characterized perceptions of barriers to high-quality handoffs and identified strategies for optimizing this process. methods: we conducted seven focus groups at three separate gatherings of ems professionals (one local, two national) in 2010/2011. snowball sampling was used to recruit 48 participants with diverse professional, experiential, geographic, and demographic characteristics. focus groups, lasting 60-90 minutes, were moderated by investigators trained in qualitative methods, using an interview guide to elicit conversation. recordings of each group were transcribed. three reviewers analyzed the text in a multi-stage iterative process to code the data, describe the main categories, and identify unifying themes. results: participants included emts, paramedics, physicians, and nurses. clinical experience ranged from 4 months to 36 years. recurrent thematic domains when discussing attitudes and beliefs were: perceptions of respect and competence, professionalism, teamwork, value assigned to the process, and professional duty. modifiers of these domains were: hierarchy, skill/training level, severity/type of patient illness, and system/ regulatory factors. strategies to improving barriers to the handoff included: fostering familiarity and personal connections between ems and ed staff, encouraging two-way conversations, feedback, and direct interactions between ems providers and ed physicians, and optimizing ways for ems providers to share subjective impressions (beyond standardized data elements) with hospital-based care teams. conclusion: ems professionals assign high value to the ed handoff. variations in patient acuity, familiarity with other handoff participants, and perceptions of respect and professionalism appear to influence the perceived quality of this transition. regulatory strategies to standardize the contents of the handoff may not alone overcome barriers to this process. miology, public health) then developed an approach to assign ems records to one of 20 symptom-based illness categories (gastrointestinal illness, respiratory, etc). ems encounter records were characterized into these illness categories using a novel text analytic program. event alerts were identified across the state and local regions in illness categories using either change detection from baseline with (cusum) analysis (three standard deviations) and a novel text-proportion (tap) analysis approach (sas institute, cary, nc). results: 2.4 million ems encounter records over a 2year period were analyzed. the initial analysis focused upon gastrointestinal illness (gi) given the potential relationship of gi distress to infectious outbreaks, food contamination and intentional poisonings (ricin). after accounting for seasonality, a significant gi event was detected in feb 2010 (see red circle on graph). this event coincided with a confirmed norovirus outbreak. the use of cusum approach (yellow circle on graph) detected the alert event on jan 24, 2010. the novel tap approach on a regional basis detected the alert on dec 6, 2009. conclusion: ems has the advantage of being an early point of contact with patients and providing information on the location of insult or injury. surveillance based on ems information system data can detect emergent outbreaks of illness of interest to public health. a novel text proportion analytic technique shows promise as an early event detection method. assessing chronic stress in the emergency medical services elizabeth a. donnelly 1 , jill chonody 2 1 university of windsor, windsor, on, canada; 2 university of south australia, adelaide, australia background: attention has been paid to the effect of critical incident stress in the emergency medical services (ems); however, less attention has been given to the effect of chronic stress (e.g., conflict with administration or colleagues, risk of injury, fatigue, interference in non-work activities) in ems. a number of extant instruments assess for workplace stress; however, none address the idiosyncratic aspects of work in ems. objectives: the purpose of this study was to validate an instrument, adapted from mccreary and thompson (2006) , that assesses levels of both organizational and operational work-related chronic stress in ems personnel. methods: to validate this instrument, a cross-sectional, observational web-based survey was used. the instrument was distributed to a systematic probability sample of emts and paramedics (n = 12,000). the survey also included the perceived stress scale (cohen, 1983) to assess for convergent construct validity. results: the survey attained a 13.6% usable response rate (n = 1633); respondent characteristics were consistent across demographic characteristics with other studies of emts and paramedics. the sample was split in order to allow for exploratory and confirmatory fac-tor analyses (n = 847/n = 786). in the exploratory factor analysis, principal axis factoring with an oblique rotation revealed a two-factor, 34-item solution (kmo = 0.943, v 2 = 23344.38, df = 561, p £.001). confirmatory factor analysis suggested a more parsimonious, two-factor, 20-item solution (v 2 = 632.67, df = 168, p £ 0.001, rmsea = 0.06, cfi = 0.92, tli = 0.91, srmr = 0.04). the factors demonstrated good internal reliability (operational stress a = 0.877, organizational stress a = 0.868). both factors were significantly correlated (p £ 0.01) with the hypothesized convergent validity measure. conclusion: theory and empirical research indicate that exposure to chronic workplace stress may play an important part in the development of psychological distress, including burnout, depression, and posttraumatic stress disorder (ptsd). workplace stress and stress reactions may potentially interfere with job performance. as no extant measure assesses for chronic workplace stress in ems, the validation of this chronic stress measure enhances the tools ems leaders and researchers have in assessing the health and well-being of ems providers. effect of naltrexone background: survivors of sarin and other organophosphate poisoning can develop delayed encephalopathy that is not prevented by standard antidotal therapy with atropine and pralidoxime. a rat model of poisoning with the sarin analogue diisoprophylfluorophosphate (dfp) demonstrated impairment of spatial memory despite antidotal therapy with atropine and pralidoxime. additional antidotes are needed after acute poisonings that will prevent the development of encephalopathy. objectives: to determine the efficacy of naltrexone in preventing delayed encephalopathy after poisoning with the sarin analogue dfp in a rat model. the hypothesis is that naltrexone would improve performance on spatial memory after acute dfp poisoning. the sarin analogue dfp was used because it has similar toxicity to sarin while being less dangerous to handle. methods: a randomized controlled experiment at a university animal research laboratory of the effects of naltrexone on spatial memory after dfp poisoning was conducted. long evans rats weighing 250-275 grams were randomized to dfp group (n = 4, rats received a single intraperitoneal (ip) injection of dfp 5 mg/kg) or dfp+naltrexone group (n = 5, rats received a single ip injection of dfp (5 mg/kg) followed by naltrexone 5 mg/kg/day). after injection, rats were monitored for signs and symptoms of cholinesterase toxicity. if toxicity developed, antidotal therapy was initiated with atro-background: one of the primary goals of management of patients presenting with known or suspected acetaminophen (apap) ingestion is to identify the risk for apap-induced hepatotoxicity. current practice is to measure apap level at a minimum of 4 hours post ingestion and plot this value on the rumack-matthew nomogram. one retrospective study of apap levels drawn less than 4 hours post-ingestion found a level less than 100 mcg/ml to be sufficient to exclude toxic ingestion. objectives: the aim of this study was to prospectively determine the negative predictive value (npv) for toxicity of an apap level of less than 100 mcg/ml obtained less than 4 hours post-ingestion. methods: this was a multicenter prospective cohort study of patients presenting to one of five tertiary care hospitals that are part of the toxicology investigator's consortium (toxic). eligible patients presented to the emergency department less than 4 hours after known or suspected ingestion and had the initial apap level obtained at greater than 1 but less than 4 hours post ingestion. a second apap level was obtained at 4 hours or more post-ingestion and plotted on the rumack-matthew nomogram to determine risk of toxicity. the outcome of interest was the npv of an initial apap level less than 100 mcg/ml. a power analysis based on an alpha = 0.05 and power of 0.80 yielded the requirement of 71 subjects. results: data were collected on 171 patients over a 30month period from may 2009 to nov 2011. patients excluded from npv analysis consisted of: initial apap level greater than 100 mcg/ml (31), negligible apap level on both the initial and confirmatory apap level (31), initial apap level drawn less than one hour after ingestion (15), or an unknown time of ingestion (1). ninety-three patients met the eligibility criteria. two patients (2.2%) with an initial apap level less than 100 mcg/ml (54 mcg/ml at 90 min, 38 mcg/ml at 84 min) were determined to be at risk for toxicity based on oh s330 2012 saem annual meeting abstracts implementation of an emergency department sign-out checklist improves patient hand-offs at change of shift nicole m ma computer-assisted self-interviews improve testing for chlamydia and gonorrhea in the pediatric emergency department is the australian triage system a better indicator of psychiatric patients' needs for intervention than the ena emergency severity index triage system? patients were given an initial dose of 10 mg droperidol intramuscularly followed by an additional dose of 10 mg after 15 min if required. inclusion criteria were patients requiring physical restraint and parenteral sedation. the primary outcome was the time to sedation. secondary outcomes were the proportion of patients requiring additional sedation within the first hour, over-sedation measured as -3 on the sedation assessment tool, and respiratory compromise measured as oxygen saturation <90%. results: droperidol was administered to 424 patients and 370 of these had sedation scores documented. presentations included 56% with alcohol intoxication. dose ranged from 2.5 mg to 30 mg, median 10 mg (interquartile range conclusion: droperidol is effective for rapid sedation for abd and rarely causes over-sedation serum creatinine (scr) is widely used to predict risk; however, gfr is a better assessment of kidney function. objectives: to compare the ability of gfr and scr to predict the development of cin among ed patients receiving cects. we hypothesized that gfr would be the best available predictor of cin. methods: this was a retrospective chart review of ed patients ‡18 years old who had a chest or abdomen/pelvis cect between 06/01/11 and 07/31/11. baseline and follow-up scr levels were recorded. patients with initial scr >1.6 mg/dl were excluded, as per hospital radiology department protocol. cin was defined as a scr increase of either 25%, 0.5 mg/dl, or a gfr decrease of 25% within 72 hours of contrast exposure. gfr was calculated using the ckd epi and mdrd formulae, and analyzed in original units and categorized form (<60, ‡60) with each additional unit decrease in ckd epi, subjects were 3% more likely to develop cin (or = 1.03) (p < 0.0281). additionally, subjects with ckd epi <60 were 3.20 (or) times more likely to have cin than subjects with ckd epi ‡60 in original units, ckd epi (p < 0.0001) and mdrd (p < 0.0016) both had a significantly higher auc than scr. conclusion: age, as an independent variable, is the best predictor of cin, when compared with scr and gfr. due to a small number of cases with cin, the confidence intervals associated with the odds ratios are wide. future research should focus on patient risk stratification and establishing ed interventions to prevent cin. 694 a rat model of carbon monoxide induced neurotoxicity heather ellsworth non-traumatic subarachnoid hemorrhage diagnosed by lumbar puncture following non-diagnostic head ct: a retrospective case-control study and decision a dass score of >14 has been previously defined as an indicator of increased stress levels. multivariable logistic regression was utilized to identify demographic and work-life characteristics significantly associated with stress. results: 53.6% of individuals responded to the survey (34,340/64,032) and prevalence of stress was estimated at 5.9%. the following work-life characteristics were associated with stress: certification level, work experience, and service type. the odds of stress in paramedics was 32% higher when compared to emt-basics (or = 1.32, 95% ci = 1.23-1.42). when compared to £2 years of experience 28-2.18) were more likely to be stressed. ems professionals working in county (or = 1 ci = 1.07-1.51) and private services (or = 1 56) were more likely than those working in fire-based services to be stressed. the following demographic characteristics were associated with stress: general health and smoking status finally, former smokers (or = 1.34, 95% ci = 1.17-1.54) and current smokers (or = 1.37, 95% ci = 1.18-1.59) were more likely to be stressed than non-smokers literature suggests this is within the range of stress among nurses, and lower than physicians. while the current study was able to identify demographic and work-life characteristics associated with stress, the long-term effects are largely unknown methods: design: prospective randomized controlled trial. subjects: female sus scrofa swine weighing 45-55kg were infused with amitriptyline 0.5 mg/kg/minute until the map fell to 60% of baseline values. subjects were then randomized to experimental group (ife 7 ml/kg followed by an infusion of 0.25 ml/kg/minute) or control group (sb 2 meq/kg plus equal volume of normal saline). interventions: we measured continuous heart rate (hr), sbp, map, cardiac output (co), systemic vascular resistance (svr), and venous oxygen saturation (svo 2 ). laboratory values monitored included ph, pco 2 , bicarbonate, lactate, and amitriptyline levels. descriptive statistics including means, standard deviations, standard errors of measurement, and confidence limits were calculated. results: of 14 swine, seven each were allocated to ife and sb groups. there was no difference at baseline for each group regarding hr, sbp, map, co, svr, or svo 2 . ife and sb groups required similar mean amounts of tca to reach hypotension one ife and two sb pigs survived. conclusion: in this interim data analysis of amitriptyline-induced hypotensive swine, we found no difference in mitigating hypotension between ife and sb lipid rescue 911: a survey of poison center medical directors regarding intravenous fat emulsion therapy michael r. christian 1 , erin m. pallasch cook county hospital (stroger), chicago, il 745 reliability of non-toxic acetaminophen concentrations obtained less than 4 hours after ingestion evaluating age in the field triage of injured background: hiv screening in eds is advocated to achieve the goal of comprehensive population screening. yet, hiv testing in the ed is sometimes thwarted by a patient's condition (e.g. intoxication) or environmental factors (e.g. other care activities). whether it is possible to test these patients at a later time is unknown. objectives: we aimed to determine if ed patients who were initially unable to receive an hiv testing offer might be tested in the ed at a later time. we hypothesized that factors preventing testing are transient and that there are subsequent opportunities to repeat testing offers. methods: we reviewed medical records for patients presenting to an urban, academic ed who were approached consecutively to offer hiv testing during randomly selected periods from january 2008 to january 2009. patients for whom the initial attempted offer could not be completed were reviewed in detail with standardized abstraction forms, duplicate abstraction, and third-party discrepancy adjudication. primary outcomes included repeat hiv testing offers during that ed visit, and whether a testing offer might eventually have been possible either during the initial visit or at a later visit within 6 months. outcomes are described as proportions with confidence intervals. results: of 824 patients approached, initial testing offers could not be completed for 120 (15%). these 120 were 62% male, 52% white, and had a median age of 41 (18-64). a repeat offer of testing during the initial visit would have been possible for 99/120 (83%), and 52/99 (53%) were actually offered testing on repeat approach. of the 21 for whom a testing offer would not have been possible on the initial visit, 14 (67%) had at least one additional visit within 6 months, and 11/14 (79%) could have been offered testing on at least one visit. overall, a repeat testing offer would have been possible for 110/120 (93%, 95% ci 85-96%). conclusion: factors preventing an initial offer of hiv testing in the ed are generally transient. opportunities for repeat approach during initial or later ed encounters suggest that, given sufficient resources, the ed could succeed in comprehensively screening the population presenting for care. ed screening personnel who are initially unable to offer testing should repeat their attempt. hiv adopt an ''opt-out'' rapid hiv screening model in order to identify hiv infected patients. previous studies nationwide have shown acceptance rates for hiv screening of 20-90% in emergency departments. however, it is unknown how acceptance rates will vary in a culturally and ethnically diverse urban emergency department.objectives: to determine the characteristics of patients who accept or refuse ''opt-out'' hiv screening in an urban emergency department.methods: a self-administered, anonymous survey is administered to ed patients who are 18 to 64 years of age. the questionnaire is administered in english, russian, mandarin, and spanish. questions include demographic characteristics, hiv risk factors, perception of hiv risk, and acceptance of rapid hiv screening in the emergency department. results: to date 145 patients responded to our survey. of the 145, 102 (70.3%) did not accept an hiv test (group 1) in their current ed visit and 43 (29.7%) accepted an hiv test (group 2). the major two reasons given for opting out (i.e., group 1) was ''i do not feel that i am at risk'' (59.8%) and ''i have been tested for hiv before'' (25.5%). there was no difference between the groups in regards to sex (p = 0.737), age (p = 0.351), religious affiliation (p = 0.750), marital status (p = 0.331), language spoken at home (p = 0.211), and whether they had been hiv tested before (73.2% in group 1 and 59.4% in group 2; p = 0.123). however, there was a statistically significant difference with regards to educational level and income. more patients in group 1 (69.0%) and 46.1% in group 2 had less than a college level education (p < 0.05). similarly, more patients in group 1 (58.3%) and only 34.8% in group 2 had an annual household income of £$25,000 (p < 0.05). conclusion: in a culturally and ethnically diverse urban emergency department, patients with a lower socioeconomic status and educational level tend to opt out of hiv screening test offered in the ed. no significant difference in acceptance of ed hiv testing was found to date based on primary language spoken at home or religious affiliation background: antimicrobial resistance is a problem that affects all emergency departments. objectives: our goal was to examine all urinary pathogens and their resistance patterns from urine cultures collected in the emergency department (ed).methods: this study was performed at an urban/suburban community-teaching hospital with an annual volume of 40,000 visits. using electronic records, all cases of urine cultures received in 2009 were reviewed for data including type of bacteria, antibiotic resistance, and health care exposure (hcx). hcx was defined as no prior hospitalization within the previous six months, hospitalization within the previous three months, hospitalization within the previous six months, nursing home resident (nh), and presence of an indwelling urinary catheter (uc). an investigator abstracted all data with a second re-abstracting a random 5% for kappa statistics between 0.697 and 1.00. group background: approximately 12-20% of patients treated with epinephrine for anaphylaxis receive a second dose but the risk factors associated with repeat epinephrine use remain poorly defined. objectives: to determine whether obesity is a risk factor for requiring 2 + epinephrine doses for patients who present to the emergency department (ed) with anaphylaxis due to food allergy or stinging insect hypersensitivity. methods: we performed a retrospective chart review at four tertiary care hospitals that care for adults and children in new england between the following time periods: massachusetts general hospital (1/1/01-12/31/ 06), brigham and women's hospital (1/1/01-12/31/06), children's hospital boston (1/1/01-12/31/06), hasbro children's hospital (1/1/04-12/31/09). we reviewed the medical records of all patients presenting to the ed for food allergy or stinging insect hypersensitivity using icd9cm codes. we focused on anthropomorphic data and number of epinephrine treatments given before and during the ed visit. among children, calculated bmis were classified according to cdc growth indicators as underweight, healthy, overweight, or obese. all patients who presented on or after their 18th birthday were considered adults.background: transitions of care are ubiquitous in the emergency department (ed) and inevitably introduce the opportunity for errors. despite recommendations in the literature, few emergency medicine (em) residency programs provide formal training or standard process for patient hand-offs. checklists have been shown to be effective quality improvement measures in inpatient settings and may be a feasible method to improve ed hand-offs. objectives: to determine if the use of a sign-out checklist improves the accuracy and efficiency of resident sign-out in the ed as measured by reduced omission of key information, communication behaviors, and time to sign-out each patient. methods: a prospective study of first-and second-year em and non-em residents rotating in the ed at an urban academic medical center with an annual ed volume of 55,000. trained clinical research assistants observed resident sign-out during shift change over a two-week period and completed a 15-point binary observable behavior data collection tool to indicate whether or not key components of sign-out occurred. time to sign out each patient was recorded. we then created and implemented a computerized sign-out checklist consisting of key elements that should be addressed during transitions of care, and instructed residents to use this during hand-offs. a two-week post-intervention observation phase was conducted using the same data collection tool. proportions, means, and non-parametric comparison tests were calculated using stata. results: one hundred fifteen sign-outs were observed prior to checklist implementation and 72 after; one sign-out was excluded for incompleteness. significant improvements were seen in four of the measured signout components: inclusion of history of present illness increased by 18% (p < 0.001), likely diagnosis increased by 17% (p = 0.015), disposition status increased by 18% (p < 0.01), and patient/care team awareness of plan increased by 19% (p < 0.01). (figure 1 ) time data for 108 sign-outs pre-implementation and 72 post-implementation were available. seven sign-outs were excluded for incompleteness or spurious values. mean length of sign out was 83s (95% ci 65 to 100) and 71.7s (95% ci 52 to 92) per patient. conclusion: implementation of a checklist improved the transfer of information but did not affect the overall length of time for the sign-out. the objectives: to determine risk factors associated with adult patients presenting to the ed with cellulitis who fail initial antibiotic therapy and require a change of antibiotics or admission to hospital. methods: this was a prospective cohort study of patients ‡18 years presenting with cellulitis to one of two tertiary care eds (combined annual census 120,000). patients were excluded if they had been treated with antibiotics for the cellulitis prior to presenting to the ed, if they were admitted to hospital, or had an abscess only. trained research personnel administered a questionnaire at the initial ed visit with telephone follow-up 2 weeks later. patient characteristics were summarized using descriptive statistics and 95% confidence intervals (cis) were estimated using standard equations. backwards stepwise multivariable logistic regression models determined predictor variables independently associated with treatment failure (failed initial antibiotic therapy and required a change of antibiotics or admission to hospital). results: 598 patients were enrolled, 47 were excluded, and 53 were lost to follow-up. the mean (sd) age was 53.1 (18.4) and 56.4% were male. 497 (99.8%) patients were given antibiotics in the ed. 185 (37.2%) were given oral, 231 (46.5%) were given iv, and 81 (16.3%) patients were given both oral and iv antibiotics. 102 (20.5%) patients had a treatment failure. fever (temp >38°c) at triage (or: 4.1, 95% ci: 1.5, 10.7), leg ulcers (or: 3.1, 95% ci: 1.4, 6.6), edema or lymphedema (or: 2.5, 95% ci: 1.4, 4.5), and prior cellulitis in the same area (or: 1.8, 95% ci: 1.1, 2.9) were independently associated with treatment failure. conclusion: this analysis found four risk factors associated with treatment failure in patients presenting to the ed with cellulitis. these risk factors should be considered when initiating empiric outpatient antibiotic therapy for patients with uncomplicated cellulitis. use background: children presenting for care to a pediatric emergency department (ped) commonly require intravenous catheter (iv) placement. prior studies report that the average number of sticks to successfully place an iv in children is 2.4. successfully placing an iv requires identification of appropriate venous access targets. the veinviewer visionò (vvv) assists with iv placement by projecting a map of subcutaneous veins on the surface of the skin using near infrared light. objectives: to compare the effectiveness of the vvv versus standard approaches: sight (s) and sight plus palpation (s+p) for identifying peripheral veins for intravenous catheter placement in children treated in a ped. methods: experienced pediatric emergency nurses and physicians identified peripheral venous access targets appropriate for intravenous cannulation of a cross-sectional convenience sample of english speaking children aged 2-17 years presenting for treatment of sub-critical injury or illness whose parents provided consent. the clinicians marked the veins with different colored washable marker and counted them on the dorsum of the hand and in the antecubital fossa using the three approaches: s, s+p, and vvv. a trained research assistant photographed each site for independent counting after each marking and recorded demographics and bmi. counts were validated using independent photographic analyses. data were entered into sas 9.2 and analyzed using paired t-tests. results: 146 patients completed the study. clinicians were able to identify significantly more veins on the dorsum of the hand using vvv than s alone or s+p, 3.26 (p < 0.0001, ci 2.89-3.64) and 2.31 (p < 0.0001, ci 1.97-2.65), respectively, as well as significantly more veins in the antecubital fossa using vvv than s alone or s+p, 2.62 (p < 0.0001, ci 2.29-2.96) and 1.93 (p < 0.0001, ci 1.62-2.42), respectively. the differences in numbers of veins identified remained significant at p < 0.05 level across all ages, races, and bmis of children and across clinicians and validating independent photographic analyses. conclusion: experienced emergency nurses and physicians were able to identify significantly more venous access targets appropriate for intravenous cannulation in the dorsum of the hand and antecubital fossa of children presenting for treatment in a ped using vvv than the standard approaches of sight or sight plus palpation. an background: mental health emergencies have increased over the past two decades, and contribute to the ongoing rise in u.s. ed visit volumes. although data are limited, there is a general perception that the availability of in-person psychiatric consultation in the ed and of inpatient psychiatric beds is inadequate. objectives: to examine the availability of in-person psychiatry consultation in a heterogeneous sample of u.s. eds, and typical delays in transfer of ed patients to an inpatient psychiatric bed. methods: during 2009-2011, we mailed a survey to all ed directors in a convenience sample of nine us states (ar, co, ga, hi, ma, mn, or, vt, and wy). all sites were asked: ''are psychiatric consults available in-person to the ed?'' (yes/no), with affirmative respondents asked about the typical delay. sites also were asked about typical ed boarding time between a request for patient transfer and actual patient departure from the ed to an inpatient psychiatric bed. ed characteristics included rural/urban location, visit volume (visits/hour), admission rate, ed staffing, and the proportion of patients without insurance. data analysis used chi-square tests and multivariable logistic regression. results: surveys were collected from 495 (91%) of the 541 eds, with >80% response rate in every state. overall, only 30% responded that psychiatric consults were available in-person to the ed. in multivariable logistic regression, ed characteristics independently associated with lack of in-person psychiatric consultation were: location within specific states (eg, ar, ga), rural location, lower visit volume, and lower admission rate. among the subset of eds with psychiatric consults available, 48% reported a typical wait time of at least 1 hour. overall, 54% of eds reported that the typical time from request to actual patient transfer to an inpatient psychiatric bed was >6 hours, and 47% reported a maximum time in past year of >1 day (median 3 days, iqr 2-4). in a multivariable model, location in ma and higher visit volume were associated with greater odds of a maximum wait time of >1 day. conclusion: among 495 surveyed eds in nine states, only 30% have in-person psychiatric consultants available. moreover, approximately half of eds report boarding times of >6 h from request for transfer to actual departure to an inpatient psychiatric bed.background: many emergency departments (ed) in the united states use a five tiered triage protocol that has a limited evaluation of psychiatric patients. the australian triage scale (ats), a psychiatric triage system, has been used throughout australia and new zealand since the early 1990s. objectives: the objective of the study is to compare the current triage system, emergency nurses association (ena) esi 5-tier, to the ats for the evaluation of the psychiatric patients presenting to the ed. methods: a convenience sample of patients, 18 years of age and older, presenting with psychiatric complaints at triage were given the ena triage assessment by the triage nurse. a second triage assessment, performed by a research fellow, included all observed and reported elements using the ats protocol, a self-assessment survey and an agitation assessment using the richmond agitation sedation scale (rass). the study was performed at an inner city level i trauma center with 60,000 visits per year. the ed was a catchment facility for the police department for psychiatric patients in the area. patients were excluded if they were unstable, unable to communicate, or had a non-psychiatric complaint. results were analyzed in spss v16. the analysis of data used frequencies, descriptive and anova. results: a total of 100 patients were enrolled in the study: 72% were african american, 14% caucasian, 13% hispanic, 1% asian, and 1% indian; 63% of subjects enrolled were male. the patients' level of agitation using rass showed 59% were alert and calm, 22% were restless and anxious, 6% were agitated, and 5% combative, violent, or dangerous to self. the only significant correlation found was among the ats and several self assessment questions: ''i feel agitated on a 0 to 10 scale'' (p = 0.031) and ''i feel violent on a 0 to 10 scale'' (p = 0.001). there were no significant correlations found among the ena triage, rass scores, and throughput times. conclusion: the ats test was more sensitive to the patient declaring that he or she was agitated or felt violent. this shows that this system might be a more useful system in determining the severity of need of psychiatric patients presenting to the ed. variations background: hemoglobin-based oxygen carriers (hbocs) have been evaluated for small-volume resuscitation of hemorrhagic shock due to their oxygen carrying capability, but have found limited utility due to vasoactive side-effects from nitric oxide (no) scavenging. objectives: to define an optimal hboc dosing strategy and evaluate the effect of an added no donor, we use a prehospital swine polytrauma model to compare the effect of low-vs. moderate-volume hboc resuscitation with and without nitroglycerin (ntg) co-infusion as an no donor. we hypothesize that survival time will improve with moderate resuscitation and that an no donor will add additional benefit. methods: survival time was compared in groups (n = 7) of anesthetized swine subjected to simultaneous traumatic brain injury and uncontrolled hemorrhagic shock by aortic tear. animals received one of three different resuscitation fluids: lactated ringers (lr), hboc, or vasoattenuated hboc with ntg co-infusion. for comparison, these fluids were given in a severely limited fashion (sl) as one bolus every 30 minutes up to four total, or a moderately limited fashion (ml) as one bolus every 15 minutes up to seven total, to maintain mean arterial pressure ‡60 mmhg. comparison of resuscitation regimen and fluid type on survival time was made using two-way anova with interaction and tukey kramer adjustment for individual comparisons. results: there was a significant interaction between fluid regimen and resuscitation fluid type (anova, p = 0.011) indicating that the response to sl or ml resuscitation was fluid type-dependent. within the lr and hboc+ntg groups, survival time (mean, 95%ci) was longer for sl, 323.5 min ( injuries are common and result from many different mechanisms of injury (moi). knowing common fracture locations may help in diagnosis and treatment, especially in patients presenting with distracting injuries that may mask the pain of a radius fracture.objectives: we set out to determine the incidence of radius fracture locations among patients presenting to an urban emergency department (ed).background: carbon monoxide (co) is the leading cause of poisoning morbidity and mortality in the united states. standard treatment includes supplemental oxygen and supportive care. the utility of hyperbaric oxygen (hbo) therapy has been challenged by a recent cochrane review. hypothermia may mitigate delayed neurotoxic effects after co poisoning as it is effective in cardiac arrest patients with similar neuropathology. objectives: to develop a rat model of acute and delayed severe co toxicity as measured by behavioral deficits and cell necrosis in post-sacrifice brain tissue.methods: a total of 28 rats were used for model development; variable concentrations of co and exposure times were compared to achieve severe toxicity. for the protocol, six senescent long evans rats were exposed to 2,000 ppm of co for 20 minutes then 1,500 ppm for 160 minutes, followed by three successive dives at 30,000 ppm with an endpoint of apnea or seizure; there was a brief interlude between dives for recovery. a modified katz assessment tool was used to assess behavior at baseline and 2 hours, 1 day, and 1, 2, 3, 4, 5, and 6 weeks post-exposure. following this, the brains were transcardially fixed with formalin, and 5 lm sagittal slices were embedded in paraffin and stained with hematoxylin and eosin. a pathologist quantified the percentage of necrotic cells in the cortex, hippocampus (pyramidal cells), caudoputamen, cerebellum (purkinje cells), dentate gyrus, and thalamus of each brain to the nearest 10% from 10 randomly selected high power fields (400x background: there remains controversy about the cardiotoxic effects of droperidol, and in particular the risk of qt prolongation and torsades des pointes (tdp).objectives: this study aimed to investigate the cardiac and haemodynamic effects of high-dose parenteral droperidol for sedation of acute behavioural disturbance (abd) in the emergency department (ed). methods: a standardised intramuscular (im) protocol for the sedation of ed patients with abd was instituted as part of a prospective observational safety study in four regional and metropolitan eds. patients with abd were given an initial dose of 10 mg droperidol followed by an additional dose of 10 mg after 15 min if required. inclusion criteria were patients requiring physical restraint and parenteral sedation. the primary outcome was the proportion of patients who have a prolonged qt interval on ecg. the qt interval was plotted against the heart rate (hr) on the qt nomogram to determine if the qt was abnormal. secondary outcomes were frequency of hypotension and cardiac arrhythmias. results: ecgs were available from 273 of 424 patients with abd given droperidol. the median dose was 10 mg (iqr 10-15 mg; range: 5 to 30 mg). the median age was 33 years (rnge: 16 to 92) and 163 were males (60%). a total of four (1%) qt-hr pairs were above the ''at-risk'' line on the qt nomogram. transient hypotension occurred in 8 (3%), and no arrhythmias were detected.conclusion: droperidol appears to be safe when used for rapid sedation in the dose range of 5 to 30 mg. it rarely causes hypotension or qt prolongation. blood background: soldiers and law enforcement agents are repeatedly exposed to blast events in the course of carrying out their duties during training and combat operations. little data exist on the effect of this exposure on the physiological function of the human body. both military and law enforcement dynamic entry personnel, ''breachers'', began expressing sensitivity to the risk of injury as a result of multiple blast exposures. breachers apply explosives as a means of gaining access to barricaded or hardened structures. these specialists can be exposed to as many as a dozen lead-encased charges per day during training exercises.objectives: this observational study was performed by the breacher injury consortium to determine the effect of short-term exposure to blasts by breachers on whole blood lead levels (blls) and zinc protoporphyrin levels (zppls). methods: two 2-week basic breaching training classes were conducted by the united states marine corps' weapons training battalion dynamic entry school. each class included 14 students and up to three instructors, with six non-breaching marines serving as a control group. to evaluate for lead exposure, venous blood samples were acquired from study participants on the weekend prior and following training in the first training class, whereas the second training class had an additional level performed mid-training. blls and zppls were measured in a whole-blood sample using the furnace atomic absorption method and hematofuorimeter method, respectively. results: analysis of these blast injury data indicated students demonstrated significantly increased blls post-explosion (mean = 7 mcg/dl, sd 2.42, p < 0.001) compared to pre-training (mean = 3 mcg/dl, sd 1.60) and control subjects (mean = 3 mcg/dl, sd 2.73, p < 0.001). instructors also demonstrated significantly increased blls post explosion (mean = 6 mcg/dl, sd 1.95, p < 0.02) compared to pre-training (mean = 3 mcg/ dl, sd 1.14) and control subjects (mean = 3 mcg/dl, sd 2.73, p < 0.001). student and instructor zppls were not significantly different in post-training compared to pretraining or control groups. conclusion: the observation from this study that breachers are at risk of mild increases in blls support the need for further investigation into the role of lead following repeated blast exposure with munitions encased in lead. direct observation of the background: notification of a patient's death to family members represents a challenging and stressful task for emergency physicians. complex communication skills such as those required for breaking bad news (bbn) are conventionally taught with small-group and other interactive learning formats. we developed a de novo multi-media web-based learning (wbl) module of curriculum content for a standardized patient interaction (spi) for senior medical students during their emergency medicine rotation.objectives: we proposed that use of an asynchronous wbl module would result in students' skill acquisition for breaking bad news. methods: we tracked module utilization and performance on the spi to determine whether students accessed the materials and if they were able to demonstrate proficiency in its application. performance on the spi was assessed utilizing a bbn-specific content instrument developed from the griev_ing mnemonic as well as a previously validated instrument for assessing communication skills.results: three hundred seventy-two students were enrolled in the bbn curriculum. there was a 92% completion rate of the wbl module despite students being given the option to utilize review articles alone for preparation. students interacted with the activities within the module as evidenced by a mean number of mouse clicks of 42.1 (sd 21.6). overall spi scores were 94.5%, (sd 4.4) with content checklist scores of 92.8% (sd 5.7) and interpersonal communication scores 97.9% (sd 4.7). five students had failing content scores (<75%) on the spi and had a mean number of clicks of 30.8 (sd 28.2), which is not significantly lower than those passing (p = 0.21). students in the first year of wbl deployment completed self-confidence assessments which showed significant increases in confidence (2.86 tobackground: pelvis ultrasonography (us) is a useful bedside tool for the evaluation of women with suspected pelvic pathology. while pelvic us is often performed by the radiology department, it often lacks clinical correlation and takes more time than bedside us in the ed. this was a prospective observational study comparing the ed length of stay (los) of patients receiving ed us versus those receiving radiology us. objectives: the primary objective was to measure the difference in ed los. the secondary objectives were to 1) assess the role of pregnancy status, ob/gyn consult in the ed, and disposition, in influencing the ed los; and 2) to assess the safety of ed us by looking at patient return to the ed within 2 weeks and whether that led to an alternative diagnosis.methods: subjects were women over 13 years old presenting with a gi or gu complaint, and who received either an ed or radiology us. a t-test was used for the primary objective, and linear regression to test the secondary objective. odds ratios were performed to assess for interaction between these factors and type of ultrasound. subgroup analyses were performed if significant interaction was detected. results: forty-eight patients received an ed us and 85 patients received a radiology us. subjects receiving an ed us spent 162 minutes less in the ed (p < 0.001). in multivariate analysis, even when controlling for pregnancy status, ob/gyn consult, and disposition, patients who received an ed us had a los reduction of 108 minutes (p < 0.05). in odds ratio analysis, patients who were pregnant were 11 times more likely to have received an ed us (p < 0.05). patients who received an ob/gyn consult in the ed were five times more likely to receive a radiology us (p < 0.05). there was no association between type of us and disposition. in subgroup analyses, pregnant and non-pregnant patients who received an ed us still had a los reduction of 140 minutes (p < 0.01) and 112 minutes (p < 0.05), respectively. sample sizes were inadequate for subgroup analysis for subjects who had ob/gyn consults. in patients who did not receive an ob/gyn consult, those who received an ed us had a los reduction of 139 minutes (p < 0.001). finally, 10% of subjects returned within two weeks, but none led to an alternative diagnosis. conclusion: even when controlling for disposition, ob/gyn consultation, and pregnancy status, patients who received an ed us had a statistically and clinically significant reduction in their ed los. in addition, ed us is safe and accurate. background: although early surface cooling of burns reduces pain and depth of injury, there are concerns that cooling of large burns may result in hypothermia and worse outcomes. in contrast, controlled mild hypothermia improves outcomes after cardiac arrest and traumatic burn injury. objectives: the authors hypothesized that controlled mild hypothermia would prolong survival in a fluidresuscitated rat model of large scald burns. methods: forty sprague-dawley rats (250-300 g) were anesthetized with 40 mg/kg intramuscular ketamine and 5 mg/kg xylazine, with supplemental inhalational isoflurane as needed. a single full-thickness scald burn covering 40% of the total body surface area was created per rat using a mason-walker template placed in boiling water (100 deg c) for a period of 10 seconds. the rats were randomized to hypothermia (n = 20) and nonhypothermia (n = 20). core body temperature was continuously monitored with a rectal temperature probe. hypothermia was induced through intraperitoneal injection of cooled (4 deg c) saline. the core temperature was reduced by 2 deg c and maintained for a period of 2 hours, applying an ice or heat pack when necessary. the rats were then rewarmed back to baseline temperature. in the control group, room temperature saline was injected into the intraperitoneal cavity and core temperature was maintained using a heating pad as needed. the rats were monitored until death or for a period of 7 days, whichever was greater. the primary outcome was death. the difference in survival was determined using a kaplan-meier analysis or log rank test. results: the mean core temperatures were 32.5 deg c for the hypothermic group and 35.6 deg c for the normothermic group. the mean survival times were 124 hours for the hypothermic group (95% confidence interval [ci] = 98 to 150) and 100 hours for the normothermic group (95% ci = 68 to 132). the seven-day survival rates in the hypothermic and non-hypothermic groups were 67% and 53%. these differences were not significant, p = 0.33 for both comparisons. conclusion: induction of brief mild hypothermia increases but does not significantly prolong survival in a resuscitated rat model of large scald burns. serum objectives: we sought to determine levels of serum mtdna in ed patients with sepsis compared to controls and the association between mtdna and both inflammation and severity of illness among patients with sepsis. methods: prospective observational study of patients presenting to one of three large, urban, tertiary care eds. inclusion criteria: 1) septic shock: suspected infection, two or more systemic inflammatory response (sirs) criteria, and systolic blood pressure (sbp) <90 mmhg despite a fluid bolus; 2) sepsis: suspected infection, two or more sirs criteria, and sbp >90 mmhg; and 3) control: ed patients without suspected infection, no sirs criteria, and sbp >90 mmhg. three mtdnas (cox-iii, cytochrome b, and nadh) were measured using real-time quantitative pcr from serum drawn at enrollment. il-6 and il-10 were measured using a bio-plex suspension array system. baseline characteristics, il-6, il-10, and mtdnas were compared using one way anova or fisher exact test, as appropriate. correlations between mtdnas and il-6/il-10 were determined using spearman's rank. linear regression models were constructed using sofa score as the dependent variable, and each mtdna as the variable of interest in an independent model. a bonferroni adjustment was made for multiple comparisons.results: of 93 patients, 24 were controls, 29 had sepsis, and 40 had septic shock. we found no significant difference in any serum mtdnas among the cohorts (p = 0.14 to 0.30). all mtdnas showed a small but significant negative correlation with il-6 and il-10 (q = )0.24 to )0.35). among patients with sepsis or septic shock (n = 69), we found a small but significant negative association between mtdna and sofa score, most clearly with cytochrome b (p = 0.001). conclusion: we found no difference in serum mtdnas between patients with sepsis, septic shock, and controls. serum mtdnas were negatively associated with inflammation and severity of illness, suggesting that as opposed to trauma, serum mtdna does not significantly contribute to the pathophysiology of the sepsis syndromes. methods: we consecutively enrolled ed patients ‡18 years of age who met anaphylaxis diagnostic criteria from april 2008 to july 2011 at a tertiary center with 72,000 annual visits. we collected data on antihypertensive medications, suspected causes, signs and symptoms, ed management, and disposition. markers of severe anaphylaxis were defined as 1) intubation, 2) hospitalization (icu or floor), and 3) signs and symptoms involving ‡3 organ systems. antihypertensive medications evaluated included beta-blockers, angiotensin converting enzyme (ace) inhibitors, and calcium channel blockers (ccb). we conducted univariate and multivariate analyses to measure the association between antihypertensive medications and markers of severe anaphylaxis. because previous studies demonstrated an association between age and the suspected cause of the reaction with anaphylaxis severity, we adjusted for these known confounders in multivariate analyses. we report associations as odds ratios (ors) and corresponding 95% cis with p-values. results: among 302 patients with anaphylaxis, median age (iqr) was 44 (31-58) and 204 (67.5%) were female. eight (2.7%) patients were intubated, 57 (19%) required hospitalization, and 139 (46%) had ‡3 system involvement. forty-nine (16%) were on beta-blockers, 34 (11%) on ace inhibitors, and 22 (7.3%) on ccb. in univariate analysis, ace inhibitors were associated with intubation and ‡3 system involvement and ccb were associated with hospital admission. in multivariate analysis, after adjusting for age and suspected cause, ace inhibitors remained associated with hospital admission and beta-blockers remained associated with both hospital admission and ‡3 system involvement. conclusion: in ed patients, beta-blocker and ace inhibitor use may predict increased anaphylaxis severity independent of age and suspected cause of the anaphylactic reaction. background: advanced cardiac life support (acls) resuscitation requires rapid assessment and intervention. some skills like patient assessment, quality cpr, defibrillation, and medication administration require provider confidence to be performed quickly and correctly. it is unclear, however, whether high-fidelity simulation can improve confidence with a multidisciplinary group of providers with high levels of clinical experience. objectives: the purpose of the study was to test the hypothesis that providers undergoing high-fidelity simulation of cardiopulmonary arrest scenarios will express greater confidence. methods: this was a prospective cohort study conducted at an urban level i trauma center from january to october 2011 with a convenience sample of registered (rn) and license practical nurses, nurse practitioners, resident physicians, and physician assistants who agreed to participate in 2/4 high-fidelity simulation (laerdal 3g) sessions of cardiopulmonary arrest scenarios about 3 months apart. demographics were recorded. providers completed a validated preand post-test five-point likert scale confidence measurement tool before and after each session that ranged from not at all confident (1) to very confident (5) in recognizing signs and symptoms of, appropriately intervening in, and evaluating intervention effectiveness in cardiac and respiratory arrests. descriptive statistics, paired t-tests, and anova were used for data analysis. sensitivity testing evaluated subjects who completed their second session at 6 months rather than 3 months. results: sixty-five subjects completed consent, 39 completed one session, and 23 completed at least two background: prehospital studies have focused on the effect of health care provider gender on patient satisfaction. we know of no study that has assessed patient satisfication with patient and prehospital provider gender. some studies have shown higher patient satisfaction rates when cared for by a female health care provider.objectives: to determine the effect of ems provider gender on patient satisfaction with prehospital care. methods: a convenience sampling of all adult patients brought in to our ed, an urban level i trauma center by ambulance. a trained research associate (ra) stationed at triage conducted a survey using press ganey ems patient satisfaction questions. there were thirteen questions evaluating prehospital provider skills such as driving, courtesy, listening, medical care, and communication. each skill was assigned a point value between one and five; the higher the value the better the skill was performed. the patient's ambulance care report was copied for additional data extraction.results: a total of 225 surveys were done. average patient age was 71, and 54% were female. scores for all questions totaled 65 (mean 62.63 ± 5.1). prehospital providers pairings were: male-male (n = 141), male-female (n = 71), and female-female (n = 13). there were no statistically significant differences in scores between our pairings (mean scores for male:male 19.3, male:female 19.1, and female:female 19.2; p = 0.73). we found nonstatistical differences in satisfaction scores based on the gender of the emt in the back of the ambulance: males had a mean score of 62.7 and females had a mean score of 62.6 (p = 0.91). we examined gender concordance by comparing gender of the patient to the gender of the prehospital provider and found that male-male had a mean score of 62.8, female-female 62.2, and when the patient and prehospital provider gender did not match, 62.5 (p = 0.71). conclusion: we found no effect of gender difference on patient satisfaction with prehospital care. we also found that overall, patients are very satisfied with their prehospital care. objectives: we set out to determine the sensitivity and specificity of eps in determining the presence of recently ingested tablets or tablet fragments.methods: this was a prospective volunteer study at an academic emergency department. healthy volunteers were enrolled and kept npo for 6 hours prior to tablet ingestion. over 10 minutes subjects ingested 800 ml of water and 30 tablets. ultrasounds video clips were performed prior to any tablet ingestion, after drinking 200 ml of water, after 10 tablets, after 20 tablets, after 30 tablets, and 60 minutes after the final tablet ingestion yielding six clips per volunteer. all video clips were randomized and shown to three eps who were fellowship-trained in emergency ultrasound. eps recorded the presence or absence of tablets.results: ten volunteers underwent the pill ingestion protocol and sixty clips were collected. results for all cases and each rater are reported in the table. overall there was moderate agreement between raters (kappa = 0.42). sub-group analysis of 10, 20, or 30 pills did not show any significant improvement in sensitivity and specificity.conclusion: ultrasound has moderate specificity but poor sensitivity for identification of tablet ingestion. these results imply that point-of-care ultrasound has limited utility in diagnosing large tablet ingestion. background: intravenous fat emulsion (ife) therapy is a novel treatment that has been used to reverse the acute toxicity of some xenobiotics with varied success. us poison control centers (pcc) are recommending this therapy for clinical use, but data regarding these recommendations are lacking.objectives: to determine how us pcc have incorporated ife as a treatment strategy for poisoning. methods: a closed-format multiple-choice survey instrument was developed, piloted, revised, and then sent electronically to every medical director of an accredited us pcc using surveymonkey in march 2011; addresses were obtained from the aapcc listserv, participation was voluntary and remained anonymous; three reminder invitations were sent during the study period. data were analyzed using descriptive statistics.results: forty-five of 57 (79%) pcc medical directors completed the survey. all 45 respondents felt that ife therapy played a role in the acute overdose setting. thirty (67%) pcc have a protocol for ife therapy: 29 (97%) recommend an initial bolus of 1.5 ml/kg of a 20% lipid emulsion, 28 (93%) pcc recommend an infusion of lipids, and 27/28 pcc recommend an initial infusion rate of 0.25 ml/kg of a 20% lipid emulsion. thirty-three (73%) felt that ife had no clinically significant side effects at a bolus dose of 1.5 ml/kg (20% emulsion). forty-four directors (98%) felt that the ''lipid sink'' mechanism contributed to the clinical effects of ife therapy, but 26 (58%) felt that there was a yet undiscovered mechanism that likely contributed as well. in a scenario with cardiac arrest due to a single xenobiotic, directors stated that their center would always or often recommend ife after overdose of bupivicaine (43; 96%), verapamil (36; 80%), amitriptyline (31; 69%), or an unknown xenobiotic (12; 27%). in a scenario with significant hemodynamic instability due to a single xenobiotic, directors stated that their pcc would always or often recommend ife after overdose of bupivicaine (40; 89%), verapamil (28; 62%), amitriptyline (25; 56%), or an unknown xenobiotic (8; 18%).conclusion: ife therapy is being recommended by us pcc. protocols and dosing regimens are nearly uniform. most directors feel that ife is safe but are more likely to recommend ife in patients with cardiac arrest than in patients with severe hemodynamic compromise. further research is warranted. levels drawn at 4 hours or more (240 mcg/ml at 5 hours, 198 mcg ⁄ ml at 4 hours, respectively). npv for toxic ingestion of an initial apap level less than 100 mcg/ml was 97.8% (95% ci 92.3-99.7%).conclusion: an apap level of less than 100 mcg/ml drawn less than 4 hours after ingestion had a high npv for excluding toxic ingestion. however, the authors would not recommend reliance on levels obtained under 4 hours to exclude toxicity as the potential for up to 6.7% false negative results is considered unacceptable. background: genetic variations in the mu-opioid receptor gene (oprm1) mediate individual differences in response to pain and addiction.objectives: to study whether the common a118g (rs1799971) mu-opioid receptor single nucleotide polymorphism (snp) or the alternative splicing snp of oprm1 (rs2075572) was associated with overdose severity, we assessed allele frequencies of each including associations with clinical severity in patients presenting to the emergency department (ed) with acute drug overdose. methods: in an observational cohort study at an urban teaching hospital, we evaluated consecutive adult ed patients presenting with suspected acute drug overdose over a 12-month period for whom discarded blood samples were available for analysis. specimens were linked with clinical variables (demographics, urine toxicology screens, clinical outcomes) then de-identified prior to genetic snp analysis. in-hospital severe outcomes were defined as either respiratory arrest (ra, defined by mechanical ventilation) or cardiac arrest (ca, defined by loss of pulse). blinded taqman genotyping (applied biosystems) of the snps were performed after standard dna purification (qiagen) and whole genome amplification (qiagen repli-g). the plink 1.07 genetic association analysis program was used to verify snp data quality, test for departure from hardy-weinberg equilibrium, and test individual snps for statistical association. results: we evaluated 178 patients (37% female, mean age 41.2) who overall suffered 13 ras and 3 cas (of whom 2 died). urine toxicology was positive in 33%, of which there were positives for 32 benzodiazepines, 26 cocaine, 21 opiates, 13 methadone, and 6 barbiturates. all genotypes examined conformed to hardy-weinberg equilibrium. the 118g allele was associated with 2.5fold increased odds of ca/ra (or 2.5, p < 0.05). the rs2075572 mutant allele was not associated with ca/ ra. conclusion: these data suggest that the 118g mutant allele of the oprm1 gene is associated with worse clinical severity in patients with acute drug overdose. the findings add to the growing body of evidence linking the a118g snp with clinical outcome and raise the question as to whether the a118g snp may be a potential target for personalized medical prescribing practices with regard to behavioral/physiologic overdose vulnerability.