Journal of Emergency Medicine, Trauma and Acute Care - 2 - International Conference in Emergency Medicine and Public Health-Qatar Proceedings, أكتوبر ٢٠١٦

Introduction: Diagnosis of patients in a pre-hospital setting is a challenging process that depends primarily on clinical evaluation. The pre-hospital environment presents particular challenges such as scanty information and limited diagnostic tools. Nonetheless, accurate diagnosis is key to activate the appropriate cascade of management, level(s) of dispatch and disposition. This study aims to compare the ambulance paramedic diagnosis with that determined in the Emergency Department (ED).

Method: This is a multi-centered cohort prospective study comparing pre-hospital diagnosis with emergency physicians' primary diagnosis. We included all adult patients in the ED of Hamad General Hospital, Al Khor Hospital and Al Wakrah Hospital, but excluded all poly-trauma patients (trauma level 1). Pre-hospital diagnosis was reviewed from the ambulance patient care record and compared with documented primary diagnosis provided by ED physicians during August 2015.

Results: A total of 747 records were reviewed; of which, 154 records were excluded from the Study due to missing data. The comparison results showed that 389 files were congruent and 200 were non-congruent. They included common diagnoses such as trauma (9%), abdominal pain (12%) and renal colic (12%), and had concordance as high as 90.5%.

Conclusion: Pre-hospital diagnosis was congruent in 66% of the cases reviewed when compared with emergency physicians' provisional diagnosis. As the study did not include the final diagnosis, accuracy of diagnosis was not assessed for both the pre-hospital setting and ED physicians. The most common cause of incongruity was documenting a specific diagnosis instead of provisional diagnosis, which increases the risk of missing related differential diagnosis.

Recommendations: Such studies may help identify opportunities of improvement for healthcare providers to make optimal decisions. Therefore, further studies are required to reveal the areas of improvement.

Background: Despite the great success in controlling infectious disease in children, house accidents have increased, especially in developing countries, in the last years. WHO has reported that more than 20% of hospital cases involve children under 5 years of age and are caused by house accidents. Foreign body aspiration (FBA) is a preventable accident with a high risk of mortality. The objective of this study is to identify the epidemiology of FBA in children admitted to Al Bashir Hospital in 2011.

Methods: A retrospective cross-sectional study was conducted in 135 children who were admitted to the hospital and bronchoscopy was conducted for diagnosis and treatment. Data was collected from the files of those patients by using a questionnaire, which included variables (age, sex, type of foreign body, location of foreign body, main presenting symptoms, referred status). SPSS 17 used for analysis.

Results: A majority of the patients (63%) were between 1 and 3 years, mean age 3.2 years, (59% male, 41%female) with a M:F ratio 1.4:1. Bronchoscopy findings 113 out of 135 (84%) showed positive foreign bodies, Rt main bronchus is the common site 56% of the cases. Most of the foreign bodies were organic, seeds and peanuts (72%). The majority of the cases presented with cough (97%), choking (64%), and shortness of breathing (39%). Thirty percent of the cases were referred from peripheral hospitals. Mean hospital stay was 2.1 days. One patient developed cardiac arrest and convulsion occurred in one case. Chest infection was seen in 10 cases. No other complication was seen.

Conclusions: Detailed history from the parents about foreign body aspiration is important for diagnosis of FBA, when suspected prompt bronchoscopy should done to prevent further complication, the doctors should not depend exclusively on radiological examination for the diagnosis of FBA as most foreign bodies are radiopaque.

Background: The emergency department physicians rarely see high-pressure injection injuries (HPI) to the hand. These work-related injuries can have a devastating effect on hand function, particularly if not treated early. These injuries are usually caused by the introduction of chemicals into the wound. Chemicals under high-pressure cause local tissue damage, ischemia, and acute and chronic inflammation. The initial assessment may suggest a trivial injury to the inexperienced physician. HPI should be considered as a surgical emergency. Wound exploration, cleansing, and decompression usually preserve the optimal functions. The prognosis of these HPI depends upon the time of presentation, the type of the fluid injected, the pressure, volume, site of injection and appropriate management.

Aim: We aim to highlight the importance of early recognition of HPI by the emergency physician.

Case presentations: We present two cases of HPI. Both of them presented with a small puncture wound on their hands within 1–2 hours of the injury. The first patient was treated with analgesia and antibiotics and was discharged home. He returned again to the Emergency Department after 24 hours with increased pain, swelling, and discoloration of the fingers. He was referred for surgical exploration but required amputation of the index finger. The second patient was immediately referred to the hand surgeon for surgical exploration. He was able to make a good functional recovery within 3 months of the accident.

Conclusion: These cases highlight the importance of early identification and referral by emergency physicians to ensure appropriate multidisciplinary treatment to prevent long-term disability.

Introduction: Renal colic is one of the common abdominal emergency presentations to an ED. The cost of imaging, health care resources and time spent in the Emergency Department (ED) is huge. There is good evidence supporting the role of ED bedside ultrasound in detecting hydronephrosis.^1,2 We plan to study the role of bedside ultrasound in renal colic as a pilot audit for the QIP.

Method: A convenience sample was selected prospectively. In all patients, a bedside ultrasound was performed by emergency ultrasound fellow, focused to answer presence or absence of hydronephrosis was performed. The results of ultrasound were recorded using online Google docs. A CT-KUB scan was performed for all these patients as per departmental guidelines. The results of CT and USG finding, disposition, and timings for the registration, to perform USG, and to get CT reports were recorded and analyzed.

Results: A total of 24 patients aged between 18 and 65 years were included in the study. The average length of stay (LOS) in ED was 15.1 hours (3.7–60.3 hours). The mean time to perform bedside USG was 4.0 ± 2.4 hour. The average time to get the CT-KUB results was 6.0 ± 2.4 hours. The negative predicative value of bedside USG was 80%. None of the patients without hydronephrosis had obstructing stone or required admission. In patients without hydronephrosis, the average LOS of ED stay, in disposition based on CT results, was 2.08 hours higher than the disposition bedside USG results.

Conclusion: These observations are limited as part of small audit data. However, it could be future direction to explore, the role of bedside USG performed by ED physicians, in renal colic to decrease the ED LOS.

Background: Today, e-learning is of strategic importance to teaching and learning in Emergency Medicine (EM). We adopted an interactive e-learning platform based on the open source software called MOODLEa using a blended learning strategy to assist the implementation of a dedicated faculty development program known as the EM consolidation program. This 12-month program was designed to meet the developmental needs of 20 EM specialists who qualified from different parts of the world. The program is delivered through an innovative blend of workplace and simulation-based assessments, educational portfolio and individualized training in selected clinical areas. The e-learning platform was used by the program participants to share learning resources, communicate, and coordinate various educational activities over the last 6 months.

Methods: We sought feedback from the participants through a MOODLE-based online questionnaire to evaluate their satisfaction, usage patterns and feedback of their e-learning experience.

Results: Out of 20 participants, 90% (n = 18) completed the questionnaire. Two-thirds declared proficiency in computer skills and were enthusiastic about the technology. Their prior experience was related to certified courses rather than interactive forum-based e-learning. About their current experience with MOODLE, 86.7% of participants found it easy to use without any major technical problems. Most of them preferred to access the platform once or twice a week, with 20% accessing on a daily basis. Of the participants, 75% of them accessed MOODLE through their smartphones and 12.5 % through tablet devices. All areas of the e-learning course were found to be useful. The forum-based discussion area was highly rated. The overall learning material was perceived as appropriate and well designed. Among the participants, 62.50% liked the current methodology of blended learning, and 31.25% wished to replace traditional method with e-learning. Also 93.75% of the respondents stated that e-learning was time saving.

Conclusion: Learners involved in this e-learning initiative were overall satisfied by the current implementation of MOODLE and with a third of users preferring e-learning to traditional learning. The use of smartphones and tablet devices was widespread in this small study and hence we recommend support for these devices in implementing similar e-learning initiatives.

Reference: [1] Cook DA, Yvonne S. Online learning for faculty development: A review of the literature. Med Teach. 2013;35(11):930–937.

a MOODLE – Modular Object Orientated Dynamic Learning Environment. http://moodle.org.

Background: Procedural sedation (PS) is commonly used in the Emergency Department (ED) to lessen pain, apprehension, and agony for patients during medical procedures. PS encompasses administering of sedative medications with or without the simultaneous delivery of analgesic agents. Safe and effective PS in the ED is a skill that is fundamental to practice of Emergency Medicine. Patients undergoing PS in ED should have a documented evidence of pre-sedation assessment, including prediction of difficulty in airway management, ASA physical status and fasting status.

Aim: The aim of this audit, as a part of a QIP, was to assess the current practice and documentation of PS pre-reassessment among the ED physicians.

Methods and settings: This was an electronic questionnaire survey sent to all ED physicians via their work e-mails. Sixty-seven emergency physicians took part in the survey; however, only 62 completed it. This is a high-volume ED in a large tertiary care hospital where up to 1,600 patients are seen daily and PS is practiced frequently.

Results: Sixty-two ED physicians completed the electronic survey. Only 33.33% (n = 21) stated that they document PS pre-assessment as a usual practice. Among the participants, 69.35% (n = 43) stated the lack of time as the commonest reason for not documenting the PS pre-assessment. And 79.03% (n = 49) admitted that availability of a PS pre-assessment form would improve practice and documentation.

Conclusion and recommendation: Only one-third of the physicians documented PS pre-assessment as a usual practice. The majority of the physicians indicated lack of time as the reason for not documenting the PS pre-assessment. There is a need for a simple assessment form with a checklist and regular training for all ED physicians in PS pre-assessment to practice safely and effectively.

Background: Delays in clinical handover can compromise a patient's care. The handover is not the sole responsibility of the ambulance personnel or the emergency departments. Reducing delays requires the working together of the entire organization, as well as designing efficient emergency and ambulance departments.

Objectives: The study aims at exploring the quality of clinical handover between the emergency department personnel and the ambulance personnel at Hamad General Hospital.

Methods: This is a descriptive study using two kinds of anonymous questionnaire surveys to gauge the current opinion regarding patient handover. One was aimed at physicians, who are the hospital employees, and the second was intended for the ambulance personnel. The employees of the Emergency Department were asked to provide their opinion of the handovers that the ambulance employees provided in a given clinical situation. The clinical situations in question included: cardiac arrest, pediatric emergencies, sepsis, chest pain, head injury, and trauma.

Results: A total of 65 ambulance employees and 70 medical employees completed the survey. The findings of the study indicate that there is a formal training procedure for patient handover, and that, in general, the quality of communication of history, the general quality of handover, and the knowledge of vital signs reported were high. The ambulance personnel were satisfied with their quality of handover. However, the medical staff were less positive, particularly for sepsis and pediatric emergencies. The findings also indicate that the ambulance employees perceived a high level of delay regarding patient handover.

Conclusions: It was encouraging that both groups had a positive perception about the handover. The areas for improvement identified by the medical employees were sepsis and pediatric emergencies, while the ambulance employees perceived a significant delay in the handover. In conclusion, the study proposes the following recommendations as possible solutions: interdisciplinary training, addressing organizational culture, and flexibility in organizational processes.

Background: This study is a quality improvement project that aimed at improving patient flow in Male Urgent Area (MUA), one of the busiest areas in the largest emergency department in the state of Qatar.

Methods: The baseline process was designed by mapping and drawing a cause-and-effect diagram. Pre- and post-auditing was done after careful intervention of introducing a phlebotomy room in Male See and Treat area, the main feeder to MUA. The feeding areas to MUA and the daily flow of patients were studied in detail. Points of interest in the baseline process map were identified and targeted. Supporting data of about 398 patients helped in designing the process map and identifying the point of interest.

Results: Post-intervention analysis showed a remarkable improvement in time to phlebotomy in Hamad General Hospital Emergency Department. The proportion of patients moving to MUA and receiving phlebotomy increased from 48.6% to 84.1% in the first hour. Patients' hematological laboratory workup that helps MUA's physicians in decision making was readily available.

Conclusion: Patient flow and phlebotomy time can be significantly improved by introducing a dedicated phlebotomy room in a busy emergency department. It is concluded that identification and targeting of the main point of interest in baseline process mapping is crucial and of considerable importance in a quality improvement project.

Keywords: Emergency department, phlebotomy time, patient flow

Introduction: Sepsis is a major cause of hospitalization with a high mortality rate. Early recognition and management of sepsis have shown to improve mortality outcomes. A proactive alert system for improving the response of the interdisciplinary team may decrease the time to intervention and improve patient outcomes.

Objective: The study evaluated the impact of an early alert system, “CODE SEPSIS”, on adherence to the sepsis management bundle and time to intervention among patients at risk for sepsis.

Method: Patients presenting to the Emergency Department (ED) and meeting two or more criteria on the sepsis screening tool were intended to trigger an overhead alert known as CODE SEPSIS, which was activated based on the physician's decision. Data were retrospectively collected over a 3-month period for all hospitalized adult patients with confirmed sepsis (age above 18 years). We evaluated the time from ED presentation to diagnostic and treatment interventions. A data collection tool was designed to record information.

Results: A total of 36 sepsis patients were identified, among which 18 were classified as CODE SEPSIS and 18 were classified as non-CODE SEPSIS. We found that the CODE SEPSIS group showed greater improvement than the non-CODE SEPSIS group from ED presentation to intravenous catheter insertion (37.3 to 31.5 minutes, 15.6%), fluid administration (41 to 39 minutes, 4.9%), microbiological workup (91 to 33 minutes, 63.7%), lactate level (69 to 66 minutes, 4.3%), prescribing antimicrobial therapy (92 to 44 minutes, 52%), and administration of antimicrobial therapy (88 to 46 minutes, 47.7%). Patients in the non-CODE SEPSIS group showed a 1-day decrease in length of hospital stay.

Conclusion: The CODE SEPSIS alert system developed at Al Wakra Hospital promoted early and standardized management among patients at risk for sepsis, which may lead to improved patient outcomes.

Background: Rhabdomyolysis, which can be defined as a CPK level greater than five times the upper limit of normal, is related to muscle breakdown and hypovolemia in heat stroke patients.¹ CPK levels will likely be higher because of increased muscle breakdown in exertional heat stroke when compared with classic heat stroke.

Methods: We reviewed 50 patients who came into the Emergency Department of Hamad General Hospital during the months of July to September 2015, and who were diagnosed with exertional heat stroke.

Results: In 44 out of 50 heat stroke patients, the level of serum CPK was markedly elevated (mean 20,300 ± 25,500 U/l) compared with the elevated levels of other lab values (serum myoglobin 2500 ± 3000 ng/ml, creatinine 1.8 ± 2.4 mg/dL, BUN 90 ± 104 mg/dL, potassium 2.6 ± 3.6 mEq/L, sodium 135 ± 155 mEq/L) on admission. The repeated lab values after the 12th hour showed that the CPK rose further (28,500 ± 32,500 U/L) while the others (serum myoglobin 800 ± 1,200 ng/ml, creatinine 1.1 ± 1.4 mg/dl, BUN 35 ± 60 mg/dL, potassium 2.2 ± 3.4 mEq/L, sodium 110 ± 130 mEq/L) recorded a decrease.

Conclusion: In our cohort of patients, CPK levels were significantly high in the setting of exertional heat stroke. A possible relation to renal failure need to be explored in a prospective research design.

Keywords: exertional heat stroke, rhabdomyolysis, creatinine phosphokinase REFERENCE: [1] Santelli J, Sullivan J. An evidence based approach on emergency medicine. Emerg Med Prac. 2014;16:6–15.

Background: Although the majority of sudden cardiac deaths (SCD) are due to CAD and poor LVEF, there is a considerable fraction of idiopathic ventricular fibrillation (IVF) causing SCD that is secondary to channelopathies and other inherited arrhythmias.

Objective: The present report aims to raise awareness about the prevalence of inherited arrhythmogenic disorders, besides the commonly attributed CAD causing SCD.

Case report: We report the case of a patient with a history of sudden collapse after routine duty. He had ventricular fibrillation and was successfully defibrillated to normal sinus rhythm. On examination, he was found to have a structurally normal heart, and the ECG showed early repolarisation (ERPS) with a short QT interval.

Review of the literature: SCD is defined as IVF in the absence of an identifiable cause. IVF could be the manifestation of concealed forms of arrhythmogenic disorders exacerbated by appropriate triggers. Long QT syndrome presents with structurally normal heart, QT prolongation, syncope, and SCD. Incomplete penetrance gene presents as Brugada syndrome, short QT syndrome, ERPS, sinus node dysfunction, and progressive conduction defects. Subtle ECG changes may be present, which, if identified early, can lead to further focused evaluation, leading to the prevention of a potentially life-threatening arrhythmia. ECG changes that should be looked for include: ERPS changes, especially in the inferior and lateral leads, ‘Rs’ in the inferior leads – >2 mm deep in lead II, small slurred S wave in the inferior leads, incomplete or complete RBBB with J point elevation and coved ST segment in V1 and V2 for Brugada, and long or short QT interval.

Conclusion/summary: It is important to recognise channelopathies causing SCD. This is because a majority of these channelopathies are ‘inherited’ and can cause more deaths in the family. Such potential information obtained from ECG features can help categorise patients as ‘suspected high-risk’ and provide appropriate advice.

Background: Peripheral oxygen saturation (SpO2) and heart rate (HR) are important indicators for various medical conditions such as cardiopulmonary disorders and respiratory diseases. The main objectives of this study is to design and implement a portable embedded medical system. This system wirelessly obtains SpO2 and HR data from a patient as well as his/her coordination, and sends a short messaging service (SMS) alarm to the emergency control room to contact the patient and confirm his/her health status or dispatch an ambulance in case of his/her measurements are outside the normal range based on the Qatar Early Warning Scoring (QEWS) system.

Methods: The system mainly consists of a Bluetooth finger pulse oximeter, a Bluetooth-enabled microcontroller, a global positioning system (GPS) and a General Packet Radio Service (GPRS) module. It is divided into three main stages. In the first stage, the readings of SpO2 and HR are obtained from the patient in real time. During the second stage, the readings obtained are sent over Bluetooth to the signal acquisition and processing unit. The received data is processed and a decision is made whether a SMS alarm should be sent or not. The final stage is concerned with sending the alarming SMS to the emergency control room over the GPRS network based on the QEWS system.

Results: The system was implemented and successfully tested as a stand-alone unit by avoiding the use of a PC or a smartphone for data processing. The transmitted SMS alarm includes the SpO2 and HR readings, the QEWS score and the GPS coordinates.

Conclusions: The designed system is wireless, portable, and user-friendly. This system possibly promotes quality of care for the patient living outside hospital and could improve response time from an ambulance service point of view by determining the exact location of the patient.

Background: Qatar Hamad Medical Corporation Ambulance Service (HMCAS) major incident response guide is intended to address techniques in field operations that must be utilized in the event of a major incident. This guide standardizes operations during major incidents, regardless of what caused the incident, number of patients, severity of the injuries or the complexity of the incident.

Methods: This plan was tested and implemented across the ambulance service and Hamad International Airport (HIA) in collaboration with other agencies such as police, civil defense and HIA safety department through a full-day training program. Different training methods such as workshops, lectures and simulated exercises was conducted using different scenarios.

Results: This system was implemented for five real major incidents during 2014–2015 in Qatar. The average time for all units to be on scene was 20 minutes. The total units needed by this system were 33 units, approximately according to the predetermined attendance sheet (PDA). These units include all on-scene structure of command according to the HMCAS major incident response guide. The average time to transport the victims from the scene to the hospitals was 10 minutes or less. Three communication channels were established during the whole process.

Conclusion: The designed system is suitable for up to 100 patients in pre-hospital emergency care in case of a major incident. The system would need to be tested and evaluated regularly to ensure compliancy and understanding from all staff in HMCAS to ensure that they are ready at all times in the event of a major incident.

Background:Neisseria meningitidis (NM) is a leading cause of meningitis and septicemia. NM has an overall dispersion at rate of 11%, assuming that 10%–20% of the population carries NM in their throat at any given time, and increased carriage rate may be seen during epidemics.

Objective: This study aimed to describe the incidence and epidemiological characteristics NM in Qatar.

Methods: A retrospective review of epidemiological data for cases of NM reported to the Department of Public Health, HP & CDC section in 2010–2014 form all active surveillance sites in the health region. NM types of isolates from cases were serogrouped at Microbiology Laboratory in Hamad Medical Corporation. Estimates of the incidence and number of cases in the state of Qatar were calculated by sex and age group.

Results: A total of 41 cases of NM were reported during the study period. The incidence of NM in Qatar ranged between 0.8, 0.2, 0.3 and 0.4 cases per 100,000 population in 2010, 2011, 2012, and 2013 respectively and then considerably increased by end of 2014 (0.6 per 100,000 population). The incidence of NM was highest among males (37 cases) than females (4 cases), while NM occurred mainly in young adult group of the population.

Conclusion: The incidence of NM was very low in Qatar with young adults being at the highest risk. Active surveillance and dynamic research, fast conspicuous verification, and serotyping of NM will support public health decision making in the control of rising strains in Qatar.

Keywords:Neisseria meningitidis, Qatar, active surveillance, epidemiology, Supreme Council of Healt

Introduction: Acute aortic dissection (AAD) is one of the most challenging cardiovascular emergencies presenting to the Emergency Department (ED). Prompt diagnosis and treatment is the key to patient survival. Though most AADs present with typical symptoms, it has been reported to present with a myriad of symptoms. We report a case of an AAD, which presented to our ED with predominant neurological symptoms.

Case description: A 47-year-old male was brought to our ED with acute confusion and history of seizure. He did not have any history of trauma or report any chest pain, headache or fever. He was vitally stable except for slight tachycardia and his physical examination was unremarkable. All investigations including a CT head were reported normal except leukocytosis (27 × 109/L). A few hours after admission, he started deteriorating, developed hypotension and became more agitated. Resuscitative measures were started. Ultrasound scan of the heart was performed to confirm central venous access showed a pericardial effusion and a flap in the ascending aorta. A diagnosis of AAD was made. An urgent CT was performed, which showed an extensive Type A aortic dissection extending into the branches, with rupture into pericardial cavity. During transportation for surgery, the patient had a cardiac arrest from which he could not be resuscitated.

Conclusion: AADs may present in an unusual manner with predominantly neurological manifestations such as acute confusion and seizure. In patients with unexplained acute confusional state the possibility of an AAD should be considered in the differential diagnosis. Bedside TTE has a limited sensitivity but high specificity in diagnosis of Type A AD and its early utilization may facilitate timely diagnosis improving outcome. Given the high specificity of TTE and time-dependent survival in Type A AD, institutional protocols to expedite the transfer to the operating room without waiting for CT confirmation might be considered.

Background: Injuries from air bag deployment have long been documented and studied like orbital blowout fractures, auditory injuries, etc. However, we report here a case of an alveolar process fracture associated with dental injuries and clear history of face-to-air bag impact only, which has rarely been documented and hence important to be reported.

Case report: A 25-year old female front-seat passenger was involved in a head-on collision between her large four-wheel drive vehicle and another similar-sized vehicle. She was unrestrained and suffered facial and dental pain after the air bag was deployed. She denied hitting the dashboard or losing her consciousness.

On examination, there was mild skin erythema associated with marked tenderness over her left maxilla and left upper jaw. Her upper left medial incisor was missing, while the lateral incisor and adjacent canine seemed to have been pushed upwards and embedded in their respective sockets. No other injury was elicited and she remained vitally stable.

X-ray and CT scan imaging confirmed an alveolar bone fracture with upward displacement of the alveolar margin of the maxilla. Loss of medial upper left incisor, and impaction of the adjacent lateral incisor and canine teeth in the soft tissues at the left naso-labial fold, antero-lateral to the left nasolacrimal bones were also noted.

Discussion: It is important to report these to be included in the potential range of injuries associated with air bag impact MVC. It will help widen the physicians range of possible injuries while evaluating an air bag impact MVC patient, hence aiding diagnosis and management. It will also help in the ongoing research for further modifying the techniques and types of protective devices currently used in vehicles to help prevent such injuries, as well as further highlighting the use of restraint along with use of such devices.

Background: In the past 3 years, average length of stay in the emergency department has increased by 20–30%. It was found that one of the most important factor causing this was increased number of X-rays done. At an average one x-ray adds 4–5 hours to disposition time. An observational study was done to find out reasons for the low compliance with usage of Ottawa ankle rules.

Methods: Initially observational study was done where 100 physicians were observed while they examine ankle and foot sprain cases for requesting x-ray. This was done without their knowledge. Then a questionnaire was distributed among 100 Emergency doctors to determine the factors that lead to non-compliance with use of Ottawa rules as screening tool for requesting x-ray.

Result: In the initial observational study done on 100 cases we found that, only 20 patients presenting with symptoms of ankle /foot injury had bony injury ruled out by Ottawa rules and in 11 out of these, Ottawa rule was not done appropriately. The questionnaire was completed by 100 physicians. The result showed that 64% of physicians were afraid of the liability of missing fracture. 56% were not comfortable because of difficulty in follow up. 24% expressed that increased number of patients with limited time to assess patient thoroughly put a pressure to do X-ray. 48% were not aware of Ottawa rules. 32% mentioned that lack of emergency follow-up clinics for those with persistent symptoms compel them to request x-rays than to decide clinically.

Conclusion: A proper follow-up system for patients discharged after screening will reduce the fear of liability of missing fractures. This will reduce the number of x-rays and length of stay in ED.

Introduction: We present a case of bilateral ureteric colic that causes anuric acute renal failure. Bilateral ureteric colic causing acute renal failure is not a new presentation. However, the patient had only 3 mm calculi, making our case unique.

Background: Bilateral renal calculi are an uncommon cause of acute kidney injury (AKI). Obstructing ureteroliths rarely lead to AKI without any underlying renal disease or anatomic abnormalities, such as a solitary kidney or horseshoe kidney. The literature has reported the incidence of a unilateral ureterovesicular junction obstruction secondary to a stone as 20%. However, there are a very few case reports in the literature of urology, nephrology or emergency medicine regarding the incidence of bilateral ureteric calculi. Cases of bilateral ureteric calculi are rare, and cases with AKI and anuria are very rare.

Case presentation: A 30-year-old male presented with bilateral colicky flank pain for 4 days and started to develop macroscopic haematuria. After proper pain management in the Emergency Department, the patient was found to have a raised serum creatinine level (152 μmol/L). A CT scan was performed showing two 3 mm calculi in the left and right proximal ureters. Ultrasound showed moderate left and mild right hydroureteronephrosis. Due to the relatively small size of the stones, and the clinical image of the patient, he was planned for medical expulsive therapy. Surprisingly, the patient developed complete anuria for 2 days and presented to the ED with a serum creatinine level of 843 μmol/L. Bilateral double J stents were placed and urgent ureteroscopy was done. Following treatment, the patient's condition significantly improved and his renal function returned to normal within 4 days.

Conclusion: Even small bilateral stones can result in acute kidney injury.

Background: The South West London & Surrey Trauma Network has one major trauma centre (MTC) and seven acute trauma units (TUs) over a wide geographical area. Seventy-five percent of the major trauma patients (injury severity score >15) were taken to MTC. However, many were admitted in trauma units. Available data indicates that there is a possibility that patients in TU rather than MTC may receive less than optimal care.

Aims: We would like to describe the development of a new system and process to review the management of ISS>15 cases under governance framework, assuring the delivery of safe and effective trauma care outside a MTC.

Description: The standard operating procedure and flow chart process were developed for review of major trauma cases. TARN Office identified patients were reviewed using a proforma, with key trauma measures as quality indicators. The notes were initially reviewed by clinicians, and in due course by the MDT team for the whole patient journey from arrival to discharge.

Outcomes: The commonest age group is >65 years. Head injury is most common, resulting from a fall from standing height (64%) causing subdural haemorrhage (57%). Most arrive by blue-light ambulance (86%). There is evidence of specialist team involvement in 64% of the cases and multidisciplinary team involvement in 55% of the cases. However, there are issues with the quality of record keeping, Timely CT scans and incorporating rehabilitation prescriptions into discharge letters were done.

Issues with care were formally registered with hospital incident reporting system and registered in the trauma risk register. Findings were presented in the hospital audit study day, in the Trust Governance Committee and disseminated for development. This governance system has evolved with more concrete systems now in place.

Conclusion: Initiating a robust governance system and process will minimise substandard care and help standardise care across the network.

Background: Management of serious paracetamol overdose with N-acetylcysteine (NAC) is an effective strategy. Early treatment with NAC prevents the formation of a toxic metabolite that leads to hepatic injury. However, inappropriate treatment with NAC and overtreatment with NAC can lead to potential adverse side effects and unnecessary hospital admission.

The aim of the study was to assess the administration of NAC in the setting of paracetamol overdose and determine whether the institutional use of this antidote is consistent with the international standards. We hypothesize that some patients receive antidotal NAC unnecessarily after paracetamol exposure, and that a simple quality improvement intervention in educational activity may improve the administration of this antidote.

Methods: A retrospective quality improvement chart review evaluated charts of patients who were treated with NAC for paracetamol exposure over a 2-month period in the Emergency Department of Hamad General Hospital. The quality improvement intervention consisted of establishing a paracetamol clinical practice guideline, providing access to a treatment nomogram for NAC use, enhancing educational activities to improve the clinician's understanding of appropriate NAC use, and establishing a clinical toxicology service for all paracetamol exposures.

Results: NAC administration to 67% of the cases after paracetamol exposure were found to be medically unnecessary according to the established international guidelines for management of paracetamol overdose. Post-intervention measurement showed significant improvement by decreasing unnecessary NAC administration to only 33%.

Conclusion: In our institution, NAC treatment after paracetamol exposure is usually administered unnecessarily. Inappropriate administration of this antidote results in a significant waste of resources and unnecessarily prolonged hospital stay.

Adherence to the clinical practice guidelines may lead to a significant improvement in this antidote use after paracetamol exposure. Given that this antidote is used inappropriately despite widespread knowledge that guidelines for paracetamol exposure exist, we believe that continuous education on the topic, chart audits and feedback, and use of a clinical toxicology service may improve the knowledge and appropriate use of this antidote and will improve patient care.