Invited Lecture 1
19th Nov (Mon) 13:20 - 14:20 Room 503

IL1 Medical preparedness for mass gatherings: Lessons andobservations from the WHO Mass Gathering Collaborating
Centre network

Torrens Resilience Institute, Flinders University

Paul Arbon

Professor Arbon is a Matthew Flinders Distinguished Professor, and Director of the Torrens Resilience Institute and the World HealthOrganisation Collaborating Centre for Mass Gatherings and Global Health Security at Flinders University, Adelaide Australia.
The Torrens Resilience Institute was established in 2009 to improve the capacity of organisations and societies to respond to disruptive
challenges that have the potential to overwhelm local emergency management capabilities and plans. Current research and development
is focused on community and organisational disaster resilience, mass gathering management and emerging health security threats.
Professor Arbon is former President of the World Association for Disaster and Emergency Medicine, past Chief Commissioner of St
John Ambulance Australia, a member the United Nation’s International Health Regulations Roster of Experts, Editorial Board Memberof the disaster journal Pre Hospital and Disaster Medicine and Fellow of the Australian College of Nursing and the American Academyof Nursing. He has published extensively on mass gathering health and leads a program of research and development work in this field.
Mass gatherings occur frequently and present a unique set of challenges with respect to attendees’ health and wellbeing, and theprovision of timely and appropriate healthcare. The potential for illness and injury at these events is increased because of the interplay of
a range of environmental factors, including crowd density and behavior, weather, and the consumption of alcohol and other drugs.
Prevailing social and political factors may also play a role in determining the level of risk and likely adverse consequences. Massgatherings challenge the provision of effective public health services and acute medical responses. On-site medical care can deliver
timely interventions and prevent undue strain on local health services.
The network of World Health Organization Collaborating Centers for Mass Gatherings has identified key lessons and emerging issues
relevant to the provision of acute medical services. These include techniques to model the expected number and type of patientpresentations, focus on environmental drivers of medical presentations including heat and the consumption of alcohol and other drugs,
the threat of and preparedness for deliberate events including lone actor attacks and the malicious use of chemical and biological agents,
and the emergence of novel infectious diseases that may threaten the safe conduct of the event.
This presentation will focus on current lessons and observations on medical preparedness for mass gatherings, discussion of emerging
threats including likelihood and consequence(s), and possible responses to these issues.

Invited Lecture 2
20th Nov (Tue) 13:40 - 14:40 Room 503

IL2 Hierarchical model of modern resuscitation for improvement ofcardiac arrest survival

Chairman, Emergency Medicine, Donald and Barbara Zucker School of Medicine at Hofstra

Lance B. Becker

Education:
1977-81
MD University of Illinois College of Medicine
Postgraduate Training and Fellowship Appointments:
1981-84
Resident, Michael Reese Hospital and Medical Center, Chicago, IL
Faculty Appointments:
2001-2006
Professor, Department of Emergency Medicine, University of Chicago, Chicago, IL
2006-presProfessor, Department of Emergency Medicine, the University of Pennsylvania, Philadelphia, PA
2008-13
Professor, Department of Clinical Studies-Philadelphia, the University of Pennsylvania, Philadelphia, PA
2013-15
Professor, Center for Mitochondrial and Epigenomic Medicine（CMEM）at The Children's Hospital of Philadelphia
2015-presProfessor and Chairman, Department of Emergency Medicine, Hofstra Northwell School of Medicine
2016-presProfessor, Center for Immunology and Inflammation, Feinstein Institute for Medical ResearchAwards, Honors and Membership in Honorary Societies: 17 more awards
2010
Giant of Resuscitation Award from the American Heart Association’s International Liaison Committee on Resuscitation（ILCOR）
2012
Hans H. Dahll Award from the Emergency Cardiovascular Care Citizen CPR Foundation in Orlando, FL
2012
Lifetime Achievement Award in Cardiac Resuscitation Science honored at the American Heart Association’s Resuscitation Science Symposium’s Annual
Meeting in Los Angeles, CA
2012 Elected to Lifetime Honorary Member, the European Resuscitation Council（ERC）Scientific Congress, Vienna
2013 Karolinska Institute, Sweden – Elected for The Annual Clinical Science Lecture
2014
Outstanding Contribution in Research 2014 Award at the American College of Emergency Physicians Annual Meeting, Chicago, IL
2015 Selected as the 2015 Recipient of the Asmund S. Laerdal Lecture Award from the Society of Critical Care Medicine’s Critical Care Congress, Phoenix, Arizona

Todays lecture for the JAAM will focus on new concepts in resuscitation care under a proposed novel model of resuscitation care termed the hierarchical model ofresuscitation.
Developments in science and technology are fundamentally altering the way to improve survival of cardiac arrest. These developments have created a modern and unique styleof resuscitation care. Under the hierarchical model , more and more resuscitation technology is delivered progressively to the patient in cardiac arrest in a logical step-wisefashion that starts at the bottom（simplest）but progresses to the top（most advanced）steps, as rescuers are able to provide more advanced therapies to the patient. The
hierarchical model starts with the provision of simple hands only CPR/BLS care, but then steps up to monitoring the rescuers actions like compression, ventilation, drugs andother ACLS therapies. A key factor is the need to measure metrics of rescuer action and we are now using video monitoring at Northwell Health to accomplish this difficult goal;
to really know the quality of resuscitation performed by our rescuers.
The next steps up in the hierarchy involve monitor the actual impact of the resuscitation on the patient’s physiology（i.e. not the rescuers action but the impact of the rescuers
actions on the patient’s physiology）. Possible monitoring modalities will be discussed for monitoring of resuscitation impact. A focus of the lecture will on using oxygen
consumption and CO2 generation as a new physiological monitor. While both oxygen consumption and CO2 generation are well known, they have not been applied to ourresuscitation care. We have recently discovered（reported first by Shinozaki in 2018）a new phenotype of altered oxygen consumption and CO2 generation in post-cardiac arrest
rodents that does not fit into any currently described pattern. Hence we proposed that this is a new phenotype of oxygen consumption and CO2 generation wherein oxygen
consumption is markedly elevated while CO2 generation remains normal. The evidence for this new phenotype will be reviewed along with the possible interpretations of thisnew data. Our current understanding of aerobic respiration does not explain the O 2 consumption measured in rats resuscitated from prolonged cardiac arrest. Even more
intriguingly, there is a new human report from an independent group in Boston, which reports low RQ in humans after cardiac arrest, thus independently raising the possibility
that we have discovered a new post-resuscitation metabolic phenotype. Many future studies are required to further explore this concept but future monitors and therapies may bebased on this new finding.
The next steps up in the hierarchy model involve advanced resuscitation where tradition CPR generated blood flow is replaced by an artificial lung with a mechanical pump.
This is termed ECMO resuscitation, ECPB, ECPR, or other terms- the many terms reflect that it is the relatively new
nature of these advance approaches. Pioneered by several resuscitation visionaries（like K. Nagao, T Sakamoto, andProgressive?? Future ???
many others）, Japan has led in the implementation of this life saving advanced resuscitation modality and many(new discoveries)
Hierarchal model
lives have been saved. However, we believe it is possible to significantly improve this approach by the addition of anfor improving survival
ECPB & Reperfusion Drugs(add brain focused protection)
anti-reperfusion injury cocktail （i.e. a combination of several drugs that work synergistically to combat reperfusion
Emergency Cardiopulm Bypass (ECPB)
injury particularly in the brain）. The scientific evidence for this approach will be reviewed and the basic science(artificial circulation)
rational behind the use of a cocktail plus ECPB will be presented, along with current possible components of a
Measure vital end‐organ physiology(VCO2/VO2/RQ, brain oximetry)neuro-protective cocktail that can be used along with ECPB.
Measure patient’s circulatory physiology
The final portion of the lecture will address the need for the resuscitation community to join together in a global(pulse detection)
Measure rescuer actions (CPR quality, pauses)
resuscitation network to conduct the studies required to save more lives globally. Our enduring friendship andcollaboration over the pacific will eventually involve all resuscitation caregivers in the near future. It is a time to act.
Start traditional CPR, ACLS (measure nothing)Invited Lecture 3
21st Nov (Wed) 10:40 - 11:40 Room 503

IL3 New Insights in Pathogenesis and Management of Disseminated‌intravascular coagulation（DIC）

University College London, United Kingdom & University of Amsterdam, the Netherlands

Marcel Levi

Marcel Levi（1964）is professor of Medicine at University College London and chief executive of University College London
Hospitals（UCLH）. He is also a practicing consultant in general and acute medicine at UCLH. His previous position was professor
and dean of the Faculty of Medicine of the University of Amsterdam and chairman of the Executive Board of the Academic Medical
Center in Amsterdam, the Netherlands. After his medical training and specialization in Internal Medicine at the University of
Amsterdam he obtained his PhD with honours（1991）and was appointed as a Fellow by the Royal Netherlands Academy of Science.
He worked at the University of Perugia, Italy and the Center for Transgene Technology and Genetherapy of the University of Leuven,
Belgium and followed a MSc program at the University of Oxford in Evidence-based Health Care. He has published more than 700
articles in international scientific journals, has been awarded a number of international research awards（including twice the Biennial
Award for Contributions to Haemostasis of the ISTH：Investigator Recognition Award（2005）and the Distinguished Career Award（2013）. He was chairman of the Netherlands Society of Thrombosis and Haemostasis between 2000-2007 and chairman of theNetherlands Organization for Medical Research（ZON-MW）between 2008 and 2016. He was elected as a member of the Royal
Netherlands Academy of Science（KNAW）and is a fellow of the Royal College of Physicians in the UK. He is associate editor of
JTH, senior associate editor of Seminars in Thrombosis and Hemostasis and deputy chief editor of the European Journal of Internal
Medicine.
Several clinical conditions, in particular those associated with a systemic inflammatory response, can cause some degree of activationof coagulation but when the procoagulant stimulus is sufficiently severe and overcomes the natural anticoagulant mechanisms of
coagulation, disseminated intravascular coagulation（DIC）may occur. The clinical manifestations of DIC encompass multiorgan
dysfunction caused by fibrin-platelet clots in the microcirculation, and bleeding caused by consumption of platelets and coagulation
factors. Molecular mechanisms that play a role in inflammation-induced effects on coagulation have been recognized in much detail.
Exposure of blood to tissue factor is the most common trigger, whereas the intravascular coagulation is propagated due to loss offunction of physiological anticoagulants and impaired fibrinolysis. New roles are described for neutrophil extracellular traps, histones,
ADAMTS13, and platelets. In patients with DIC various abnormalities in routine coagulation parameters may be observed, including
thrombocytopenia, prolonged global coagulation assays, or high levels of fibrin split products. In addition, more sophisticated tests for
activation of individual factors or pathways of coagulation may point to specific involvement of these components in the pathogenesis of
the disorder. A combination of readily available tests is usually sufficient in establishing the diagnosis of DIC and for this purpose
several scoring algorithms have been developed. Some specific clinical situations may elicit coagulation responses that can be
distinguished from DIC or may occur in combination with DIC, including dilutional coagulopathy, liver failure-related coagulation
derangement and thrombotic microangiopathies. The foundation of the management of coagulation in DIC is the explicit and thoroughtreatment of the underlying disorder by antibiotic treatment and source control measures. Adjunctive strategies focused at the impairmentof coagulation, including anticoagulants and restoration of physiological anticoagulant mechanisms, may supposedly be indicated andhave been found advantageous in experimental and initial clinical trials. The role of supplementing natural anticoagulant pathways, suchas by administration of recombinant thrombomodulin or antithrombin concentrate is evolving and new clinical studies show promising
results.

Asian Special Lecture 1
19th Nov (Mon) 11:00 - 11:40 Room 501

ASL1 Robot CPR as an alternative to manual CPR : a Preliminary
Study

Department of Emergency Medicine, Seoul National University Hospital

Gil Joon Suh

Current Appointments
Professor, Department of Emergency Medicine, Seoul National University College of Medicine, Seoul National University Hospital
Education
1978 – 1984 : Seoul National University College of Medicine, MD
1992 – 1996 : Seoul National University College of Medicine, MS & PhD
Positon & Employment
1988 – 1992 : Residency, Department of Surgery, Seoul National University Hospital
1992 – 1997 : Director, Department of Surgery, Korea Veterans Hospital
1997 – 1998 : Visiting Scholar, Department of Emergency Medicine, Stanford Medical Center, CA, USA
1999 – 2008 : Assistant & Associate Prof. Department of Emergency Medicine, Seoul National University College of Medicine
2008 – present : Professor, Seoul National University College of Medicine
2000. 7 – 2010. 7 : Chairperson, Department of Emergency Medicine, Seoul National University College of Medicine, Seoul National University Hospital
Professional Organizations & Committees
2006-2007 : Chairpersion, Organizing Committee of 6APBC
2007-2008 : Secretary General, Organizing Committee of 8APCDM
2009-2011 : Chairman, Board of Director, Korean Society of Emergency Medicine
2009- 2011 : President, the Korean Society of Disaster Medicine (KSDM)
2011- 2013 : President, the Korean Society of Traumatology
2014. 11 – present : president, the Korean Shock Society
Publications : 81 SCIs
Despite the latest advances in resuscitation care, the survival rates among cardiac arrest victims remain low. Manual chest compression is a key component of
CPR. Its goal is to provide oxygen-rich blood to the brain and coronary artery. High-quality manual CPR requires extreme power consumption and easily leads tophysical exhaustion of rescuers. To overcome these problems in manual CPR, several mechanical CPR devices such as the Autopulse and LUCAS wereintroduced to provide an uninterrupted CPR without rescuer’s fatigue. However, these devices are bound to the chest and compress on only one fixed position, so
they must be unbound when there is a need to change the compression position. This unbinding can cause the interruption of chest compression, which decreases
CPR quality.
A robot CPR system could be a good alternative to overcome the shortcomings of manual CPR and mechanical CPR devices. A robot has enough power toachieve high-quality CPR. It can also give a continuous CPR and change its compression position during CPR without stopping. Recently, we developed theautomated robot CPR system to perform high quality of CPR. The robot CPR system performs CPR automatically and analyses the patient’s condition and relays
the information to the CPR system. If an end-tidal CO2 monitoring device as an indicator of the quality of chest compressions during CPR is added to the robot
CPR system, the system can receive real-time end-tidal CO2 feedback from the victims which enables the robot to perform better CPR.
We also developed the algorithm of the robot CPR system which automatically finds the optimal compression position under the guidance of end-tidal CO2
feedback in swine models of cardiac arrest. Then, 18 pigs after 11 minutes of cardiac arrest were randomly assigned to one of three groups, robot CPR, LUCAS
CPR, and manual CPR groups (n = 6 each group). Return of spontaneous circulation (ROSC) and Neurological Deficit Score 48 hours after ROSC werecompared. A ROSC was achieved in 5 pigs, 4 pigs, and 3 pigs in the robot CPR, LUCAS CPR, and manual CPR groups, respectively (p = 0.47). Robot CPR
showed a significant difference in Neurological Deficit Score 48 hours after ROSC compared to manual CPR, whereas LUCAS CPR showed no significant
difference over manual CPR. (p = 0.01; Robot versus Manual adjusted p = 0.04, Robot versus LUCAS adjusted p = 0.07, Manual versus LUCAS adjusted p =1.00)
In conclusion, the end-tidal CO2-guided automated robot CPR system did not significantly improve ROSC rate in a swine model of cardiac arrest. However,robot CPR showed significant improvement of Neurological Deficit Score 48 hours after ROSC compared to Manual CPR while LUCAS CPR showed nosignificant improvement compared to Manual CPR. The robot CPR system could be a promising alternative to manual CPR.

Asian Special Lecture 2
20th Nov (Tue) 14:40 - 15:20 Room 502

ASL2 Global Resuscitation Alliance; the concept and the current
statusDepartment of Emergency Medicine, Seoul National University College of Medicine and Seoul
National University Hospital

Sang Do ShinExperiences
1995

Graduated from Seoul National University College of Medicine

2000

Graduated from the MPH course on Epidemiology at Seoul National University School of Public Health2003

Graduated from the PhD course on Epidemiology at Kangwon National University School of Medicine

1996-2000

Residency program at Department of Emergency Medicine of Seoul National University Hospital

2012-2013

Visiting Scholar and adjunctive professor at School of Public Health of Emory University, USA

2004-present

Assistant professor, associated professor, and professor at department of emergency medicine of Seoul National
University College of Medicine and Hospital

2009-2011

Founding Chair, Asian Emergency Medical Service Council (AEMSC)

2009-present

Co-chair, Pan-Asian Resuscitation Outcome Study Clinical Research Network

2014-present

Chair, Pan-Asian Trauma Outcomes Study Clinical Research Network

2016-present

Chair, Board member of the Global Resuscitation Alliance, Chair of Asian Chapter, Global Resuscitation Alliance

Research interest
Emergency Medical Services System Development
Cardiac Arrest and Trauma
Disaster Medical Services Medicine
The Global Resuscitation Alliance（GRA）is the new organization for improving resuscitation outcomes through implementing the
Utstein 10 steps. In 2015, at the Stavanger in Norway, more than 30 experts from around the world analyzed the causes of regionalvariations in CPR and determined the 10 steps scientifically well known as a community implementation program essential for survival.
In order to improve the survival rate of CPR, scientific research, development of educational methods based on these sciences, andcommunity intervention to apply it to the local community are indispensable. However, community intervention has not been sufficiently
emphasized. Historical background, cultural differences, deviations in resources, and diversity of legal systems have not been fully
applied to individual communities, despite the development of educational methods and the results of scientific research. The
Resuscitation Academy（RA）is the new program to educate and train the trainer, educator, medical directors, public officials who workin the CPR community. The RA is the core program of the GRA for implementing the Utstein 10-steps.

Asian Special Lecture 3
20th Nov (Tue) 15:20 - 16:00 Room 502

ASL3 Building World-Class EMS and Community Chain-ofSurvival：Translating Science into Education and
Implementation

Professor of Emergency Medicine, National Taiwan University, TaiwanVice Superintendent, National
Taiwan University Hospital Yunlin Branch, Taiwan

Matthew Huei-Ming Ma

Dr. Ma graduated from National Taiwan University medical school in 1989, completed an internal medicine residency, a cardiology
fellowship and an emergency medicine residency at NTU hospital in 1994. He then went on to receive a PhD in Health Policy andManagement from the Johns Hopkins University in 1997. He is now Professor of Emergency Medicine at National Taiwan University,
and Vice Superintendent of National Taiwan University Hospital, Yunlin Branch
A renowned regional expert in emergency medicine and EMS and resuscitation, Prof. Ma has played a key role in contributing to theadvancement of pre-hospital care, community chain-of-survival, and resuscitation science, particularly in Taiwan, where he serves acrossvarious boards and committees. His interests in clinical research and outcomes in emergency medicine is no small feat; Prof Ma as
authored over 170 publications, and speaks regularly at conferences around the world. In 2016, he received the 4th Asian EMS Lifetime
Achievement Award.
Prof. Ma currently serves on the Asian Association for EMS as Chair, and the Pan Asian Resuscitation Outcomes (PAROS) CRN as
Vice Chairman; is a Task Force Member (Education, implementation, and Teams) of the International Liaison Committee on
Resuscitation (ILCOR). He sits in the editorial board of the journals Resuscitation, and International Journal of Cardiology.
The goals of emergency medical services（EMS）systems in the community are to decrease morbidity and mortality from acuteinjuries and illnesses, and to maximize patient well being. Due to the changing demographics of the population the complexity of
diseases, and the parties involved in the system, the success of systems depends heavily on consensus building among major players andthe integration of community resources. EMS activities in Taiwan rapidly developed in the last two decades, especially after National
EMS legislation in 1995 and National Specialty Board Status for Emergency Medicine in 1998. With the joint efforts of emergency
physicians, central and local health and fire departments, involved community leaders and stakeholders, ongoing activities over the years
have cumulated into the current comprehensive EMS systems and community chain-of-survival. Projects initiated over the last years
include：wide-spread citizen CPR training and community-wide early defibrillation programs, medical direction system, the training of
EMT-paramedics and implementation of prehospital advanced life support. In addition, Taiwan has also strengthened the in-hospital
chain-of-survival, including the implementation of post-resuscitation care and CPR with extracorporeal support. To optimize system
implementation, medical direction, performance evaluation and research infrastructure were built early during system design.
Discoveries in resuscitation science and epidemiology of cardiac arrests from local communities were made, and have been translated
successfully into education and system implementation. Over the years, we have witnessed a 7-fold increase in the survival of out-ofhospital cardiac arrests as well as marked improvement in trauma survival. These would not have been achievable without thecommitment and dedication of physicians and organizations.

Asian Special Lecture 4
21st Nov (Tue) 13:20 - 14:00 Room 501

ASL4 How to improve global emergency medicine?
Department of Emergency Medicine, Yonsei University, Wonju College of Medicine, South Korea

Kang-Hyun Lee

Dr. Kang Hyun Lee is a professor of emergency medicine and dean at the Yonsei University, Wonju College of Medicine, Wonju,
South Korea. He is chair of organizing committee of 2019 ICEM (international conference of EM). He is president of Korean Society ofTraumatology. He is past chairman of Board of Directors of the Korean Society of Emergency Medicine. He served as a medical advisor
during the 2018 PyeongChang Winter Olympic Games. He has been some project leader of global emergency medicine and EMS system
in Korea. He was born in South Korea on June 15, 1963. He graduated Yonsei University, Wonju College of Medicine at 1989. He isboard-certified in emergency medicine at 1997 and critical care medicine at 2009. He has published over 100 papers, 7 books and given
many speeches about emergency medicine, disaster medicine and traumatology at the scientific conferences in the world.
So many emergency physicians are actively engaged in the development the many spectrums of global emergency care, emergency
medical services (EMS), and prevention of injury or disaster preparedness in multiple settings internationally. Global emergency
medicine (EM) is a subset of global health concerned with acute and urgent aspects of illness and injury. The discipline is centred on
capacity development for emergency medicine, but also includes aspects of disaster preparedness and humanitarian assistance. As theburden of non-communicable disease and injury grows in low- and middle-income countries, demand for global emergency medicine isincreasing. This has catalysed the global expansion of EM as a specialist discipline, which is now recognised in over 40 countries.
International emergency medicine is the one of the sub-specialty of EM concerned with global EM development and the broader field ofglobal emergency care. Global EM is not solely about development of EMS but is instead better described as the training required forand the reality of practicing the specialty outside of one's native country. Many emergency physicians involved in global emergency care
activities require skills, knowledge and attributes that may not be acquired in the course of a conventional health professional education.
Global EM training programs have emerged to equip emergency physicians with the competencies required for emergency care practicein international and cross-cultural environments. Many challenges faced in global EM include a lack of adequate EMS systems including
emergency transportation system or manpower for EMS, immature or non-existent training programs of EM, a shortage of resources tofund for EMS development, and an absence of research that could inform developing countries how to best spend the resources.
Additionally, the standards and methods used in countries with mature EMS are not always suited for use in developing countries due toa lack of infrastructure, and shortage of resources or funds. I will discuss the effective deveoping way for the global EM and also talkabout diverse issues on evidence-based medicine in global EM.

International Symposium
20th Nov (Tue) 17:30 - 19:00 Room 304
ISY01-1 THE ASSOCIATION BETWEEN DURATION TO
OPERATION AND MORTALITY RATE IN PENETRATINGTRAUMA PATIENTSDivision of Trauma, Department of Surgery, Khon Kaen Hospital, Thailand
Tawatchai Impool，Pothipong Reungjui，Supaporn Tansura
In the management of severe trauma cases, shortening the interval fromemergency room（ER）to operating theater is a key. Trauma Fast Track（TFT）strategy, in which trauma patients are transferred to the theater as
quickly as practicable, was established in most trauma centers in Thailand.
In this strategy, we have to know about patient data before their arrival by
two-way communication between doctors at community hospitals and Khon
Kaen Hospital. While waiting for the patients, we prepare the operating
theater and activate the trauma team. When the patients arrive at the ER, we
immediately pass them to the operating theater without usual resuscitation
procedures. Moreover, we conducted an analysis to know the influence ofthe time factor on the patient outcome. We enrolled 163 trauma patients withpenetrating torso injuries and hemodynamic instability, who underwent
laparotomy and/or thoracotomy in Khon Kaen Hospital from October 2011
to September 2017. Of them, 128（78.5%）had penetrated injuries at
abdomen and 35（21.5%）at chest; mean Injury Severity Score was 19.7;
mean interval from ER to the theater was 41.7 minutes; 39（23.9%）of themdied. Delayed transfer to the theater（interval from ER to the theater > 30
minute）were associated with higher mortality risk than early transfer（≤ 30
min）［odds ratio, 4.11; 95% confidence interval, 1.24–13.64］. The mortality
rate of penetrating torso patients with hemodynamic instability was strongly
associated with the interval from ER to the theater. TFT to shorten theinterval is a promising strategy to improve patient outcomes. Thus, weshould avoid unnecessary procedures or interventions at ER that would
prolong the interval.

ISY01-3 The training of CPR for healthcare staff working at dental
office: New activity in Vietnam
1

Hanoi Medical University
Department of Emergency Medicine, Teikyo University School of Medicine
Bui Hai Hoang1，Kim Quan Hoang1，Tien Dung Ngo1，Xuan Dung Dao1，
Minh Nong Nguyen1，Dinh Hung Vu1，Giang Phuc Do1，Nakahara Shinji2

ISY01-2 A mobile app for management of animal attack victims
at rural hospitals in Sri Lanka
1

Postgraduate Institute of Medicine, University of Colombo
Faculty of Medicine and Allied Sciences, Rajarata University of Sri Lanka.
Anuradhapura, Sri Lanka
3
Health Informatics Society of Sri Lanka（HISSL）, Sri Lanka
Achala Upendra Jayatilleke1，Sujeewa Priyantha Bandara Thalgaspitiya2，
Roshan Hewapathirana3
2

Animal attacks are common in Sri Lanka specially in remote and wilderness
areas where no proper emergency care services are available. Anuradhapura
is a district located in North Central province of Sri Lanka where many wild
animal attacks are reported frequently. Usually the first contact is a rural
hospital and majority of the patients are subsequently transferred to the
Teaching Hospital Anuradhapura, which is the main tertiary care center inthe province. Doctors in peripheral hospitals contact surgeons in the tertiarycare center over the phone for specialized advice. We conducted this study
with the objective of introducing a mobile application for medical doctors inrural hospitals to communicate with surgeons in the tertiary care settings
regarding victims of wild animal attacks effectively.A data submission andmanagement tools were developed based on the Open Data Kit（ODK）
platform, which consists of an open source mobile application and a web
server. The mobile app can be installed in Android smart phones as the datasubmission tool. Doctors in the periphery can communicate with the centerusing the mobile App. They can share photos, images with the expert
surgeons and get their advice on management. ODK Aggregate server backend has the capability to send metadata in the XML format, known as
XForms to mobile devices to generate the questionnaire dynamically. This
low-cost technology can be used for effective management of animal attack
victims at rural hospitals and to create a database which can be used for
future research.

ISY01-4 An Innovative Pre-hospital Care Provider Training
Course for Improving Emergency Medical Care System in
Cambodia2

Saw Swee Hock School of Public Health, National University of Singapore,
Singapore ＆ KHANA Center for Population Health Research, Cambodia
Siyan Yi

Bystander first-aid is an important factor to improve outcomes of people
with out-of-hospital cardiac arrests, which is a growing health issue in lowand middle-income countries. To improve access to bystander first-aid suchas chest compression, we need to increase the number of those who can
perform first aid. This requires training of laypeople and also training oftrainers. We present our new activity in Hanoi, in which we train healthcare
staff.The program started in 2016. We have held 30 classes and trained
approximately 1500 learners in various areas: Ha Noi, Bac Giang, Hai
Duong, Da Nang, and Ho Chi Minh City. The trainees are dentists and dental
technician; most of them are working for the private sector. A class consistsof one-hour theory lecture and two-hour skill training of cardiopulmonary
resuscitation（CPR）. In the skill training, we use a mannequin and instruct
two learners to cooperate and provide CPR as a team（one provides chest
compressions and the other rescue breathing）according to the protocol ofAmerican Heart Association. After the classes, the trainees receive a
certificate and exchange contact information for further updates. So far, wehave not yet evaluated the effects of this project. However it has a potential
to contribute to increasing access to bystander first-aid. They may encountercardiac arrest in their dental office. In addition, they may provide chest
compression to OHCA patients near their offices. More importantly, they
have a potential to be trainers to general public in the future although theirskills and knowledge are not enough to be trainers.

Over recent decades, the healthcare system and civil infrastructure in Cambodia haveadvanced remarkably. The Kingdom now possesses many of the essential components
required to establish a well-functioning emergency medical system including the widespread
availability of emergency communication channels, enhanced access to emergency
transportation through large-scale road development efforts, and increased access to healthservices for poor patients through the implementation of health financing schemes. However,many Cambodians continue to experience inadequate access to quality emergency medical
services. The emergency healthcare system requires well-trained pre-hospital care providers
and other supporting systems in place. In response to the need of a good model to improve
pre-hospital care services, a team from Stanford University School of Medicine, inpartnership with Preventive Medicine Department in Cambodia, has implemented an
innovative, context-specific pre-hospital care training course for local health care providers
from December 2013 to February 2016. In Cambodia, due to the limited health workforce, aprovider is usually selected from the on-duty staff of the most appropriate ward when thefacility is called upon to accompany a patient during transport. It was decided that the
selection of attendees for the pre-hospital care training course would follow the same model,
selecting attendees from the pool of actively practicing providers at ambulance-possessing
government referral hospitals. Participants were therefore selected from the emergency
department, maternity ward, and pediatric ward in all 42 referral hospitals in the nine
provinces where the USAID Quality Health Services Project was implemented. Participants
were a mix of physicians, medical assistants, nurses, and midwives. The course focuses on
training on pre-hospital care skills and knowledge most applicable to the local healthcare
system. The course was divided into four modules:（1）Basic pre-hospital care skills andadult medical emergencies,（2）Traumatic emergencies,（3）Obstetric emergencies, and（4）Neonatal/pediatric emergencies. In total, during the 27-month period, the course wasadministered to 1,083 local healthcare providers, with 947 attending the entire course andpassing the course completion examination. The details of the course curriculum andmaterials will be further discussed.

International Symposium
20th Nov (Tue) 17:30 - 19:00 Room 304
ISY01-5

The development of EMS system Khon Kaen Province

Khon Kaen Hospital
Seathapong Thanoorat
This paper describes the development of nationwide emergency medical service（EMS）system in Thailand. The first formal EMS that started in Khon Kaen
Province successfully improved the prehospital care and inspired policy makers to
expand the system nationwide. In the early 1990s, various innovations in emergency
care system took place in Khon Kaen Province, specifically by the involvement ofKhon Kaen Regioal Hospital. One is EMS established in 1991 to deal withincreasing traffic injuries. Another is the injury surveillance program that started in
1992 in Khon Kaen Hospital; based on the surveillance data, reports were published.
This informed many hospital administrators and policy makers of the necessity tohandle injuries: e.g., through nationwide EMS and injury surveillance. In 1993, theon-scene care committee was set up in Khon Kaen to implement EMS at provincial,
district, and sub-district levels. In doing this, the committee gave full consideration
to resource-limited situations and community involvement. The first EMS unit wasdeveloped by a private organization, Chit-Kuson Khon Kaen Foundation; itscommand center was placed in a police station with the phone number of 191（thenumber has been changed to nationwide single number of 1669 in 1995）and Khon
Kaen Hospital established its own EMS unit in 1994.The Khon Kaen EMS systemstarted with 3 levels of pre-hospital care providers. Community health volunteers
were supposed to provide first-aid and contact the EMS system as needed; subdistrict EMS provide basic life support; and the formal hospital EMS provide basic
and advanced life support with quality improvement program. The sub-district EMS,
which transfer most of the emergency cases, was based on simple but effective
technologies and training. The key to the development of EMS system is policy
commitment and hospital administrators’ awareness, which would lead to support
for project planning, resource allocation, and human resource development. The factthat Khon Kaen EMS system could reduce mortality and morbidity of trauma andseriously ill patients persuaded policy makers in the Ministry of Health so that they
developed strategies to expand the system nationwide. Various sectors including
academia, clinicians, and politicians supported the strategies. After nearly 30 yearsof development, there are 27 provincial level and 191 sub-district level EMS systems
with 3,963 registered EMS personnel. The success in the quality management andsustainable development of EMS system has resulted from regular monitoring,supervision, and communication within the system.

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INT1-1

Neuroprotection post cardiac arrest; does midazolam havepositive effect?
1

Department of Emergency Medicine, Yamagata Prefectural Central Hos-会

研セ

Bathing-Related Out of Hospital Cardiopulmonary Arrest

Investigated by Post-Mortem CT
1

宮崎県立延岡病院

救急センター・集中治療室，2 宮崎県立延岡病院

救急pital， Department of Anesthesiology, Yamagata University

センター， 宮崎大学医学部附属病院

Asumi Sugiura1，Kaneyuki Kawamae2

矢野隆郎 1，川名【Background】Targeted temperature management（TTM）is current standard neuroprotective therapy【Purpose】For the recognition of the causes of ambulance runs due to accidental

post cardiac arrest（CA）. Although midazolam is considered as neuroprotective agent through reduction

victims during bathig in Nobeoka City, we analyzed the databases using the Usteinof dopamine release in the brain, there is scant evidence exists. Purpose of this study is to investigate

style【Subjects and methods】69 bathing victims of 731 Out of Hospital
Cardiopulmonary Arrest（OHCA）cases were reviewed between Dec., 2010 and2predictors of outcome and midazolam effect on post CA patients’ outcome.【Method】Retrospective chart
review. Patients admitted to our intensive care unit post CA with prolonged comatose from October 2015
to February 2018 were extracted. We used 48 hours of 35.5 ℃ followed by 12 hours of rewarming for
TTM protocol. Patient demographics, physiological data and management were analyzed.【Results】19
patients were extracted. Median age of 60, 32% were women. 2 received TTM via VA-ECMO, 16 byexternal cooling device, one didn’t receive TTM due to short ischemic time. At one month from CA, 6
survived without respiratory support, all of those had Cerebral Performance Category（CPC）of 1. 5
survived with respiratory support, 8 died. Within each groups mean CA time was 28, 31, 43 minutes
respectively. With regards to midazolam dose, 50% of good outcome patients received more than 0.2mg/kg/hr for longer than 48 hours, where 60% for moderate group. All the patients in moderate outcome
group continued to receive more than 0.1mg/kg/hr longer than rewarming completion.【Conslusion】All3

救急センター
遼 2，遠藤穣治 2，長嶺育弘 2，落合秀信 3，山内弘一郎 2

Feb., 2018. The postmortem CT（PMCT）was performed in all cases.【Results】
Dissecting aortic rupture（4%）, subarachinoid hemorrhage（6%）, and other causes（6%）were noted and the top diagnosis was drowning（77%） with severe
atherosclerotic calcification（aortic valve 36%, coronary artery 59%, internal carotid
58%, vertebral artery 64%）and brain atrophy（mean bicaudate ratio 0.19, meansylvian fissure ratio 0.11）by the findings of PMCT.【Conclusion】PMCT of
Bathing-Related OHCA could detect definite cause of death below one fourth cases
and reveal the drowning signs above three fourth cases with cardio-cerebral
atherosclerotic changes.

the patients with good outcome recovered to CPC 1 at one month. Those tended to receive less midazolam
dose during TTM compared to those with moderate outcome, suggesting good outcome did not depend
much on midazolam dose.

INT1-2 Can we predict return of spontaneous circulation of out-ofhospital cardiac arrest according to blood gas data ?
宮崎県立延岡病院救急センター・ICU，2 宮崎県立延岡病院救急センター
矢野隆郎 1，山内弘一郎 1，川名 遼 2，遠藤穣治 2，長嶺育弘 2
1【Purpose】Blood gas data during cardiopulmonary resuscitation（CPR）of out-ofhospital cardiac arrest（OHCA）patients at a community hospital in Nobeoka City,
Japan, were retrospectively evaluated to predict return of spontaneous circulation（ROSC）.【Subjects and Methods】Between October, 2012, and April, 2017, 150 of
453 OHCA cases were for analysis; blood gas data were available before ROSC
within 30 min after emergency department（ED）arrival. The primary outcomes
were ROSC at ED and survival to admission. The odds ratios（OR）were calculated
by a multiple logistic-regression analysis for independent predictors of ROSC at ED
and survival to admission. All statistical analyses were performed with R version
3.3.2.【Results】The pO2 and serum potassium were independent predictors for
ROSC［pO2（OR: 1.01; P ＜ 0.01）, serum potassium（OR: 0.68; P ＜ 0.01）］and
survival to admission［ pO2（OR: 1.01; P ＜ 0.01）, serum potassium（OR: 0.61; P ＜0.01）］.【Conclusions】The pO2 and serum potassium may be the most usefulpredictors for ROSC.

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INT1-4

INT1-5 Are school hours associated with better outcomes of out-ofhospital cardiac arrest in school children? A propensity-matched cohort
study
1Department of Circulatory Emergency and Resuscitation Science, Kanazawa
University Graduate School of Medicine， 2 Ishikawa Prefectural Central
Hospital，3Department of Emergency Medicine, Kanazawa Medical University
Hideo Inaba1，Minoru Kubo2，Keisuke Ohta2，Hisanori Kurosaki1，Yukihiro Wato3【Aims】To investigate whether school hours are associated with better outcomes of school children with
out-of-hospital cardiac arrest（OHCA）.【Methods】From the 2005-2014 nation-wide databases, we
extracted the data for 1, 660 bystander-witnessed OHCA cases of school children with ages of 6-17 years.
School hours are defined as 8:00 am to 6:00 pm. School days were determined in each prefecture.
【Results】Neurologically favourable 1-month survival during school hours was better than that during
non-school hours only in school days: 18.5%（76/412）vs 10.5%（51/486）in school days（Unadjusted
OR;95% CI, 1.93;1.32-2.83）, 10.9%（43/395）vs 9.0%（33/367）in non-school days（1.24;0.77-1.99）.
OHCA cases during school hours in school days more frequently received bystander CPR and publicaccess defibrillation（PAD）, and had shockable initial rhythm and presumed cardiac aetiology. However,the survival or witness-to-first CPR interval（CPR-free time）during school hours was not improved. Furthermore, the rate of survival did not significantly
change during the study period（P for trend = 0.21）
differ between school hours in school days and others after propensity-matching: 16.2%（52/321）vs15.6%（50/321）, P = 0.83. Stepwise multivariate logistic regression analysis after propensity-matching
disclosed that shockable initial rhythm（5.53;2.10-16.4）, PAD（4.89;2.34-10.5）, medical cause（3.56;1.42-9.03）, and shorter response time interval（1.12;1.03-1.23 per 1 min）and witness-to-first CPRinterval（1.06;1.02-1.10）were major factors associated with survival.【Conclusions】Early bystanderand EMS-performed basic life support based on a proper preparedness is predominantly associated with
better outcomes of OHCA in school children.

INT1-3 Virtual Reality based learning platforms for ongoing Cardio
Pulmonary Resuscitation training at Accident and Orthopedic Service,
National Hospital of Sri Lanka

INT1-6 The influence of excluding patients with bystander interventionsin the current Utstein-style database1

Accident and Orthopaedic Service, National Hospital of Sri Lanka，2University ofColombo School of Computing， 3 District General Hospital Gampaha, SriCity, Tokyo, Japan，2Japan Emergency Medical System Co. Ltd, Misato-Town,
Miyazaki, Japan， 3 Research Institute of Disaster Management and EMS,

Lanka，4Postgraduate Institute of Medicine, University of Colombo, Sri Lanka
C.Wanigatunga Janith1，M.A.S.C. Samarakoon1，H.S.U. Liyanage2，
K.L. Jayaratne2，M.A.A.K. Munasinghe3，Achala U. Jayatilleke4

Kokushikan University, Tama-City, Tokyo, Japan
Hiroshi Otani1,2，Ryo Sagisaka1，Hideharu Tanaka1,3，Hiroshi Takyu1，
Takahiro Hara1，Toru Shirakawa1,2，Shota Tanaka3【Introduction】Training a large cohort of people is challenging due to availability of resources. For
instance, manikins used in training are fragile while manikin models which can provide feedback on CPR
quality are expensive. Therefore, providing alternative solutions which are more cost effective and provide
immersive training experience will improve the outcomes of training programs.【Objectives】To
implement a virtual reality（VR）based CPR program by modifying the existing low-cost manikins toprovide cost effective training and enhance learning process.【Methodology】This project employs a VR
enabled CPR training technology developed by the University of Colombo School of Computing. Funding
will be allocated from Inventors Commission Sri Lanka. Firstly, existing low-cost manikins will be
modified with sensors to be compatible with the new VR system. Secondly, VR environment and an avatar
to replicate the manikin will be created using Unity 3D software. In order to reduce the cost of equipment,
off-the-shelf effective hardware such as HTC Vive VR headsetsTM, Leap motion sensorsTM will be used.
Finally, the avatar developed in VR environment is mapped to the manikin using a computer system to
execute CPR training scenarios. Results/product: This low-cost VR Learning platform will be
implemented at the AOS CPR Training Programs as a pilot project and further improvements will be madewith user feedback to provide further improvement to the system.【Conclusion/Implications】This projectis expected to provide realistic and interactive training experience while providing an alternative to
expensive manikins.

【Background】The effect of bystander interventions has been extensively evaluated by cerebral function
after post-resuscitation. However, patients who received bystander cardiopulmonary resuscitation（BCPR）and achieved the return of spontaneous circulation（ROSC）before the arrival of the emergency
medical system（EMS）are routinely defined as other electrocardiogram（ECG）waveforms（others）
and are usually excluded before analysis.【Aim】To clarify the influence of excluding others group,
which includes cases of bystander ROSC, from the out-of-hospital cardiac arrest（OHCA）database.
【Methods】This nationwide population-based observational study was conducted in Japan using Utsteinstyle data from 2011 to 2014. In total, 92, 156 patients with bystander-witnessed OHCA of presumed
cardiac origin received resuscitation attempts in the pre-hospital setting. We analysed the differences ofdatasets that included and excluded the others group and determined the effect on outcomes bymultivariate logistic regression and odds ratios（ORs）with 95% confidence intervals（95% CIs）.
【Results】When the others group was excluded from the data, the adjusted odds ratio（AOR）of
cardiopulmonary resuscitation（CPR）to favourable cerebral performance category（CPC）1 or 2 wasdecreased（conventional CPR: AOR, 2.12 to 1.78; hands-only CPR: AOR, 2.22 to 1.80）compared to theothers group’s inclusion. Conversely, the AOR of public-access defibrillation（PAD）was significantly
increased（AOR, 4.63 to 6.44）.【Conclusion】The exclusion of others from a dataset may lose ROSC
patients by bystander CPR, causing selection bias to affect outcomes. The definition of others should be
redefined according to the introduction of a new Utstein-style guide line.

1

Graduate School of Emergency Medical System, Kokushikan University, Tama-INT2-1

Usefulness of Coagulation Biomarkers to Detect Arterial

Extravasation in Pelvic Fracture Patients with Stable Hemodynamics
1

Department of Emergency Medicine, Gunma University Graduate School of

INT2-4

Participatory discharge planning model for patients with severe

traumatic brain injuries in trauma surgery unit, Khon Kaen Hospital
Department of Nursing, Khon Kaen Hospital, Thailand

Medicine，2Advanced Medical Emergency Department and Critical Care Center,

Pimwara Akaratiensin，Potjana Tupsai，Winitra UtchooJapan Red Cross Maebashi Hospital，3Department of Diagnostic and Interventional
Radiology, Gunma University Graduate School of Medicine【Introduction】Severe traumatic brain injury（STBI）is a major problem in Khon Kaen Hospital. The

Makoto Aoki1，Takayuki Ogura2，Shuichi Hagiwara1，Masato Murata1，
Hiroyuki Tokue3，Mitsunobu Nakamura2，Kiyohiro Oshima1【Background】It is important whether there is active arterial hemorrhage or not in acute phase to makedecision for the treatment strategy in patients with pelvic fractures. The purpose of this study is to evaluate
whether coagulation biomarkers could predict the arterial extravasations especially in pelvic fracture
patients with stable hemodynamics.【Methods】We studied pelvic fracture patients who had systolicblood pressure above 90mmHg on arrival. Patients were divided into two groups: patients with arterial
extravasations on enhanced CT or angiography（Extra（+）group）, and those without arterial
extravasations（Extra（-）group）. The levels of fibrin degradation products（FDP）and D-dimer（DD）
measured on arrival were statistically compared between the two groups. Receiver operating
characteristics analyses provided area under the receiver-operating characteristic curves（AUROC）anddiagnostic indicators at the estimated thresholds including sensitivity, specificity, positive and negative
predictive values and diagnostic odds ratio（DOR）.【Results】Seventy-nine patients could be analyzed.
FDP and DD levels were significantly higher in the Extra（+）group than in the Extra（-）group（FDP,
261.9 μg/mL（149.9-402.5）vs. 96.2 μg/mL（59.6-155.0）; DD, 96.5 μg/mL（45.3-173.0）vs. 39.7 μg/
mL（25.6-88.0））. The predictive ability in terms of DOR was relatively better with FDP of 179 μg/mL（sensitivity, 0.73; specificity, 0.80; DOR, 10.81; AUROC 0.79）than DD of 52.0 μg/mL（sensitivity,
0.73; specificity, 0.68; DOR, 5.75 ; AUROC, 0.72）【Conclusion】FDP and DD could be useful to predict
the existence of arterial extravasations in pelvic fracture patients with stable hemodynamics.

length of hospital stay（LOS）and unexpected readmission among patients with STBIs are increasing.
This caused a problem of high cost in medical treatments.【Methods】We conducted a participatory
action research in the trauma surgery unit of Khon Kaen Hospital. Data were collected by observation,interview, and focus group discussion between October 1, 2015 and September 30, 2017. The study
participants include physicians, nurses, pharmacists, physical therapists, nutritionists, patients and theirrelatives. First, to identify problems in the structure of the health personnel in the unit and the process ofcare and discharge planning, we conducted 9 focus group discussions among the participants. Then weheld seminars for health personnel in the unit about the clinical situations of STBIs, necessity and contents
of discharge planning, and the role of multidisciplinary team. Daily discharge planning and health careinformation started to be given to patients and their relatives. These activities were evaluated with average
LOS, readmission within 28 days, and satisfactory score rated by relatives as the outcome indicators.
【Results】After the implementation of this activity, the average LOS decreased from 21 days to 14 days.
There was no unexpected re-admission within 28 days of discharge. Overall relatives’ satisfaction scores
increased from 86.9 in 2014, to 90.8, 92.8, 93.4in 2015, 2016, and 2017, respectively.【Conclusion】The
participatory action research and resulting discharge planning model for patients with STBIs in trauma
surgery unit was effective and appropriate.

INT2-2 Is the external fixation appropriate strategy in the pelvic ringfracture in elderly?

INT2-5 Development of a case management model for severe traumaticbrain injuries

兵庫県立西宮病院 四肢外傷センター，2 兵庫県立西宮病院 救命救急セン
ター
北田真平 1，山田 聖 1，荻田誠司 2，林 伸洋 2，高岡 諒 2，杉野達也 2，
鴻野公伸 1,2

1

1【Introduction】The purpose of this study is to investigate the rationale of theexternal fixation（Ex-Fix）for the elderly patients.【Material and Methods】We
retrospectively analyzed 5 cases of pelvic fracture treated with Ex-Fix. The mean age
was 79.6（74-86）. Injury mechanism, waiting periods for the surgery, AO
classification, duration of the Ex-Fix application, clinical results and complications
were reviewed.【Results】High energy cases were in four cases. All fractures wereclassified into AO type B. The mean waiting periods were 2.2 day（0-7）. The mean
duration of the application was 32.4 day（7-50）. All fractures were healed. But theearly pin loosening was seen in two cases because of the violation to the fixators by
the patients with delirium. One patient died due to the aspiration pneumonia.
【Conclusion】We observed early pin loosening in forty percent of the cases. Ex-Fix
for the pelvic fracture in elderly was not appropriate strategies because of the bone
fragility and mental disturbance of the patients.

INT2-3 A trauma case of renal arterial occlusion treated by endovascularintervention after damage control surgery
1

Department of Emergency and Critical Care Medicine, Tokyo Saiseikai Central

Hospital，2Department of cardiology, Tokyo Saiseikai Central Hospital
Shiho Irino1，Yu Michiura1，Motojiro Takebe1，Kenji Suzuki2，Yoko Sugawara1，
Yuya Masuzawa1，Tomohiro Kamagata1，Yoshiro Kikuoka1，Kazuhiko Sekine1
Here, we present the case of a polytrauma patient with right renal artery occlusion, whose
renal function was finally preserved by endovascular treatment postadmission. A 43-year-oldman, who had been resuscitated by substantial transfusion and resuscitative endovascularballoon occlusion（REBOA）at another hospital, was transferred to our hospital for urgent
surgery. Upon arrival, he was hemodynamically unstable under REBOA; contrast-enhanced
CT scans, taken at the previous hospital, revealed hemothorax, pelvic fractures, andextravasation from the mesenteric arteries. In addition, the scans also revealed a lack ofcontrast enhancement of the right kidney. We performed urgent laparotomy and found active
bleeding in the transverse mesocolon, retroperitoneal hematoma, and sequential coagulopathy.
The patient underwent damage control surgery, including an intra-abdominal gauze pack tocontrol the arterial bleeding and vacuum pack closure, and postoperative transcatheter arterial
embolizaton（TAE）for the pelvic fractures. During TAE for hemorrhage from the pelvic
fractures, we identified right renal arterial occlusion and revascularized it by endovascularintervention with thrombus aspiration（349 min after the injury）. Although the patient needed
temporary dialysis for 33 days postadmission, he was discharged on day 58 without any
treatment for renal function. This case showed that endovascular revascularization for renalartery occlusion after DCS could be effective for salvaging the kidneys.

Department of Nursing, Khon Kaen Hospital, Thailand，2Sri Maha Sarakham
Nursing College raboromrajchanok institute, Maha Sarakham Province,
Thailand，3Department of Surgery and Neurosurgery, Khon Kaen Hospital, Thailand.
Anchalee Sophon1，Phadoongsit Chumnanborirak2，Praivan Promtee1，
Surakrant Yutthakasemsunt2，Oratai Pochaisan1【Purpose】To improve the care for patients with severe traumatic brain injuries, we developed,
implemented, and evaluate a case management model.【Method】The study consisted of four phases: 1）
situation analysis which included reviewing medical records, observing care practices, and data collection
through group discussion and questionnaire survey among stakeholders; 2）development of a casemanagement model to solve identified problems; 3）model implementation; and 4）evaluation of themodel using performance indicators（waiting time, length of hospital stay, and satisfaction among
stakeholders based on 5-point Likert satisfaction scale）. In the evaluation, 60 stakeholders participated.
【Results】The situation analysis indicated the average waiting time for the computerized tomography（95minutes）and average length of hospital stay（six days）as performance indicators to be improved.
Insufficient care by nurses, errors in patient referral, lack of coordination with multidisciplinary team
were also identified. To improve these situations, a case management model（practice guidelines）wasdeveloped and implemented. After the implementation, the average waiting time for the computerized
tomography reduced to 58 minutes and the average length of hospital stay to five days. The patients did
not have any complications. Lastly, the average satisfaction scores were 4.9（SD = 0.34）among themultidisciplinary team and 4.9（SD = 0.24）among the patients' relatives.【Conclusion】The casemanagement model based on the situation analysis improved care and outcomes for the patents with severtraumatic brain injuries practices. Such a model is useful in working with the multidisciplinary team.

INT3-1

An autopsy report analysis on common fatalities in Sri Lanka

1

Postgraduate Institute of Medicine, University of Colombo, Sri Lanka，2Institute ofForensic Medicine and Toxicology, Colombo, Sri Lanka
Jayatilleke Achala Upendra1，Apsara De Silva1，Ajith Tennakoon2，A.L.M. Hanas2【Introduction】Non-communicable diseases（NCDs）and injuries are becoming a significant burden in
Sri Lanka. Information obtained from autopsy reports play a vital role in developing preventive measures
to control NCDs and injuries. However, information related to fatalities remain relatively under studied. A
retrospective study was carried out with data extracted from autopsy reports registries at Institute ofForensic Medicine and Toxicology（IFMT）, Colombo which is the leading institute that performs larger
part of autopsies in Sri Lanka.【Methods】We analyzed autopsy data from July 2013 to December 2016
excluding cases that are incomplete. In total, 4530 autopsies were performed during the study period. We
extracted data from autopsy reports and analyzed using Microsoft Excel.【Results】Out of 4530 deaths,
3622（80%）were males and 900（19.9%）were females. Deaths due to accidents, suicides, homicide,and NCDs were 1923（42.5%）, 320（7.1%）, 167（3.7%）, and 1794（39.6%）, respectively. The
commonest mechanism of injury among the accident group was road traffic crashes（n=1384, 72%）
followed by falls（n=240, 12.5%）. Of the 2410 injury deaths, 1085（46.8%）were sustained head injuries.
Of 1794 NCD deaths, 822（45.8%）were due to coronary artery diseases, 164（9.1%）were due tospontaneous intracerebral haemorrhage, 156（8.7%）were pneumonia, and 135（7.5%）were chronic lungdisease. There were 41 maternal deaths.【Conclusion】Significant number of deaths due to injuries andnon-communicable diseases were reported and remain top killers in Sri Lanka over the years. Further
studies are required to identify risk factors for the increase in fatality rates.

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INT3-2The psychiatric background of torso stab wounds

横浜市立大学附属市民総合医療センター
高橋

航，加藤

高度救命救急センター

真，山口敬史，日野耕介，安部猛，高橋耕平，

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University of Tsukuba， 2 National Trauma Orthopedic Research Center,

Mongolia，3Department of Emergency Medicine, Teikyo University School of【Background】Few studies have compared self-inflicted（SI）torso stab wounds

Medicine，4Department of Global Public Health, University of Tsukuba
Gunsmaa Gerelmaa1，Tumen-Ulzii Badrakh2，Shinji Nakahara3，Masao Ichikawa4（TSWs）to TSWs inflicted in an assault（A-TSWs）.【Patients and Methods】We
retrospectively reviewed and compared the SI-TSWs（n=46）and A-TSWs（n=11）
over a 5-year period.【Results】The mean age and gender ratio were similar.
Multiple wound locations were more frequently seen in A-TSWs（SI-TSW vs
A-TSW: 5 vs 5, p=0.017）, and the mean ISS was more severe（6.7［1-25］vs 12.3
［2-29］, p=0.026）. Thirty-six of the patients had an accompanying psychiatricepisode（32 vs 4）. All patients were discharged alive, while 46 patients（42 vs 4, p
＜ 0.01）had a concurrent psychiatric diagnosis. Although the duration of
hospitalization was similar between the two groups, 24 SI-TSW patients required
additional hospitalization for a psychiatric condition; in contrast, only one A-TSW
patient required（p=0.015）.【Conclusion】Patients with SI-TSWs had less severe
ISS values, and more frequency had psychiatric complications; however, patientswith A-TSWs also tended to demonstrate psychiatric episodes.

The NOMESCO Classification of External Causes of Injury（hereinafter called the
NOMESCO Classification）was developed by the Nordic Medico-Statistical Committee（NOMESCO）in 1984 to monitor emergency room patients. The NOMESCO Classification isdifferent in its structures from the International Classification of Diseases（ICD）or its
extended classification called the International Classification of External Causes of Injury（ICECI）. We used the NOMESCO Classification in our recent study on child burn injuries in
Mongolia where burn injury is the leading cause of mortality among young children. Briefly,
this study aimed to describe the circumstances of burn injury occurrence among Mongolianchildren aged 15 years or younger who were admitted to the National Trauma Orthopedic
Research Center. We collected data on those patients’ demographics and the etiology andclinical features of their burn injuries, and analyzed the data based on the NOMECSOClassification. In the NOMESCO Classification, a simple model of etiology is proposed,
which describes the sequence of events precipitating the moment of injury and the productinvolved in the events: the mode of injury, such as contact with hot liquids; the injury event（the event immediately preceding the injury）, such as overflowing of hot liquids from a
cooking pot; and the precipitating event/activity, such as pulling down a cooking pot. TheNOMESCO Classification is useful to understand the etiology of injury well and provides aclue for developing effective injury prevention programs.Keywords: NOMESCO
classification, external causes, burn injuries, etiology, children, Mongolia

INT3-3 The Significance of Neurosurgical Treatment for Abusive Head
TraumaINT4-1 Implementing a Medical Emergency Team（MET）system toidentify a deteriorating patient in non-intensive care setting in Sri Lanka

Department of Emergency and Critical Care Medicine, Saitama Medical Center,
Saitama Medical Unversity
Takashi Araki

1【Purpose】The outcome of Abusive Head Trauma（AHT）is compared with theoutcome of traumatic brain injury（TBI）cases with simple accident.【Material andMethods】19 patients who underwent decompressive craniectomy（DC）in 50 casesof severe TBI caused by simple accident under 16 and 16 cases who was diagnosed
with AHT under 2 which required DC were included.【Results】Poor prognosis
was commonly seen in AHT than in simple accident（P ＜ 0.05）and longer
hospitalization was required. The ICP value was markedly decreased by DC in bothgroups and DC was not associated with mortality. The period that ICP management
was required（AHT group; 3.1 ± 1.7, simple accident; 10.7 ± 5.4）was longer in thesimple accident group（P ＜ 0.01）. Rapid progression of atrophic change of brain
parenchyma was commonly seen in the AHT.【Discussion】In AHT group, rapid
progression of atrophy in brain parenchyma was remarkable. The outcome of AHT is
extremely pessimistic, however, reports on the effectiveness of rehabilitation are
accepted to preserve normal remaining function.

夫リア

Application of NOMESCO Classification of External Causes of

Injuries in burn injury research in Mongolia

岩下眞之，竹内一郎

ポル

INT3-5

Accident and Orthopaedic Service, National Hospital of Sri Lanka，2Postgraduate
Institute of Medicine, University of Colombo, Sri Lanka，3District General Hospital
Gampaha, Sri Lanka
Samarakoon Samiddhi1，Janith C. Wanigatunga2，Aruna Munasinghe3，
Achala U. Jayatilleke2【Introduction】Accident and Orthopedic Service（AOS）at the National Hospital of Sri Lanka（NHSL）
is providing emergency care for more than 100, 000 patients annually. On average, 36 deaths occur
monthly and the events leading to these deaths occur with prior warning signs for an average of 6-8 hours.
Therefore, detecting signs and delivering prompt treatment to resuscitate the patients will reduce themortality and morbidity and improve the quality of emergency care. Objectives:To implement a Medical
Emergency Team（MET）system to identify deteriorating patients in non-intensive care setting in AOS.
【Methods】Current practices of managing emergencies in non-intensive care setup at AOS/NHSL will be
evaluated for requirement elicitation. An early warning score system will be introduced to identify
deteriorating patients, and a person/s, who will trigger an emergency calling will be identified. MET
members will be identified and necessary training will be provided. Further, the guidelines and protocols
will be introduced and required instruments will be provided. An evaluation tool will be developed tomonitor the performance of the MET system and the outcome will be assessed.【Results/product】A
Designated person will trigger a calling alarm once the predefined calling criteria is met. MET team will
receive audible alert and SMS message to arrive at the scene.【Conclusion/Implications】In ward patients
will have a monitoring system which can predict the monitoring frequency and set thresholds to trigger
MET system according to the severity of their clinical symptoms. The patients will receive specialized
emergency care rapidly and promptly.

INT3-4 A new classification of foreign body airway obstruction and its
association with survival outcomes

INT4-2 Development of discharge planning model for pediatric patientswith pneumonia based on caregiver empowerment

1

Pediatric Nursing Department, Khon Kaen Hospital, Thailand

Department of Critical Care Medicine, Osaka Habikino Medical Center,

JP， 2 Department of ER Medical Center, Osaka Police Hospital, Osaka,
JP，3Department of Emergency and Critical Care Medicine, Nippon Medical School
Hospital, Tokyo, JP，4Department of Emergency Medicine, University of New
Mexico, Albuquerque, USA
Sung-Ho Kim1,2，Yutaka Igarashi3，Shimpei Nagata2，Tatsuya Norii4，
Yasuaki Mizushima2，Hiroyuki Yokota3【Background】Foreign body airway obstruction（FBAO）is a potentially life-threatening event. No
standard classification of FBAO is currently available. We classified FBAO cases into three types basedon anatomical and physiological characteristics of FBAO and evaluated survival outcomes.【Methods】
We retrospectively evaluated patients who presented to the emergency department with FBAO in two
hospitals in Japan. The location of the FBAO was classified into one of three types at the time of choking:type 1 is defined as upper airway obstruction by a large foreign body（FB）that cannot be passed throughthe vocal cord and completely obstructs the airway; type 2 is defined as trachea and/or bilateral main
bronchus obstruction by a FB; type 3 is defined as unilateral bronchus and/or distal bronchus obstruction
by a FB. Following group classification, we compared survival outcomes.【Results】We enrolled 137
patients from January 2011 to February 2018. The median age was 79（IQR: 71-86）, and there wereslightly more male patients（59.1%）. Ninety patients（65.7%）presented with cardiac arrest. The mostcommon FBAO was type 1（78.1%）, which was followed by type 2（12.4%）and type 3（9.5%）.
Mortality was significantly higher in type 2 compared to type 1（47.7% vs.82.4%, p<0.01）.【Conclusion】
We classified FBAO cases into three types based on the anatomical and physiological characteristics of
FBAO. In our classification, type 2 was associated with higher mortality.

Paneukkaew Klangka, Ampha Thawieng【Introduction】Readmission among pediatric pneumonia patients aged 1 month to 1 year is not rare.
Through situational review, we found that discharge planning was inefficient; and we developed,
implemented, and evaluated a new discharge planning model for pediatric patients with pneumonia basedon a concept of caregiver empowerment.【Methods】First, we conducted analysis of existing dischargeplanning retrospectively, brain storming, observation of practice of discharge planning, and care givers
interviewing. The planning was found to be inefficient because of insufficient participation of the
caregivers in the planning. Thus, we develop and implemented a discharge planning model enhancing
caregiver role in the care planning. Then we evaluated the effectiveness of the new model by comparing
readmission rates before and after its implementation. We also described knowledge and satisfaction
among caregivers and nurses.【Results】The new discharge planning model included; 1）flow chart ofcare using concept of family empowerment, 2）educational and training for caregivers to prepare caring athome, 3）training for nurses to care appropriately, and 4）implementing nursing standard of caring anddischarge planning. The readmission rate decreased from 7.7% to 7.1%. After implementation of the newmodel, 82% and 90% of the observed caregivers had enough knowledge and skills, respectively; 97.7% of
the caregivers and 82.3% of were satisfied with the planning model.【Conclusions】The new model using
the concept of caregiver empowerment can optimize the effectiveness in discharge planning. Nurses
should evaluate this model regularly to know the problems which lead to continuous quality improvement.

INT4-3

Effects of a clinical nursing practice guideline among

mechanically ventilated patients in critical care department, Khon Kaen
Hospital
1

Department of critical care, Khon Kaen Hospital, Thailand，2Faculty of Nursing,Khon Kaen University，3Department of General Surgical Intensive Care Unit, Khon
Kaen Hospital，4Department of Trauma Surgical Intensive Care Unit 1, Khon Kaen
H o s p i t a l ， 5 D e p a r t m e n t o f M e d i c a l I n t e n s ive C a r e U n i t , K h o n K a e n
Hospital，6Department of Trauma Surgical Intensive Care Unit 2, Khon Kaen
Hospital
Tiasawat Udonlak1，Donwiwat Saensom2，Acharawun Namuangchan3，Supaporn Tansura4，Yuwadee Boonloy5，Apisara Songserm6【Introduction】Critically ill patients with respiratory failure require mechanical ventilation（MV）. However, MV is
associated with several physical complications. We developed, implemented, and evaluated effects of the clinical nursing
practice guidelines（CNPG）for MV in Khon Kaen Hospital.【Methods】After reviewing existing nursing careinterventions, we developed and implemented CNPG for mechanically ventilated patients in the intensive care unit
（ICU）. The CNPG consisted of 6 components: providing adequate oxygen and ventilation, preventing auto-extubation,
preventing VAP, preventing barotrauma, assessing and managing pain associated with MV, and assessing and promoting
MV weaning. We compared selected outcomes before and after the CNPG implementation among 62 critically illpatients during June 2016 and February 2017（31 before and 31 after implementing CNPG）; and evaluated adherence
and satisfactions among 73 nurses who cared for the patients under CNPG.【Results】When compared to patients before
CNPG implementation, those cared with the CNPG had lower VAP risk（RR 0.65, 95% CI: 0.20-2.04）, were more likely
to be assessed and properly managed for the pain（RR 20, 1.12-333.33）, had lower risk of auto-extubation（RR 0.28,
0.06-1.21）, and were more likely to be assessed and promoted for weaning（RR 34.06, 2.13-543.54）. In addition, thosecared by using the CNPG had significantly shorter ICU stays by an average of 3.9 days（95% CI: 3.4-4.3））. Lastly,nurses using the CNPG had high level of adherence to the guidelines and a high level of satisfaction in using the CNPG.
【Conclusions】Evidence-based CNPG for mechanically ventilated patients successfully promoted desirable careoutcomes.

INT4-6

Use of ketofol（combination of ketamine and propofol）forprocedural sedation and analgesia in the Emergency Departments inJapan

1
Department of Emergency Medicine and Critical Care, Center Hospital of the
National Center for Global Health and Medicine，2Department of Emergency
M e d i c i n e a n d C r i t i c a l C a r e , To ky o B a y U r a y a s u I c h i k awa M e d i c a lCenter， 3Departmenet of Critical Care Medicine, Osaka Habikino Medical
Center， 4 Department of General Medicine, Dokkyo Medical University
Hospital，5Department of anesthesiology, Otemachi Hospital， 6Department ofEmergency Medicine, The University of New Mexico
Kentaro Fukano1，Yousuke Honma2，Sonho Kim3，Hiroshi Takase4，
Akihikari Shimosato5，Tatsuya Norii6【Background】Procedural sedation and analgesia（PSA）are performed outside of the operating theater
including in the Emergency Departments（ED）. Ketofol（combination of ketamine and propofol）has
multiple theoretical advantages over ketamine or propofol alone. Although ketofol has been used for PSA
in many countries, its use for PSA in the ED has not been reported in Japan.【Methods】We analyzed theJapanese Procedural Sedation and analgesia Registry（JPSTAR）, a multi-center prospective registry ofpatients undergoing PSA in the ED in 4 teaching hospitals in Japan, and identified patients who received
ketofol.【Results】Among 332 cases in the registry from May 2017 to April 2018, we identified threepatients who received ketofol. Their ages were 49, 60, and 70. Hip joint reduction was the indication for
all three cases. No adverse events were reported. Two patients were admitted to the hospital after PSA.
The remaining patient was discharged home from the ED.【Conclusion】To our knowledge, this is thefirst report of ketofol use for PSA in the ED in Japan. Although it is difficult to make a clear conclusion
based on our small sample size data, ketofol seems to be a safe option for PSA in Japanese EDs. A larger
sample size is needed to confirm our results.

INT4-4 A CASE REPORT OF MULTIDRUG-RESISTANT ACINETOBACTERBAUMANNII VENTRICULITIS AND MENINGITIS

INT4-7 Comparison of the efficiency of oral airway and nasal airway
inserted in the oral airway during mask ventilation

Hanoi Medical University
Hai Hoang Bui，Nguyen Anh Dung，Nguyen Tien Thanh，Hoang Kim Quan

Department of Anesthesiology and Pain Medicine, Seoul National University
Bundang Hospital
Jaesung Lee，Seongjoo Park，Jin-Woo Park，Sung-Hee Han，Jin-Hee Kim

Antibiotic resistance is a growing global concern, which is a pressing issue particularly in theintensive care units of hospitals. Administering appropriate antibiotics has been shown to
reduce mortality, length of hospital stay, and lower care cost. Along with antibiotic selection,
the route of administration also contributes to increasing favorable outcomes in antimicrobial
therapy to infectious diseses. To further demonstrate this issue, this paper details a case at
Hanoi Medical University（HMU）Hospital whose multidrug-resistant Acinetobacterbaumannii ventriculitis causing meningitis was successfully treated using intraventricular
injections of colistin. A 74-year-old male patient was admitted to the emergency departmentof HMU Hospital due to a headache. Following examination, he was diagnosed with cerebellar
hemorrhage and was given hematoma evacuation. After the surgery, due to modest
improvements in consciousness and persistent high fever, samples of cerebrospinal fluid（CSF）and a brain CT scan were acquired. The patient was diagnosed with multidrug-resistantAcinetobacter baumannii ventriculitis and meningitis. Treatments included a combination of
intravenous meropenem in a dosage of six grams per day and intravenous colistin; however,there were no signs of improvements after a few days. Then intraventricular 100000 UI ofcolistin was admistered to the patient per day. Following the treatments, the fever resolved
after four days, CSF became clear after 14 days and antibiotics were ceased on day 18.In
conclusion, the combination of intravenous meropenem and intraventricular administration ofcolistin is a possible course of action to treat ventriculitis and meningitis caused by multidrugresistant Acinetobacter baumannii.Keywords: ventriculitis, meningitis, multidrug-resistant,Acinetobacter baumannii【Backgrounds】The purpose of this study was to investigate the efficiency of nasal airway
inserted in the oral airway（ON airway）in securing the airway patency during mask
ventilation.【Methods】Fifty-eight patients undergoing general anesthesia were randomly
assigned to either oral airway group（Group O）or ON airway group（Group N）. In bothgroup, 2 mg/kg of propofol was infused intravenously and mask ventilation was performed in
the sniffing position without head extension or jaw thrust. The patients were ventilated with avolume-controlled ventilator with O 2 flow of 10 l/min, tidal volume of 10 ml/kg, andrespiratory rate of 10 /min. Before the start of mask ventilation, airway was placed in the oralcavity. Oral airway was used in Group O and ON airway was used in Group N. Peakinspiratory pressure（PIP）, tidal volume and EtCO2 were compared between the two groups.
The location of airway tip was graded by fiberoptic bronchoscope as; 0: airway obstructed by
tongue, 1: epiglottis visible, 2: airway touches epiglottis tip, 3: airway passes beyond epiglottis
tip.【Results】Compared with Group O, Group N showed significantly lesser PIP（25.0［18.0- 29.0］vs. 18.0［16.0 - 19.0］, P < 0.001, Group O and N, respectively）and greater tidal
volume and EtCO2 during mask ventilation. In the bronchoscopic findings, airway obstruction
was more frequent in group O（P <0.001）.【Conclusions】Compared with oral airway, ON
airway facilitates the mask ventilation by promoting the patency of airway.

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INT4-5 Low dose of recombinant tissue-type plasminogen activator（rtPA）in the treatment of acute pulmonary embolism in Vietnam

INT4-8 Macrophage-HMGB1 is involved in the development of cystic
pain in mice

キ

1

福岡大学

委

Hanoi Medical University and Hanoi Medical University Hospital，2Hospital of
Thu Duc District, Ho Chi Minh City，3Bach Mai Hospital，4Da Nang General
Hospital
Hai Hoang Bui1，Phuc Giang Do1，Lac Duy Le2，Thinh Nghia Bui2，
Chinh Quoc Luong3，Hieu Huu Hoang4，Nhan Duc Le4【Background】Recommended dose of recombinant tissue plasminogen activator（rt-PA）to treat acutepulmonary embolism（PE）is 100mg infusion over 2 hours. However, some evidences suggest that a low
dose rt-PA regimen can be equally effective but potentially safer.【Objectives】To evaluate the safety andefficacy of low-dose rt-PA on management of acute PE.【Methods】A retrospective observation of caseseries in 5 hospitals in Vietnam from 2010 to 2018 was described. Acute PE patients were treated with thesame protocol: the total dose of 0.6 mg/kg t-PA through a peripheral line in 15 minutes was administered.
The other treatments followed the standard protocol. Changing in RV diameter, pulmonary artery systolicpressure（PASP）, severity index score were evaluated after 1 week, 1 month and 3 months respectively.
The mortality and complications were also assessed.【Results】Of the 51 patients included（mean age 62± 19.2 years, female 70.5%）, 26 had high risk and 25 had intermediate-high risk of mortality. Mean RV
diameter decreased from 31.1 mm at baseline to 26.8, 23.5, and 24.0. Mean PASP declined from 52.8mmHg to 41.0, 33.5, and 29.7; the severity score droped from 56.8 to 29.9 at 1 month, and 4.5 at 3 months（n=11, no visible emboli after 1 month in 40 others）. There were 2 deaths（not related directly to PE）, no
major bleeding, 6 minor bleeding, 1 acute pulmonary edema, and 1 carotid aneurism.【Conclusions】
Low-dose rt-PA regimen improved conditions of acute PE patients effectively with low rate of mortality
and complications. Keywords: fibrinolysis; pulmonary embolism; right ventricular failure; thrombolysis

医学部

救急医学講座入江悠平，星野耕大，村西謙太郎，中塩舞衣子，外間石倉宏恭亮，鯉江めぐみ，【Objective】We have reported that macrophage-derived HMGB1 was involved in
the pancreatic pain. In this time, we examined whether interstitial cystitis pain also
involves macrophage-derived HMGB1.【Methods】Interstitial cystitis in mice wascreated by intravesical administration of Substance P（SP）. And we evaluated thehyperalgesia 24 h after the final administration of SP, the bladder was isolated andweighed for determination of the severity of the evoked cystitis.【Results】
Pretreatment with anti-HMGB1 antibody and rhsTM, known to delete HMGB1, bothof them prevented the hyperalgesia significantly, but did not affect the bladderweight. Hyperalgesia was significant suppressed in mice pretreated with AMD 3100
or FPS-ZM1.【Conclusion】Our results suggested that macrophage-derived
HMGB1 contributes to the development of cystic pain in mice via RAGE or CXCR4
signaling and rhsTM may reduce cystic pain.

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INT5-1

The trial of "ITC（Iwate Trauma Conference）" by various

hopitals and various medical staffs
1

Morioka Yuai Hospital, Thoracic Surgery，2Iwate Prefectural Chubu Hospital,

Surgery，3Iwate Prefectural Iwai Hospital, Emergency Medicine，4Morioka Yuai
Hospital, Rehabilitation Section，5Morioka Yuai Hospital, Pharmacy，6Morioka
Yuai Hospital
Kojiro Shiga1，Fumie Obara2，Yuro Kinn3，Takaaki Katayama3，
Megumi Sasaki4，Kotaro Ishikawa4，Shintaro Abe5，Yuji Fujii1，Shigeatu Endo6
Iwate Prefecture has a wide area. Sometimes, The treatment for multiple trauma isrequired even in facilities not accustomed to such trauma. We held the Iwate Trauma
Conference（ITC）involving health professionals from different medical institutions,which aimed at sharing experience regarding multiple trauma cases and collaboration
among medical institutions. From the planning and preparation stage, we were
working with doctors and medical professionals of different medical institutions incooperation. On the day of the event, there were various types of occupation fromvarious medical institutions as well as doctors. There was a constructive questionand-answer, ranging from concrete therapy including surgical techniques torehabilitation and discharge adjustment. ITC was useful conference.

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INT5-4

Evaluation of referral centers in Khon Kaen Province

Nursing Department of Emergency Room（Referral Center）, Khon Kaen Hospital,
Thailand.
Talsab Wilawan，Watchara Sriharat【Objectives】To explore problems, make suggestions, and evaluate the performance ofreferral centers in Khon Kaen province, Thailand.【Methods】We conducted a questionnaire
survey among stakeholders of referral system in the province from July to November 2017.
Open-ended questions were used to explore problems, obstacles, and suggestions; structured
questions were used to evaluate the performances of the referral centers. This study included
178 participants selected randomly from four stratified groups in the province: hospital
directors, members of referral committees, staff of the referral centers, and staff of hospitals
referring patients to the referral centers. The questionnaires were developed for each of thefour groups, in which the participants were requested to evaluate the context, inputs, andprocess using 5-point Likert scale（high score means very good or very agree）, and toevaluate products（achieved goals）using yes-or-no questions.【Results】The participants
showed concerns about the system and its insufficient resources but willingness to support thecenters to improve their performances. The mean rating scores（SD）on the context, input,
and process were 4.14（0.57）, 4.93（0.14）, and4.01（0.53）, respectively among hospital
directors; 3.80（0.76）, 3.66（0.57）, and 3.64（0.57）, respectively among referral committee
members; 3.91（0.52）, 3.78（0.54）, and 3.79（0.56）, respectively among referral center staff;
3.70（0.57）, 3.25（0.57）, and 3.23 0（. 76）, respectively among doctors and nurses. The
product evaluation was 100% in all groups except for the doctors and nurses（84%）.
【Conclusions】Although the evaluation scores were fairly good, there is still room for
improvement in the referral system.

INT5-2 A little improvement of EMS in Hanoi through 2 different casestudies

INT6-1 Keywords in initial report which predict severity of ski andsnowboard injuries

1

手稲渓仁会病院 救急科
小野寺良太，奈良 理，森下由香，大西新介，清水隆文，大城あき子，
岡本博之，高橋宏之，杉浦 岳，和田健志郎，近藤 統

Hanoi Medical University Hospital, Hanoi Medical University，2Department ofEmergency Medicine, Teikyo University School of Medicine
Hai Hoang Bui1，Viet Ha Vu1，Anh Dung Nguyen1，Tien Thanh Nguyen1，
Ngoc Ha Le1，Giang Phuc Do1，Dinh Hung Vu1，Huy Binh Trinh1，
Tat Thanh Nguyen1，Nakahara Shinji2【Background】In severe trauma, especially in rural areas, rapid response by helicopter iscrucial. In Hokkaido, a number of specific keywords are screened for in the initial on-site

Out-of-hospital cardiac arrest requires prompt and appropriate care by bystanders and emergency medical

report to decide if helicopter dispatch is warranted. However it is unclear whether these

services（EMS）. In many low- and middle-income countries（LMIC）, bystanders often do not know

keywords accurately predict severity.【Objective】To analyze keywords that predict trauma

appropriate cardiopulmonary resuscitation（CPR）and EMS is not sufficient to meet every need. Recently
in Hanoi, there were two contrasting cases from which we can learn lessons. The first case is a 40-yearold man who was handling electric current at a railway construction site and was electrocuted. His

severity in patients injured by skiing or snowboarding.【Study design】A seven-year review
of ski and snowboard trauma patients transported by ambulance or helicopter【Patients and（シ）colleagues quickly transferred him to the emergency room by taxi without any CPR or calling EMS,

methods】Trauma patients with ski or snowboard injuries admitted to Teine Keijinkai

which took 10 minutes. At the emergency department, he was found to have ventricular fibrillation, andHospital by ambulance and helicopter from April 2012 to March 2018 were reviewed. We

resuscitated but unsuccessful. The second case is a 43-year-old man who had bronchial asthma under

defined severe traumatic patients as ISS ≧ 16 or needing emergency intervention（intubation,（パ）

regular treatment. He stayed at home with his blind wife because of dyspnea and fatigue. His dyspnea

chest drainage, emergency operation, transcatheter arterial embolization）. We examined theworsened and his wife called EMS. When the EMS reached him in 10 minutes, he was in a cardiac arrest.

keywords related to age, sex, altered conscious level and cause of injury.【Results】A total ofosreturn of spontaneous circulation. He was then placed a laryngeal mask, transferred to the hospital,

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The EMS performed CPR, oxygen squeeze, and adrenaline administration. After about 10 minutes, he got
intubated, and treated under mechanical ventilation and the bronchodilator for asthma. He was extubatedafter 3 days and discharged after 1 week.These two cases highlight the importance of the chain of survival

144 patients were identified. 41（28%）were severely injured. Age over 50 years, and impact
with tree’ were associated with an increased risk of severe injury（Age over 50 years: OR2.84,
95%CI:1.07-7.51, impact with tree: OR5.01, 95%CI:2.14-11.7）【Conclusion】This analysis

and abilities of EMS in Hanoi. It is a pressing need to raise people’s awareness of what they should do forsuggests that patients over 50 years of age who have impact with a tree’ are more likely to

OHCA patients（CPR and EMS call）.

have severe injury, and should warrant helicopter dispatch.

INT5-3 The interval from patient collapse to defibrillation of emergency
medical service and favorable neurological outcomes on out-of-hospital
cardiac arrest

INT6-2 JTAS （Japan Triage and Acuity Scale） 2012 in pediatricemergency department is a valid tool for non-traumatic patients of allages

Graduate School of Emergency Medical System, Kokushikan University, Tokyo,
Japan.
Toru Shirakawa，Ryo Sagisaka，Takahiro Hara，Soh Gotoh，Hideharu Tanaka

1【Objective】The aim of this study was to estimate the relationship between interval from patient collapse
to defibrillation by emergency medical service（EMS）and favorable neurological outcome in anationwide out-of-hospital cardiac arrest（OHCA）registry in Japan.【Methods】A retrospective
observational study was conducted with OHCA cases from 2006 to 2015（n=1, 197, 046）by nationwide
Utstein style OHCA registry in Japan. The subject was 26, 622 OHCA cases which experienced
cardiogenic cardiac arrest, witnessed by a bystander, shockable rhythm, EMS provided defibrillation andinterval of collapse to EMS defibrillation between 3 and 20 minutes, and those with bystander
defibrillation were excluded. The primary outcome was favorable neurological outcomes（Cerebral
Performance Category 1 or 2）one month after cardiac arrest. Logistic regression was conducted to
examine the relationship between outcomes and interval of collapse to EMS defibrillation.【Results】Themean interval of collapse to EMS defibrillation was 11.8（standard deviation, 3.3）minutes.The longer
interval of collapse to EMS defibrillation was associated with lower percentage of neurologicallyfavorable one-month survival（crude odds ratio for each 1-minute increase, 0.87; 95% confidence interval,
0.86 to 0.87）.【Conclusion】The shorter interval of collapse to EMS defibrillation was associated withgood favorable neurological outcomes for OHCA patients.Shorten interval of collapse to EMS
defibrillation by even a few minutes could potentially save lives.

Department of Emergency Medicine, Tokyo Metropolitan Children’s Medical
Center, Tokyo, Japan，2Department of Intensive Care Medicine, Osaka Women's

and Children's Medical Center, Osaka, Japan
Masashi Taniguchi1,2，Yusuke Hagiwara1【Background】Pediatric emergency department triage should have the reliability for all children.
Objectives: The objective of this study is to show that JTAS（Japan Triage and Acuity Scale）2012 inemergency department is reliable for non-traumatic pediatric patients regardless of their ages.【Methods】
This was a retrospective observational study evaluating all non-traumatic children who visited a pediatricemergency department of tertiary pediatric facility in Japan during 5 years from April 2012 to March2017. To analyze the reliability of JTAS 2012, patients were categorized as two groups, high acuity（triage
level 1, 2）and low acuity（triage level 3, 4 and 5）. We compared triage acuity with admission andcalculated the reliability indices such as Sensitivity（Se）, Specificity（Sp）, Positive Likelihood Ratio（PLR）and Negative Likelihood Ratio（NLR）. First, we calculated those indices in children of all ages
and compare them with those of other triage systems in previous studies. And then, we calculated theindices by age.【Results】147, 894 non-traumatic pediatric patients（aged<16）visiting an emergency
department were included. The reliability indices of JTAS 2012 of all ages were good as follows: Se of
68.1%, Sp of 92.5%, PLR of 9.0 and NLR of 0.34. In the aspect of indices, JTAS 2012 was superior to allother triage systems. Moreover, the age-related variations were slight: Se of 65.9%（IQR 62.3-69.2）, Sp
of 92.8%（IQR 92.4-93.2）, PLR of 9.0（IQR 8.2-10.0）, and NLR of 0.36（IQR 0.33-0.41）.【Conclusions】
This study shows that JTAS 2012 is a valid tool for non-traumatic patients of all ages.

INT6-3

Factors Related To Severe Injury From Motorcycle Accident In

Teenage Whom Were Cared At The Emergency Department, Khon Kaen
Hospital
1

Emergency Department, KhonKaen Hospital, Thailand， 2Faculty of Health

Sciences Khonkaen University
Setciwanon Jerawit1，Rujira Duangsong2【Introduction】Motorcycle accidence is a major health problem, especially among youths. We describedfactors associated with severe motorcycle-related injuries among teenagers.【Methods】This was an
unmatched case-control study among injured motorcyclists aged <20 years. The analysis included 244
patients treated at Emergency Department of Khon Kaen Hospital from January to December 2009.
They were divided into severe（n=122）and non-severe（n=122）groups based on Khon Kaen emergency

INT7-1

A case of acute appendicitis secondary to a foreign bodyswallowed by a patient with mental disabilities and pica
姫路赤十字病院外科

坂田寛之，河合毅，福本侑麻，信久徹治，松本祐介，甲斐恭平，佐藤四三

A 50-year-old-man with mental disabilities, autism, and pica visited another hospitalwith vomiting and high fever a day before he presented to our hospital. He had been
diagnosed with ileus, and nasogastric intubation had been performed. He did notshow improvement and therefore underwent computed tomography, which showed
an area of high density in the right lower quadrant of his abdomen. Owing to a highindex of suspicion for small bowel obstruction caused by a foreign body, he wasseverity index. Data on demographic characteristics, crash details, and road environments were derived

referred to our hospital for further management. Upon admission, he was observed

from trauma registry database of Khon Kaen Hospital. Associations between these data and injury severity

to have high fever and abdominal distention. Although he appeared to havewere determined using a multivariate logistic regression model.【Results】The study found factors

abdominal pain, we could not perform a detailed examination because of a difficultyin communication. An exploratory laparotomy was performed, which showed acutecorrelated with the severe injury among teenage motorcyclists. The correlated personal factors included
helmet non-use（OR = 17.64, 95% CI 1.16-192.55）, high speed driving（OR = 0.19, 95% CI 0.06-0.56）,
and cut in font of another car（OR = 0.19, 95% CI 0.06-0.58）. The correlated vehicle factor was crashwith a pickup truck or tricycle（OR = 4.80, 95% CI 1.22-18.87）. The correlated environmental factors
included roads with potholes wave（OR = 0.12, 95% CI 0.01-0.76）, wet roads（OR = 11.8, 95% CI 3.03-

appendicitis with abscess formation. Therefore, he underwent an appendectomy andabscess drainage. We report a rare case of acute appendicitis caused by a foreignbody.

46.03）, paved road（OR = 0.002, 95% CI 0.00-0.01）, and road obstructions or objects（OR = 0.07, 95%
CI 0.02-0.29）.【Conclusions】The study found some personal, vehicle, and environmental factors related
severe motorcyclists’ injuries.

INT6-4 Do you have a strategy to rule out pulmonary thromboembolism?
― a single-center retrospective review

INT7-2 A case of tension peumoperitoneum caused by colon cancer inwhich needle decompression was effective.

1

京都大学大学院 医学研究科 薬剤疫学分野，2 神戸市立医療センター中央
市民病院 救命救急センター
朱 祐珍 1，水 大介 2，浅香葉子 2，有吉孝一 2【Background】Pulmonary thromboembolism（PE）is still challenging to rule out in the emergency room.
A specific electrocardiogram（ECG）findings such as S1Q3T3 is one of the clues. However, due to its
low prevalence in PE patients, S1Q3T3 was paid little attention. We examined the efficacy of
S1Q3T3 in our hospital.【Method】This is a retrospective study of an urban, teaching hospital. During
the study period between April 1, 2007 and March 31, 2018, we included all patients who were diagnosed
PE in our hospital. Collected data were age, gender, vital signs, chief complainants, Wells criteria, and
ECG. We classified the patients into two groups, PE likely group and PE unlikely group based on
modified Wells criteria, and compared ECG with S1Q3T3 ratio between the two groups. We analyzed
about massive PE and non-massive PE by same method.【Results】During the 11 years period, we
enrolled 107 patients and 13 patients were diagnosed massive PE. The ratio of patients who had
S1Q3T3 was 43.1%. There was no significant difference in the prevalence between PE likely group andPE unlikely group（Chi-square test, p=0.356）. This result was followed by the relationship between
massive PE and non-massive PE（Chi-square test, p=0.887）.【Conclusion】In an 11 years, 107 patientswere diagnosed PE in our hospital. Regardless of wells criteria or severity of PE, the rates of patients who

1

Tension pneumoperitoneum is an important clinical condition, which can be
improved by rapid needle decompression like tension pneumothorax. We report acase of tension pneumoperitoneum caused by perforation of colon cancer. A 63-yearold man was brought to our emergency department with altered mental status. He
was in shock and abdominal X-ray suggested gastrointestinal perforation. Despite
rapid fluid infusion and inotropic support, his condition became deteriorated. His
abdomen was distended and abdominal CT scan revealed huge intra-abdominal gas.
We performed immediate needle decompression and his circulatory status improved
immediately. He underwent surgery and it revealed about 10 cm colon cancer which
invaded surrounding tissue and led to perforation. He received intensive care after
surgery, gradually improved and was transferred to another hospital. There are few
reports of tension pneumoperitoneum due to perforation of colon cancer. It should be
widely recognized as one of the causes of shock or cardiopulmonary arrest, since
rapid diagnosis and decompression may improve the condition.

met ECG findings S1Q3T3 were higher than recent study. This result suggests that S1Q3T3 was

INT6-5 REsident vs. Senior physicians Care of Urgent aortic dissectionin the Emergency department（RESCUE study）― a retrospective study

INT7-31

関西医科大学附属病院
村津有紗，室谷 卓，岸本真房，尾上敦規，中村文子，中嶋麻里，
高橋弘毅，櫻本和人，梶野健太郎，池側 均，鍬方安行【Background】Acute aortic dissection（AAD）is a potentially lethal cause in ER. However, variations inclinical presentations make the diagnosis difficult. Emergency medical care in Japan is still covered byjunior physicians. We investigated the time-to-diagnosis（TTD）; AAD based on level of training.
【Method】This was a retrospective study of AAD patients in an urban ER from February 1, 2015 toJanuary 31, 2018. Collected data was following: age, gender, chief complaint（CC）, Stanfordclassification and the time required for CT scan. All ER physicians were divided into two groups: juniorstndrdphysicians（1 and 2 year residents）and senior ones（>3 year in cardiology and attendings）. We
define TTD is the time required for CT scan and the primary outcome.【Result】Among all 38, 526 ER
visits, 61（0.16%）were diagnosed of AAD. The mean age was 68［58-76］, and 48（77.4%）were male.
32（52.5%）patients were Stanford A . The most common CC were back pain（n=36, 59.0%）. Therewere significant differences in TTD between the two groups（junior=57［37.5-91.5］min, senior=32［2855］min , p<0.01）. On the other hand, there were also significant differences in CC: chest pain｛junior =9（27.2%）, senior =16（51.6%）｝, others｛junior = 17（51.5%）, senior =6（18.2%）｝; all p values<0.05.【Conclusion】Over a three year study period, 61 patients diagnosed of AAD by junior and seniorresidents. There were significant difference in AAD and CC in two groups.【Discussion】The difference
between junior and senior groups is the variation of CC. We have to consider the background and we
make sense challenging of making diagnosis in ER.

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potentially useful and should be utilized.

Department of Cardiology, Osaka Police Hospital, JP，2Department of Emergency
Medicine, Osaka Police Hospital, JP，3Department of Critical Care Medicine,
Osaka Habikino Medical Center, JP， 4Department of Critical Care Medicine,
University of New Mexico, US
Mikiko Matsumura1，Sung-Ho Kim2,3，Shimpei Nagata2，Tatsuya Norii4，
Yasuaki Mizushima3

招シ

to severity of motorcyclists’ injuries. Of these factors, helmet use is the most important target to reduce

2nd year junior resident, Osaka Police Hospital, JP，2Department of Emergency
Medicine, Osaka Police Hospital, JP，3Department of Critical Care Medicine,
Osaka Habikino Medical Center, JP
Tadakiyo Ido1，Shinpei Nagata2，Sung-Ho Kim3，Yasuaki Mizushima2

特Gastric emphysema and portal emphysema complicated with

Superior Mesenteric Artery Syndrome

A 64-year-old man with a history of vomiting, abdominal distention and consciousness disturbance wastransported to our hospital. He had hypotension and tachycardia due to infection and dehydration. We
diagnosed him with septic shock and performed fluid resuscitation and administered catecholamine. His
vital signs stabilized. Abdominal contrast computed tomography（CT）revealed dilatation of the stomach
and proximal duodenum with extensive gastric wall pneumatosis and portal emphysema. Upper
gastrointestinal endoscopy showed extensive acute gastric mucosal lesions（AGMLs）. We diagnosed
gastric emphysema without necrosis of the gastric mucosa or pus. We treated the patient conservatively by
gastric drainage with a nasogastric tube and intravenous antibiotics and his general condition improved.
The same symptoms recurred whenever he started taking nutrition through the nasogastric tube. A review
of his medical history revealed a 30-kg body weight decrease over 2 years and constriction of the third
portion of the duodenum was detected on abdominal CT. Gastric emphysema by superior mesentericartery syndrome（SMAS）was diagnosed. The patient was treated by gastric drainage and nutrition wasprovided through the jejunum with a W-ED tube. Thereafter his body weight increased. He wastransferred to other hospital for rehabilitation on the 60th day of hospitalization; no recurrence wasobserved. SMAS most commonly occurs in young adult women and tends to be detected by chronic
cyclical vomiting or epigastric pain. SMAS rarely leads septic shock. We reported the case of a man who
developed septic shock caused by gastric emphysema and portal venous gas due to SMAS.

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INT7-4

Disease1

Acute Agitation as an Initial Manifestation of Neuro-Behçet’s

Advanced Critical Care and Emergency Center, Okayama University

Emergency Department, Gold Coast University Hospital
安田晃一

Yuki Otsuka1,2，Tetsuya Yumoto1，Hiromi Ihoriya1，Yoshinori Kosaki1，
Yasuaki Yamakawa1，Atsuyoshi Iida1，Hirotsugu Yamamoto1，Taihei Yamada1，

We often have patients that we feel difficult to make diagnosis. This is one of a case

Kohei Tsukahara ，Hiromichi Naito ，Atsunori Nakao
1

1

1

Acute agitation is a common condition encountered in ED and requires rapid assessment andmanagement. We report a successfully treated case of Neuro-Behçet’s disease（NBD）presenting acute
psychiatric symptoms as an initial manifestation.A 44-year-old male, who had been complaining about asevere headache and fever for three days, was admitted to our ED due to acutely presented incontinence
and agitation. He had no familial or personal psychiatric history and no psycho-social stress factors. On
admission, physical restraint and sedation with sevoflurane and propofol was required for his violent
behavior. Physical/blood test showed fever of 37.8 ℃ and swelling of the parotid glands and scrotum
associated with leukocytosis, elevation of CRP and metabolic acidosis. CSF examination revealed
increased cell count. T2-weighed MRI demonstrated a small high intensity in the bilateral caudates. As
meningoencephalitis was suspected, empirical therapy was immediately started with meropenem,
vancomycin, acyclovir, prednisolone, and immunoglobulin. He recovered uneventfully without
neurological defect in seven days. Based on positive HLA-B51 and clinical manifestations, the diagnosis
of NBD was made and remitted by steroid therapy. Behçet’s disease is a chronic multisystem vasculitic
syndrome consisting of a triad of recurrent painful oral ulcers, relapsing uveitis, and recurrent genital
ulcers. 10% of them demonstrates various lethal neurological symptoms called NBD. Although acute
NBD commonly presents with focal neurological symptoms, psychiatric symptoms could be considered
the first manifestation. A focused and thorough examination coupled with appropriate management
strategies can assist emergency clinicians safely and effectively manage these patients.

INT7-5 Secondary aortoesophageal fistula after thoracic endovascularaortic repair for traumatic thoracic aortic rupture
Niigata University Medical and Dental Hospital Advanced Disaster Medicine andEmergency Critical Care Center
Masakazu Nitta，Hiroshi Endoh，Tadayuki Honda，Yoshifumi Hoshino，Takashi Hazama，Natsuo Kamimura
A 72-year-old man who was hit by a car was brought to our emergency department. Both traumaticer

was admitted to the ICU with a hemodynamically stable state. On day 4, his consciousness improved and（シ）

but his swallowing function remained declining. About two months after the accident, he was transferred（パ）

AEF. He was re-transferred to our hospital and CT scan showed mediastinitis with an aorticos

his surgical treatment. He received palliative care and died due to rerupture of aortic pseudoaneurysm

夫

investigation. Fatal complication after TEVAR like AEF may occur, so we need to carefully follow theリア

INT7-6 Acute generalized exanthematous pustulosis induced by local
application of antibiotics in a dental procedure

研セ

How should I approach a case mimics several common disease?

A case from 'Down Under'

Hospital，2Center for Graduate Medical Education, Okayama University Hospitalシ会

INT7-7thoracic aortic rupture and intestinal perforations were diagnosed by CT scan. He underwent thoracic
endovascular aortic repair（TEVAR）followed by partial resections of jejunum. After these procedures, hehe started to go through rehabilitation. One month later, CT scan had no evidence of aortic
pseudoaneurysm, mediastinitis or aortoesophageal fistula（AEF）. He became able to walk with assistanceto another hospital that provides him with rehabilitation programs. One month after hospital transfer, he
unexpectedly had fever and hematemesis. he underwent upper gastro-intestinal endoscopy and it revealed
pseudoaneurysm. We recommended re-TEVAR and surgical treatment of esophagus to him and his
relatives. But he strongly denied such treatment. His relatives respected the will of him and didn’t want
three days after re-hospital transfer.Recently TEVAR has become one of the main therapies for aortic
diseases even if the causes of them were trauma. However long-term effectiveness of TEVAR is still underpatients who underwent TEVAR.

1

Department of Emergency and Critical Care Medicine, Japanese Red Cross Fukaya

Hospital， 2 Department of Dermatology, Japanese Red Cross Fukaya
Hospital，3Department of Dentistry and Oral-maxillofacial Surgery, Japanese Red
Cross Fukaya Hospital
Keiko Ueno1，Naoyuki Kaneko1，Miho Arai2，Tomoyoshi Koyama3【Introduction】Acute generalized exanthematous pustulosis（AGEP）is a severe cutaneous adverse
reaction（SCAR）characterized by acute onset of high-grade fever, widespread erythema, numerous small
sterile pustules, and neutrophilia from 2 to 7 days after exposure to a medication. The most common
offending agents are antibiotics. To the best of our knowledge, this is the first case report of AGEP caused
by dental triple antibiotic paste therapy.【Case】A 47-year-old male with a history of chronic
myelogenous leukemia was transferred to our emergency center for suspected severe adverse drug
reaction. Clinical history revealed that he had a dental procedure with triple antibiotics paste containing
metronidazole, ciprofloxacin and minocycline two and half months ago, and had an additional dental
procedure four days prior to the presentation. He developed rash on the forearms two hours after thesecond procedure. He subsequently developed fever, erythroderma, and pustules on his neck, elbows, andgroins. Laboratory findings showed neutrophilia, abnormal liver and renal function tests. AGEP wasconsidered as a diagnosis and intravenous prednisolone was started. Skin biopsy was consistent withfeatures of AGEP. Ciprofloxacin was a suspected causative drug on the basis of clinical course and apositive result of the lymphocyte transformation test. The patient was responded well to the systemic
steroids. However, his clinical course was complicated by another drug eruption and drug-induced liver
injury. He was discharged home on a prednisone taper after one month.【Conclusion】Emergency
physicians need to acknowledge AGEP as one of SCARs and initiate appropriate and timely management.

I had in a rural hospital in NSW, Australia. A patient was a 40 years old female,transferred from peripheral Emergency Department（ED）by ambulance service,where does not have any diagnostic image other than X-Ray, for further investigationand management. She presented to ED with acute onset of severe headache andsyncope. She noted it started with 10/10 pain and was collapsed. She herself does
not have any past medical history apart from mild Migraine. After she had several
investigations and fortunately, I was able to make diagnosis, which was an adrenal
tumour. Pathology report noted it was Pheochromocytoma. Obviously, it was not on
my differentials diagnosis list. In conclusion, this case mimics several common
diseases. I am keen to present this case and would like to share any idea on the floor
to improve our practice. And with talking through this case, if I could introduce
some of information about ED in Australia, it will be fantastic.