Towards enhanced telephone triage for chest pain: a Delphi study to define life-threatening conditions that must be identified

Background Improving telephone triage for patients with chest pain has been identified as a national research priority. However, there is a lack of strong evidence to define the life-threatening conditions (LTCs) that telephone triage ought to identify. Therefore, we aimed to build consensus for the LTCs associated with chest pain that ought to be identified during telephone triage for emergency calls. Methods We conducted a Delphi study in three rounds. Twenty experts in pre-hospital care and emergency medicine experience from the UK were invited to participate. In round I, experts were asked to list all LTCs that would require priority 1, 2, and 4 ambulance responses. Round II was a ranking evaluation, and round III was a consensus round. Consensus level was predefined at > = 70%. Results A total of 15 participants responded to round one and 10 to rounds two and three. Of 185 conditions initially identified by the experts, 26 reached consensus in the final round. Ten conditions met consensus for requiring priority 1 response: oesophageal perforation/rupture; ST elevation myocardial infarction; non-ST elevation myocardial infarction with clinical compromise (defined, also by consensus, as oxygen saturation < 90%, heart rate < 40/min or systolic blood pressure < 90 mmHg); acute heart failure; cardiac tamponade; life-threatening asthma; cardiac arrest; tension pneumothorax and massive pulmonary embolism. An additional six conditions met consensus for priority 2 response, and three for priority 4 response. Conclusion Using expert consensus, we have defined the LTCs that may present with chest pain, which ought to receive a high-priority ambulance response. This list of conditions can now form a composite primary outcome for future studies to derive and validate clinical prediction models that will optimise telephone triage for patients with a primary complaint of chest pain.

P-EGS08 What is the Best Risk Prediction Model for Oesophageal Perforation?

Background Oesophageal perforation is a challenging surgical condition associated with high mortality and morbidity. There is a lack of consensus regarding the optimal treatment strategy, when and whom to operate on. Treatment options include primary repair, t-tube repair, emergency oesophagectomy, endoscopic therapy, and palliation. Whilst many risk prediction models exist, the only specific score to predict mortality in oesophageal perforations is the Pittsburgh Severity Score (PSS). However, there is limited evidence on its validity and even less literature to predict short and long-term morbidity in these patients. Methods We compared and validated commonly used risk prediction models, including the PSS, the National Emergency Laparotomy Audit score (NELA score), the Portsmouth Physiological and Operatic Severity Score for the enumeration of Mortality (P-POSSUM), and the Surgical Outcome Risk Tool (SORT) using a dataset of 83 patients ranging from 2009 to 2021. The power to predict mortality and morbidity was assessed using the comprehensive complication index (CCI). The CCI was calculated using complications for both operative and non-operative cohorts. Results Of the scores assessed, NELA showed the most robust predictive value for in-hospital mortality, 30-day mortality, and 90 mortality (AUROC 0.812, 0.8602, 0.8302, respectively). The PSS also showed significant predictive value for in-hospital mortality, 30-day mortality, and 90 mortality (AUROC 0.792, 0.856, 0.813 respectively). Furthermore, NELA had the strongest correlation between score and CCI (rs 0.644 p &lt; 0.001). Conclusions Despite not being validated for oesophageal pathology, NELA appears to be the optimum scoring model to predict mortality and morbidity for this patient population. This is the first study to compare the efficacy of different risk prediction models in oesophageal perforations and could be used to inform shared decision making and peri-operative outcomes. Further large-scale validation of risk prediction tools is required to corroborate these findings.

THYROID ABSCESS: A CASE SERIES

Thyroid abscess is a rare surgical pathology, accounting for less than 0.7% of surgical pathologies involving the thyroid 1,2 gland. This is due to its rich blood supply and lymphatic drainage, high concentration oodine that inhibits bacterial growth, protective brous capsule, and fascial planes 2–4 separating it from other neck structures. It may lead to complications like septicaemia, paralysis of the vocal cords, retropharyngeal abscess and suppurative media stinitis and 2 may occasionally lead to osteomyelitis or septic thrombophlebitis. It 5 may also lead to tracheal and oesophageal perforation. The 6 left lobe is commonly affected. If left untreated, thyroid abscess can be life threatening resulting in a mortality of 12% 6 or more

EP.WE.1015Management of Boerhaave Syndrome

Aim Boerhaave’s Syndrome is a rare and fatal condition, characterised by a distal oesophageal tear induced by an abrupt rise in intra-luminal pressure. Treatment remains controversial; we present a recent case and review relevant literature. Methods A retrospective analysis of case-notes was performed, and a literature review undertaken on PubMed. Results A 58-year-old male presented as an emergency with severe chest pain, having choked and vomited following the ingestion of steak. Computed tomograpy scan of the thorax demonstrated a large pneumomediastinum associated with an oesophageal perforation on the anterior wall and bilateral pleural effusions. A primary laparoscopic repair was performed with jejunostomy placement for feeding. The post-operative period was complicated by a prolonged stay on intensive care with sepsis secondary to mediastinitis. A contrast swallow performed eleven days post-surgery confirmed no persistent leak and the patient was discharged five days later. Boerhaave’s syndrome accounts for 10% of oesophageal perforations and is typically associated with a history of overindulgence and vomiting. Stable patients with a contained disruption and minimal contamination, can be managed conservatively. Endoscopic therapies include clipping small perforations, self-expanding stents for larger defects, and endoluminal vacuum therapy. Operative interventions comprise primary repair, debridement and drainage of thoracic cavity, diversion operations and single stage resection with or without primary reconstruction. Conclusion Boerhaave’s Syndrome is associated with significant morbidity and mortality, but with early recognition and prompt intervention, patients can be successfully managed. Options include conservative, endoscopic and surgical, depending upon the site and size of the perforation.

599 MEDIASTINITIS SECONDARY TO ESOPHAGEAL PERFORATION: IT’S TOO LATE?

Mediastinitis secondary to esophageal perforation is a rare, progressive, and destructive disease that may often lead to an imminent risk of death. We describe a single center experience showing how early diagnosis and prompt intervention can reduce mortality and complications. Methods From February 2016 to December 2019, 15 consecutive patients were referred to the Emergency Unit of The AORN Cardarelli (Naples) with clinical and radiological (CT scan) diagnosis of acute mediastinitis secondary to oesophageal perforation (post endoscopy or after foreign body ingestion) and furthermore, referred to the Thoracic Surgery Unit, they underwent to early surgical treatment (cervicotomy and\or thoracotomy and chest drainage. Results For early detected case (occurred within 24 hours) an emergency thoracotomy/cervicotomy was performed with surgical repair. For late detected (referred from other hospitals) a Surgical esclusion (abdominal plus cervical) and toilette thoracotomy was performed in emergency. Reconstruction occurred in 5 cases with a median of 46 days after firts care. All patient were admitted to ICU unit and susbsequentily to the thoracic surgery ward. 30 days mortality occurred in two cases. Median hospital staying was 28 days, in six cases a redo surgery was necessary. Empiric antibiotic treatment was started before operation and reviewed under Infectivologist. Conclusion Mediastinitis secondary to esophageal perforation has a fulminating course with a potential risk of sepsis, pericarditis, and multiple organ failure. A prompt identification and an invasive treatment is the best and most successful option to reduce mortality and improve patient’s recovery.

1457 Subcutaneous Emphysema in Adolescents: A Trap for The Unwary

A 16-year-old, Caucasian girl presented with sudden-onset pleuritic chest pain (CP), vomiting and shortness of breath. Nil past medical history; nil medications; nil trauma/ surgery. She was tachycardic, tachypnoeic and apyrexial with oxygen saturations &gt;96% on air. There was significant right-sided facial and neck swelling. Chest palpation demonstrated crepitations suggesting subcutaneous emphysema (SE). Urinalysis was negative. Laboratory tests revealed leucocytosis and neutrophilia. Chest X-Ray: SE. CT Thorax: extensive gas within mediastinal cavity tracking along great vessels and within subcutaneous tissues with left, apical pneumothorax. Two air-filled tracts communicating between oesophagus and mediastinal cavity, ∼2cm from gastro-oesophageal junction, indicated oesophageal rupture. Conservative management included IV Fluids, antibiotics and feeding via total parenteral nutrition. After 1-week, oral water-soluble-contrast was administered. Subsequent imaging showed no evidence of extra-luminal extravasation and she was discharged. At 4-week follow-up, normal dietary intake was re-established with no complications. Discussion Boerhaave’s syndrome (BS) (described by Dutch physician Herman Boerhaave in 1724) is the phenomenon of spontaneous oesophageal perforation. The underlying mechanism is due to a sudden rise in intra-luminal pressure against a closed glottis resulting in barotrauma. BS in adolescents remains a rare entity with a paucity of reported cases. Mackler’s triad describes the classical presentation comprising vomiting, CP and SE. Non-specific presentation may delay diagnosis and a high clinical index of suspicion is required. CT thorax and water-soluble-contrast studies are diagnostic. Timing of presentation, complications and haemodynamic status dictate conservative or surgical management approach. BS carries a 20-40% mortality, and must be included in differential diagnoses of adolescents presenting with vomiting and CP.

834 ENDOSCOPIC VACUUM THERAPY IN THE MANAGEMENT OF OESOPHAGEAL PERFORATIONS AND POST-OPERATIVE LEAKS

Oesophageal perforations and post-oesophagectomy anastomotic leaks are associated with high morbidity and mortality. Endoscopic vacuum therapy (EVT) is a novel treatment strategy with the potential to promote healing and ameliorate sepsis. Few instances of the use of EVT have been reported in the UK, wioth only two cases published outside our centre representing a limited aetiological and demographic spectrum. Methods From May 2019 to November 2020 8 patients aged 27–85 years underwent EVT for disparate oesophageal wall defects. Data regarding technical success and feasibility were analysed. Video recordings of procedures were undertaken with patient consent. Results Complete defect resolution was achieved in cases (87%), requiring median of 13 days of treatment (range 6–23), and necessitating 3 replacement procedures (range 1–4). Significant improvement in C-reactive protein was achieved in all patients undergoing treatment (P = 0.015). Over an average follow up of 360 days, no severe complications resulted directly from sponge placement, however 2 individuals (25%) developed oesophageal stricture necessitating endoscopic balloon dilatation, and one died whilst undergoing treatment. Conclusion Here we provide a video demonstration of the application of EVT in patients with oesophageal perforation or post-operative leak. Our data demonstrate this approach to be a safe, valuable tool for the management of a spectrum of oesophageal wall defects, with the potential to reduce associated morbidity and mortality in selected patients. Video Video of safe application of EVT. https://www.dropbox.com/s/rgypt6o1z93iui5/EVT.mp4?dl=0.

Alternative management of delayed spontaneous oesophageal perforation by endoscopic stenting

Boerhaave’s syndrome or spontaneous perforation of the oesophagus is a life-threatening condition that carries high mortality. Delayed diagnosis has a mortality rate of 20%–50%. While surgical intervention has been the mainstay of treatment, advancements in endoscopy and oesophageal stenting have allowed for alternative management. Our case involves a 33-year-old man with self-induced emesis and DKA. After 10 days in the ICU, he developed a large right pleural effusion, which was treated with chest tube placement. Upper GI study confirmed delayed Boerhaave’s syndrome. A self-expanding stent was inserted followed by percutaneous endoscopic gastrostomy (PEG) for decompression and jejunal extension for nutrition. He developed empyema and underwent right thoracotomy for washout and lung decortication. Stent was exchanged once due to recurrent leak following migration and removed after 40 days. Endoscopic stent placement with PEG with jejunal extension followed by thoracotomy is a viable alternative to primary repair of delayed oesophageal perforation.