bluuebunny/crossref_metadata_2025 huggingface dataset:
Bronchiolitis: Can objective criteria predict eligibility for brief hospitalization?
Authors: Brown Lance , Reiley David G. , Jeng Aaron , Green Steven M.
Published: July 2016

Objective:

To determine if 3 objective criteria – pulse oximetry, respiratory syncytial virus (RSV) testing, and age – could be used to predict which children hospitalized with bronchiolitis will have brief (<36 hour) hospitalizations and therefore be potential candidates for admission to short-stay observation units.

Methods:

This was a retrospective medical record review of medically uncomplicated children 3 to 24 months of age with emergency department and hospital discharge diagnoses consistent with bronchiolitis who were admitted to a general pediatric ward in our university-based, tertiary care hospital between Jan. 1, 1992, and Nov. 12, 2002. Multiple logistic regression was used to assess the predictor variables.

Results:

Our study consisted of 225 patients (45% female) with a median age of 7 months (interquartile range [IQR], 4–11 mo; range, 3–22 mo). Median pulse oximetry value was 94% (IQR 91%–96%; range 76%–100%), and 71% of the patients tested positive for RSV. Thirty children (13%) had brief hospitalizations <36 hours, and the median hospital length of stay for the entire study group was 70 hours (IQR 46–108 h; range 6–428 h). None of the 3 predictor variables were independently associated with brief hospitalization.

Conclusions:

Pulse oximetry, RSV testing and age do not predict which children will have brief hospitalizations and are appropriate candidates for admission to short-stay observation units.
Hypoglycemia in bacterial septicemia
Authors: Preyra Ian , Worster Andrew
Published: July 2016

In the emergency department (ED), the typical manifestation of impaired glucose homeostasis seen in patients with severe bacterial infections is hyperglycemia. Severe hypoglycemia is generally not a presenting feature of sepsis in children in the emergency setting, and thus may lead to delayed diagnosis and management. We present a case of a 14-year-old boy who attended the ED with constitutional symptoms and severe hypoglycemia as the initial presentation of overwhelming meningococcal sepsis and discuss the impairment of glucose homeostasis in patients with sepsis.
Off-service residents in the emergency department: the need for learner-centredness
Authors: Carter Alix J.E. , McCauley William A.
Published: July 2016

Objectives:

Standard learning objectives enable residency directors to develop effective programs and evaluate residents based on key goals and parameters. While standards are important for ensuring basic competence, the usual process has little flexibility to address the unique needs and desires of a given resident. Our objective was to determine whether the expectations of off-service residents rotating through an emergency department (ED) rotation were being met.

Methods:

We developed a 144-item questionnaire using a 5-point Likert scale and surveyed 25 off-service residents at the beginning and end of their ED rotation. The survey was divided into 3 sections: presentations, skills and diagnoses.

Results:

The results demonstrate that certain expectations are consistently underachieved while others represent individual variations.

Conclusion:

We propose a learner-centred approach to ensure an optimal emergency educational experience for all trainees.
Acute allergic reaction due to the administration of fibrinolytic therapy for ST-segment elevation myocardial infarction: case report and discussion
Authors: Mills Geoff C. , Arntfield Robert T. , Sedran Robert J.
Published: July 2016

Although a rare phenomenon, acute allergic reactions to fibrinolytic and heparin therapy have been described in the literature. We report the case of a 63-year-old woman who experienced a severe anaphylactic reaction while undergoing fibrinolytic therapy with tissue plasminogen activator for an ST-segment elevation myocardial infarction. Overall outcome was successful, but patient morbidity was increased because of the reaction and the subsequent therapy administered.
Conflict in the emergency department: Retreat in order to advance
Authors: Ahuja Jan , Marshall Pam
Published: July 2016

Conflict that exists within a team providing services in an emergency department has the potential to be destructive to clinical care and professional relationships. A collaborative approach involving members of the team guided by a neutral facilitator can be effective in addressing important issues and creating solutions that are acceptable to the individuals and the group. By working together in such a facilitated setting, relationships between the team members can be strengthened while problems are being solved.
Can troponin I measurement predict short-term serious cardiac outcomes in patients presenting to the emergency department with possible acute coronary syndrome?
Authors: Hill Stephen A. , Devereaux P.J. , Griffith Lauren , Opie John , McQueen Matthew J. , Panju Akbar , Stanton Eric , Guyatt Gordon H.
Published: July 2016

Objective:

To determine the ability of troponin I (TnI) measurement to predict the likelihood of a serious cardiac outcome over the subsequent 72 hours in patients presenting to the emergency department (ED) with symptoms suggestive of an acute coronary syndrome.

Methods:

This prospective observational study enrolled consecutive patients presenting to 2 urban tertiary care hospital EDs over a 5-week period. Eligible patients included those for whom a TnI test was ordered within 24 hours of arrival and in whom no serious cardiac outcome occurred before the test result was available. Patients were followed for 72 hours and serious cardiac outcomes documented; these included cardiovascular death, myocardial infarction, congestive heart failure, serious arrhythmia and refractory pain. We calculated likelihood ratios (LRs) to describe the association of the TnI result with serious cardiac outcomes.

Results:

Of the 352 enrolled patients, 20 had a serious cardiac outcome within 72 hours of ED presentation. The derived LRs (and 95% confidence interval [CI]) were 0.5 (0.3–0.9) for TnI values <0.5 µg/L, 1.6 (0.4–6.5) for TnI values from 0.5 to 2.0 µg/L, 5.8 (1.7–19.5) for TnI values from >2.0 to 10.0 µg/L and 14.4 (4.8–42.9) for TnI values >10.0 µg/L.

Conclusions:

TnI values >2.0 µg/L are associated with an increased probability of serious cardiac outcomes within 72 hours. TnI values between 0.5 and 2.0 µg/L are weakly positive predictors. TnI values <0.5 µg/L have LRs in the range of 0.5 and thus are weakly negative predictors, not substantially decreasing the likelihood of serious cardiac outcomes, particularly in patients with a moderate or high pretest probability.
Paradoxical embolism: a rare life- and limb-threatening emergency
Authors: Tang Christine E.
Published: July 2016

This article presents a case of a 43-year-old man with paradoxical embolism. The patient had simultaneous deep venous thrombosis, pulmonary embolism and bilateral limb-threatening arterial occlusions. The unifying diagnosis was paradoxical embolism through a previously undetected atrial septal defect. Suggestions for the evaluation and emergency management of paradoxical embolism are outlined, and the literature is briefly reviewed.
Root cause analysis of laboratory turnaround times for patients in the emergency department
Authors: Fernandes Christopher M.B. , Worster Andrew , Hill Stephen , McCallum Catherine , Eva Kevin
Published: July 2016

Introduction:

Laboratory investigations are essential to patient care and are conducted routinely in emergency departments (EDs). This study reports the turnaround times at an academic, tertiary care ED, using root cause analysis to identify potential areas of improvement. Our objectives were to compare the laboratory turnaround times with established benchmarks and identify root causes for delays.

Methods:

Turnaround and process event times for a consecutive sample of hemoglobin and potassium measurements were recorded during an 8-day study period using synchronized time stamps. A log transformation (ln [minutes + 1]) was performed to normalize the time data, which were then compared with established benchmarks using one-samplettests.

Results:

The turnaround time for hemoglobin was significantly less than the established benchmark (n= 140,t= –5.69,p< 0.001) and that of potassium was significantly greater (n= 121,t= 12.65,p< 0.001). The hemolysis rate was 5.8%, with 0.017% of samples needing recollection. Causes of delays included order-processing time, a high proportion (43%) of tests performed on patients who had been admitted but were still in the ED waiting for a bed, and excessive laboratory process times for potassium.

Conclusions:

The turnaround time for hemoglobin (18 min) met the established benchmark, but that for potassium (49 min) did not. Root causes for delay were order-processing time, excessive queue and instrument times for potassium and volume of tests for admitted patients. Further study of these identified causes of delays is required to see whether laboratory TATs can be reduced.
Blunt traumatic rupture of the pericardium with cardiac herniation
Authors: Rippey James C.R. , Rao Sudhakar , Fatovich Daniel
Published: July 2016

Traumatic rupture of the pericardium with cardiac herniation is rare. Clinicians are often unfamiliar with the clinical and radiological manifestations of the injury, and the diagnosis is frequently missed preoperatively. This case report describes a patient with multiple trauma following a fall from a height, who developed this injury. The diagnosis was not made preoperatively despite suggestive clinical, electrocardiographic and radiological findings. Clinicians need to be aware of the presentation of this potentially fatal injury so that the diagnosis can be made and treatment instituted at an earlier stage. Pericardial rupture with cardiac herniation presents as cardiogenic shock, mimicking cardiac tamponade.
N-acetylcysteine for radiocontrast-induced nephropathy: Potential role in the emergency department?
Authors: Chong Elaine , Zed Peter J.
Published: July 2016

Objective:

To systematically review the efficacy and safety of N-acetylcysteine (NAC) for the prevention of radiocontrast-induced nephropathy (RIN), and to discuss its potential role in the emergency department.

Methodology:

We conducted a search of MEDLINE (from 1966 to December 2003), PubMed (1966 to December 2003) and EMBASE (1988 to December 2003) for English-language, prospective, randomized, controlled trials in humans using the search terms N-acetylcysteine, acetylcysteine, radiopharmaceuticals, contrast media, and kidney failure (acute).

Results:

Five trials support and 4 trials refute the hypothesis that NAC helps prevent RIN. In 7 of 9 trials, oral NAC was administered twice daily for 2 days, on the day before and on the day of the radiocontrast study — a regime not feasible for emergent situations. More recent trials suggest that adequate hydration and lower volumes of radiocontrast, rather than NAC, are more effective ways to prevent RIN.

Conclusion:

Although further study may be indicated, current evidence does not suggest that NAC has a role in the emergency prevention of RIN.
Intramuscular ketamine to facilitate pediatric central vascular access
Authors: Denmark T. Kent , Hargrove Jenny R. , Brown Lance
Published: July 2016

Objectives:

Obtaining prompt vascular access in young children presenting to the emergency department (ED) is frequently both necessary and technically challenging. The objective of our study was to describe our experience using intramuscular (IM) ketamine to facilitate the placement of central venous catheters in children presenting to our ED needing vascular access in a timely fashion.

Methods:

We performed a retrospective medical record review of all pediatric patients <18 years of age who presented to our tertiary care pediatric ED between May 1, 1998, and August 7, 2003, and underwent the placement of a central venous catheter facilitated by the use of IM ketamine.

Results:

Eleven children met our inclusion criteria. Most of the children were young and medically complicated. The children ranged in age from 6 months to 8 years. The only complication identified was vomiting experienced by an 8-year-old boy. Emergency physicians successfully obtained central venous access in all subjects in the case series.

Conclusions:

The use of IM ketamine to facilitate the placement of central venous catheters in children who do not have peripheral venous access appears to be helpful. Emergency physicians may find it useful to be familiar with this use of IM ketamine.
Needs assessment and staff education to effect long-term change in emergency medicine in rural Nepal
Authors: Krym Valerie F. , MacDonald Russell D.
Published: July 2016

Medical work in developing countries is challenging and rewarding. To make a lasting impact on the local community, a health care worker must be willing to listen to the needs of the people. The long-term impact of a needs assessment and staff education on emergency medicine at a rural hospital in Nepal is presented.

The Scheer Memorial Hospital is a 102-bed non-governmental, not-for-profit hospital in Banepa, Nepal. Nepalese and ex-patriot health care professionals staff the hospital. Medical supplies are obtained from local manufacturers or as donations from foreign organizations. The hospital waives fees for those who cannot afford care.

Two academic emergency physicians with expertise in international health undertook a needs assessment to assist in planning for long-term health care goals related to emergency medicine. The assessment focused on health care planning and education of the local health care staff. Based on interviews and objective assessments, a plan was developed and implemented to address 4 key areas: physical plant, equipment, staff training and essential tasks.

Sustainable positive change was accomplished by acknowledging local customs and standards of care, meeting the needs of local health care staff and using available resources.
Delayed presentation of a patient with a ruptured diaphragm complicated by gastric incarceration and perforation after apparently minor blunt trauma
Authors: Goh Brian K.P. , Wong Andrew S.Y. , Tay Khoon-Hean , Hoe Michael N.Y.
Published: July 2016

Rupture of the diaphragm is almost always due to major trauma and is most commonly associated with road-traffic accidents. We report a case of delayed presentation of a 35-year-old woman with a ruptured diaphragm, 11 days following apparent minor blunt trauma. This case illustrates how the diagnosis of ruptured diaphragm can be missed and demonstrates the importance of considering this diagnosis in all cases of blunt trauma to the trunk. It also demonstrates the potential pitfall of misinterpreting the chest radiograph, and the value of repeat imaging after insertion of a nasogastric tube.
Pediatric wrist buckle fractures: Should we just splint and go?
Authors: Plint Amy C. , Perry Jeffrey J. , Tsang Jennifer L.Y.
Published: July 2016

Objectives:

The objective of this study was to evaluate the utility of circumferential casting in the emergency department (ED), orthopedic follow-up visits, and radiographic follow-up in the management of children with wrist buckle fractures.

Methods:

We performed a retrospective medical record review of all children < 18 years of age who presented to our tertiary care children’s hospital between July 1, 2000, and June 30, 2001, and were diagnosed with a fracture of the wrist, radius or ulna. Based on the radiology reports, we identified buckle fractures of the distal radius, the distal ulna, or both bones. We excluded children who had other types of fractures.

Results:

We identified 840 children with fractures of the wrist, radius, or ulna. Of these, 309 met our inclusion criteria. The median age of our study cohort was 9.2 years. Emergency physicians immobilized 269 of these fractures in circumferential casts; of these, 30 (11%) had cast complications. Of the 276 subjects who had orthopedic follow-up visits and radiographs, 184 (67%) had multiple visits and 127 (46%) had multiple radiographs performed. No subjects had fracture displacement identified on follow-up.

Conclusions:

Orthopedic follow-up visits and radiographic follow-up may have minimal utility in the treatment of pediatric wrist buckle fractures. ED casting may pose more risk than benefit for these children. Splinting in the ED with primary care follow-up appears to be a reasonable management strategy for these fractures. A prospective study comparing ED splinting and casting for pediatric wrist buckle fractures is needed.
Lack of consensus on corneal abrasion management: results of a national survey
Authors: Calder Lisa , Balasubramanian Sowmya , Stiell Ian
Published: July 2016

Objectives:

Our objective was to determine the practice patterns of Canadian emergency physicians with respect to the management of traumatic corneal abrasions.

Methods:

After developing our instrument and pilot testing it on a sample of emergency residents, we randomly surveyed 470 members of the Canadian Association of Emergency Physicians, using a modified Dillman technique. We distributed a pre-notification letter, an 18-item survey, and appropriate follow-up surveys to non-responders. Those members with an email address (n= 400) received a Web-based survey, and those without (n= 70) received a survey by post. The survey focused on the indications and utilization of analgesics (oral and topical), cycloplegics, eye patches and topical antibiotics.

Results:

Our response rate was 64% (301/470), and the median age of respondents was 38 years. Most (77.7%) were male, 71.8% were full-time emergency physicians, 76.5% were emergency medicine certified, and 64.4% practised in teaching hospitals. Pain management preferences (offered usually or always) included oral analgesics (82.1%), cycloplegics (65.1%) and topical nonsteroidal anti-inflammatory drugs (NSAIDs) (52.8%). Only 21.6% of respondents performed patching, and most (71.2%) prescribed topical antibiotics, particularly for contact lens wearers and patients with ocular foreign bodies. Two-thirds of the respondents provided tetanus toxoid if a foreign body was present, and 46.2% did so even if a foreign body was not present. Most respondents (88.0%) routinely arranged follow-up.

Conclusions:

This national survey of emergency physicians demonstrates a lack of consensus on the management of traumatic corneal abrasions. Further study is indicated to determine the optimal treatment, particularly regarding the use of topical NSAIDs.
The removal of coins from the upper esophageal tract of children by emergency physicians: a pilot study
Authors: Vargas Edward J. , Mody Ameer P. , Kim Tommy Y. , Denmark T. Kent , Moynihan James A. , Barcega Besh B. , Khan Aqeel , Clark Robin T. , Brown Lance
Published: July 2016

Objective:

There are few reports in the medical literature describing removal of a coin from the upper esophageal tract of a child by an emergency physician. However, given the nature of their training and practice, emergency physicians are well suited to perform this common procedure. We describe our experience with this procedure.

Methods:

This was a retrospective review of a continuous quality improvement data set from a university-based tertiary care pediatric emergency department between Nov. 1, 2003, and Mar. 31, 2004.

Results:

Thirteen children, with a median age of 20 months, underwent rapid sequence intubation and had coins successfully removed from their upper esophageal tract by emergency physicians. In 10 cases, the coin was visible at laryngoscopy and removed with Magill forceps. In 3 cases this approach failed and a Foley catheter was used to remove the coin. One child suffered a tonsillar abrasion and two sustained minor lip trauma, but all were extubated and discharged home from the emergency department with no significant complications. Eleven of the 13 patients were successfully followed up, and the parents reported no problems.

Conclusions:

This pilot study suggests that the removal of a coin from the upper esophageal tract by an emergency physician can be both safe and effective. A larger study is needed before this procedure can be generally recommended.
Bicarbonate therapy for unstable propafenone-induced wide complex tachycardia
Authors: Brubacher Jeff
Published: July 2016

A previously healthy 73-year-old woman presented to hospital with acute atrial fibrillation. After intravenous procainamide failed to restore sinus rhythm, she was treated with 300 mg of oral propafenone and discharged with a prescription for propafenone and propranolol. Six hours later she took 150 mg of propafenone as prescribed. Within 1 hour she became dyspneic and collapsed. On arrival in hospital she was unconscious, with a wide complex tachycardia and no obtainable blood pressure. After defibrillation and lidocaine, she converted to a wide complex sinus rhythm, but remained profoundly hypotensive despite intravenous epinephrine and dopamine. Hypertonic sodium bicarbonate (HCO3) was administered and, shortly thereafter, her blood pressure increased, her QRS duration normalized and her clinical status improved dramatically. In this case of severe refractory propafenone-related cardiac toxicity, intravenous HCO3led to a profound clinical improvement. Emergency physicians should be familiar with the syndrome of sodium-channel blocker poisoning and recognize the potentially important role of bicarbonate in its treatment.
The use of induced hypothermia after cardiac arrest: a survey of Canadian emergency physicians
Authors: Kennedy Joel , Green Robert S. , Stenstrom Robert ,   on behalf of the CAEP Critical Care Committee
Published: July 2016

Objective:

Inducing mild hypothermia in survivors of cardiac arrest has been demonstrated to improve outcomes. Despite this, other studies have found that few resuscitation physicians have used hypothermia in clinical practice. The objective of this study was to characterize the use of induced hypothermia by Canadian emergency physicians.

Methods:

An internet-based survey was distributed to all members of the Canadian Association of Emergency Physicians (CAEP). Participants were asked about their experience with, methods for and barriers to inducing hypothermia.

Results:

Of the 1328 CAEP members surveyed, 247 (18.6%) responded, with the majority working in academic centres (60.3%). Ninety-five out of 202 respondents (47.0%, 95% confidence interval [CI] 40.8%–53.2%) indicated that they had induced hypothermia in clinical practice and 86 of 212 (40.6%, 95% CI 34.0%–47.2%) worked in a department that had a policy or protocol for the use of induced hypothermia. The presence of a departmental policy or protocol was strongly associated with the use of induced hypothermia (unadjusted odds ratio 10.5, 95% CI 5.3–20.8). Barriers against induced hypothermia cited by respondents included a lack of institutional policies and protocols (38.9%), and of resources (29.4%). Lack of support from consultants was relatively uncommon (8.7%) in Canadian practice.

Conclusion:

Only one-half of Canadian emergency physicians report that they have used therapeutic hypothermia in practice. Emergency departments should develop policies or protocols for inducing hypothermia in cardiac arrest survivors to optimize patient outcomes.
Bilateral pneumothoraces and pneumomediastinum complicating a generalized tonic-clonic seizure
Authors: Curran Helen , Ross John
Published: July 2016

Patients often present to the emergency department following a generalized tonic-clonic seizure, particularly of new onset. Complications associated with seizures usually arise from injuries sustained from loss of consciousness or during convulsive activity. This report describes a patient with an idiopathic seizure who developed postictal alveolar edema and delayed bilateral pneumothoraces and pneumomediastinum. A literature search revealed only 1 other case of this potentially life-threatening pulmonary complication from seizures.
Clinical outcomes and patient satisfaction of a pharmacist-managed, emergency department–based outpatient treatment program for venous thromboembolic disease
Authors: Zed Peter J. , Filiatrault Lyne
Published: July 2016

Objective:

The purpose of this study was to evaluate the efficacy, safety and patient satisfaction outcomes of our pharmacist-managed, emergency department (ED)–based outpatient treatment program for venous thromboembolism (VTE) disease.

Methods:

We conducted a prospective cohort study of all patients who were enrolled in the Vancouver General Hospital (VGH) outpatient VTE treatment program over a 7-year period (1999–2006). Efficacy outcomes include recurrent VTE events at 3 and 6 months following discharge from the program. Safety evaluation included major and minor bleeding complications and the development of thrombocytopenia during the acute phase of therapy. Patient satisfaction was assessed using an 18-question patient satisfaction survey, which was mailed to all patients following discharge from the program.

Results:

Overall, 305 patients were included in the study. Of the 260 evaluable patients, 2 patients (0.8%, 95% confidence interval [CI] 0.2–2.7) experienced a recurrent VTE at 3 months and 5 patients (1.9%, 95% CI 0.8–4.4) had a recurrence at 6 months. One patient (0.3%, 95% CI 0.1–1.8) experienced a major bleeding complication. Seven patients (2.3%, 95% CI 1.1–4.7) experienced a minor bleeding complication and no patient developed thrombocytopenia. Overall, 96.1% were comfortable having their condition treated as an outpatient and 85.7% felt it was more convenient to return to hospital daily for medications and assessment than to be admitted to hospital. Finally, 96.9% of respondents were very satisfied or satisfied with the treatment they received in the outpatient program, and 96.1% would enroll again if future treatment was indicated.

Conclusion:

Our pharmacist-managed, ED-based outpatient treatment program for VTE disease is safe, effective and achieves a high level of patient satisfaction.
Can Telehealth Ontario respiratory call volume be used as a proxy for emergency department respiratory visit surveillance by public health?
Authors: van Dijk Adam , McGuinness Don , Rolland Elizabeth , Moore Kieran M.
Published: July 2016

Objective:

There is a paucity of information regarding the usefulness of non-traditional data streams for real-time syndromic surveillance systems. The objective of this paper is to examine the temporal relation between Ontario's emergency department (ED) visits and telephone health line (Telehealth) call volume for respiratory illnesses to test the feasibility of using Ontario's Telehealth system for real-time surveillance.

Methods:

Retrospective time-series data from the National Ambulatory Care Reporting System (NACRS) and the Telehealth Ontario program from June 1, 2004, to March 31, 2006, were analyzed. The added value of Telehealth Ontario data was determined by comparing it temporally with NACRS data, which uses the International Classification of Diseases (ICD) 10-Canadian Enhancement coding system for discharge diagnoses.

Results:

Telehealth Ontario had 216 105 calls for respiratory complaints, while 819 832 ICD-coded complaints from NACRS were identified with a comparable diagnosis of respiratory illness. Telehealth Ontario call volume was heavily weighted for the 0–4 years age group (49%), while the NACRS visits were mainly from those 18–64 years old (44%). The Spearman rank correlation coefficient was calculated to be 0.97, with the time-series analysis also resulting in significant correlations at lags (semi-monthly) 0 and 1, indicating that increases in Telehealth Ontario call volume correlate with increases in NACRS discharge diagnosis data for respiratory illnesses.

Conclusion:

Telehealth Ontario call volume fluctuation reflects directly on ED respiratory visit data on a provincial basis. These call complaints are a timely, useful and representative data stream that shows promise for integration into a real-time syndromic surveillance system.
Rural emergency department use by CTAS IV and V patients
Authors: Steele Sandra , Anstett Danielle , Milne W. Ken
Published: July 2016

Objective:

For a variety of reasons, many emergency department (ED) visits are classified as less- or nonurgent (Canadian Triage and Acuity Scale [CTAS] level IV and V). A recent survey in a tertiary care ED identified some of these reasons. The purpose of our study was to determine if these same reasons applied to patients presenting with problems triaged at a similar level at a low-volume rural ED.

Methods:

A 9-question survey tool was administered to 141 CTAS level IV and V patients who attended the South Huron Hospital ED, in Exeter, Ontario, over a 2-week period in December 2006.

Results:

Of the 141 eligible patients, 137 (97.2%) completed the study. One hundred and twenty-two patients (89.1%) reported having a family physician (FP) and 53 (38.7%) had already seen an FP before presenting to the ED. Just over one-half of all patients (51.1%) had their problem for more than 48 hours, and 42 (30.7%) stated that they were referred to the ED for care. Fifty-three (38.7%) of the respondents felt they needed treatment as soon as possible. Many patients reported coming to the ED because: 1) their FP office was closed (21.9%); 2) they could not get a timely appointment (16.8%); or 3) the walk-in clinic was closed (24.8%). Only 6 patients (4.4%) specifically stated that they came to the ED because they had no FP. One-third of patients attended the ED because they believed it offered specialized services.

Conclusion:

In this rural setting, most less- or nonurgent ED patients had an FP yet they went to the ED because they did not have access to primary care, because they perceived their problem to be urgent or because they were referred for or sought specific services.
The “delay effect” of donning a gown during cardiopulmonary resuscitation in a simulation model
Authors: Watson Leah , Sault William , Gwyn Randy , Verbeek P. Richard
Published: July 2016

Objective:

We sought to determine whether the use of currently issued gowns delays initiation of chest compressions and ventilations during cardiopulmonary resuscitation and whether simple gown modifications can reduce this delay.

Methods:

Firefighter defibrillation instructors were allocated into pairs and videotaped while performing standardized cardiac arrest scenarios. Three scenarios were compared: “no gown,” “standard gown” and “modified gown.” Key time intervals were extracted from videotaped data.

Results:

Ninety-five scenarios were analyzed. Mean time interval to chest compression was 39 seconds (95% confidence interval [CI] 34–43) for “no gown” scenarios, 71 seconds (95% CI 66–77) for “standard gown” scenarios and 59 seconds (95% CI 54–63) for “modified gown” scenarios (p < 0.001). Time to first ventilation was 146 seconds (95% CI 134–158), 238 seconds (95% CI 224–253)and 210 seconds (95% CI 198–223) in the 3 groups, respectively (p < 0.001). Post hoc testing showed that the time differences between all groups were statistically significant.

Conclusion:

Standard gowns protect front-line care providers but cause significant delays to chest compressions and ventilations, potentially increasing patient morbidity and mortality. Minor gown modifications, including pre-tied neck straps and longer waist ties that tie in front, allow for easier use and shorter delays to time-critical interventions. Future research is required to reduce care delays while maintaining adequate protection of emergency medical service providers from infectious disease.
Diagnostic accuracy of clinical prediction rules to exclude acute coronary syndrome in the emergency department setting: a systematic review
Authors: Hess Erik P. , Thiruganasambandamoorthy Venkatesh , Wells George A. , Erwin Patricia , Jaffe Allan S. , Hollander Judd E. , Montori Victor M. , Stiell Ian G.
Published: July 2016

Objective:

We sought to determine the diagnostic accuracy of clinical prediction rules to exclude acute coronary syndrome (ACS) in the emergency department (ED) setting.

Methods:

We searched MEDLINE, EMBASE, Web of Science and the Cochrane Database of Systematic Reviews. We contacted content experts to identify additional articles for review. Reference lists of included studies were hand searched. We selected articles for review based on the following criteria: 1) enrolled consecutive ED patients; 2) incorporated variables from the history or physical examination, electrocardiogram and cardiac biomarkers; 3) did not incorporate cardiac stress testing or coronary angiography into prediction rule; 4) based on original research; 5) prospectively derived or validated; 6) did not require use of a computer; and 7) reported sufficient data to construct a 2 ∞ 2 contingency table. We assessed study quality and extracted data independently and in duplicate using a standardized data extraction form.

Results:

Eight studies met inclusion criteria, encompassing 7937 patients. None of the studies verified the prediction rule with a reference standard on all or a random sample of patients. Six studies did not report blinding prediction rule assessors to reference standard results, and vice versa. Three prediction rules were prospectively validated. Sensitivities and specificities ranged from 94% to 100% and 13% to 57%, and positive and negative likelihood ratios from 1.1 to 2.2 and 0.01 to 0.17, respectively.

Conclusion:

Current prediction rules for ACS have substantial methodological limitations and have not been successfully implemented in the clinical setting. Future methodologically sound studies are needed to guide clinical practice.
ALaRMED: adverse events in low-risk chest pain patients receiving continuous ECG monitoring in the emergency department: a survey of Canadian emergency physicians
Authors: Atzema Clare L. , Schull Michael J.
Published: July 2016

Objective:

Current guidelines suggest that most patients who present to an emergency department (ED) with chest pain should be placed on a continuous electrocardiographic monitoring (CEM) device. We surveyed emergency physicians to determine their perception of current occupancy rates of CEM and to assess their attitudes toward prescribing monitors for low-risk chest pain patients in the ED.

Methods:

We conducted a cross-sectional, self-administered Internet and mail survey of a random sample of 300 members of the Canadian Association of Emergency Physicians. Main outcome measures included the perceived frequency of fully occupied monitors in the ED and physicians' willingness to forgo CEM in certain chest pain patients.

Results:

The response rate was 66% (199 respondents). The largest group of respondents (43%; 95% confidence interval [CI] 36%–50%) indicated that monitors were fully occupied 90%–100% of the time during their most recent ED shift. When asked how often they were forced to choose a patient for monitor removal because of the limited number of monitors, 52% (95% CI 45%–60%) of respondents selected 1–3 times per shift. Ninety percent (95% CI 84%–93%) of respondents indicated that they would forgo CEM in certain cardiac chest pain patients if there was good evidence that the risk of a monitor-detected adverse event was very low.

Conclusion:

Emergency physicians report that monitors are often fully occupied in Canadian EDs, and most are willing to forgo CEM in certain chest pain patients. A large prospective study of CEM in low-risk chest pain patients is warranted.
A door-to-needle time of 30 minutes or less for myocardial infarction thrombolysis is possible in rural emergency departments
Authors: Vlahaki Dean , Fiaani Majed , Milne William Ken
Published: July 2016

Objective:

The Canadian Emergency Cardiac Care Coalition, the American Heart Association and similar groups have established a benchmark for the administration of thrombolytics in acute myocardial infarction (AMI) care as a door-to-needle (DTN) time of 30 minutes or less. Previous research suggests that this goal is not being achieved in Canada. The purpose of this study was to determine whether the target DTN time of 30 minutes or less for thrombolysis could be met in 2 rural Ontario emergency departments (EDs).

Methods:

We conducted a retrospective chart review and obtained descriptive data for each case, including demographic information and the Canadian Emergency Department Triage and Acuity Scale (CTAS) score. Visit timeline data were also collected and included the time during which patients saw a physician, had an electrocardiogram (ECG), received thrombolytic therapy and were discharged from the ED. Relevant time intervals, such as the median DTN time, were calculated.

Results:

A total of 454 charts were reviewed for patients with a diagnosis of AMI who were seen between 1996 and 2007. The final sample consisted of 101 patients who received thrombolytics (63% men) whose median age was 67 years and median CTAS score was Level II (Emergent). The median door-to-ECG time was 6 minutes, door-to-physician time was 8 minutes and DTN time was 27 minutes; 58% of patients received thrombolytics within 30 minutes.

Conclusion:

A DTN time of 30 minutes or less is achievable in rural EDs.
Pediatric myth: fever and petechiae
Authors: Klinkhammer Martin D. , Colletti James E.
Published: July 2016

A child presenting with petechiae and fever is assumed to have meningococcemia or another form of bacterial sepsis and therefore to require antibiotics, blood cultures, cerebrospinal fluid analysis and hospital admission. A review of the literature challenges this statement and suggests that a child presenting with purpura (or petechiae), an ill appearance and delayed capillary refill time or hypotension should be admitted and treated for meningococcal disease without delay. Conversely, a child with a petechial rash, which is confined to the distribution of the superior vena cava, is unlikely to have meningococcal disease. Outpatient therapy in this context is appropriate. In other children, a reasonable approach would be to draw blood for culture and C-reactive protein (CRP) while administering antibiotics. If the CRP is normal, these children could be discharged to follow-up in 1 day, whereas children with CRP values greater than 6 mg/L would be admitted.
Impact of a rapid access protocol on decreasing door-to-balloon time in acute ST elevation myocardial infarction
Authors: Caudle Jaelyn M. , Piggott Zoe , Dostaler Suzanne , Graham Karen , Brison Robert J.
Published: July 2016

Objective:

Ischemic cardiovascular disease is the leading cause of death in Canada. In ST elevation myocardial infarction (STEMI), time to reperfusion is a key determinant in reducing morbidity and mortality with percutaneous coronary intervention (PCI) being the preferred reperfusion strategy. Where PCI is available, delays to definitive care include times to electrocardiogram (ECG) diagnosis and cardiovascular laboratory access. In 2004, the Cardiac Care Network of Ontario recommended implementation of an emergency department (ED) protocol to reduce reperfusion time by transporting patients with STEMI directly to the nearest catheterization laboratory. The model was implemented in Frontenac County in April 2005. The objective of this study was to assess the effectiveness of a protocol for rapid access to PCI in reducing door-to-balloon times in STEMI.

Methods:

Two 1-year periods before and after implementation of a rapid access to PCI protocol (ending March 2005 and June 2006, respectively) were studied. Administrative databases were used to identify all subjects with STEMI who were transported by regional emergency medical services (EMS) and received emergent PCI. The primary outcome measure was time from ED arrival to first balloon inflation (door-to-balloon time). Times are presented as medians and interquartile ranges (IQRs). Statistical comparisons were made using the Mann–Whitney U test and presented graphically with Kaplan–Meier curves.

Results:

Patients transported under the rapid access protocol (n = 39) were compared with historical controls (n = 42). Median door-to-balloon time was reduced from 87 minutes (IQR 67–108) preprotocol to 62 minutes (IQR 40–80) postprotocol (p < 0.001).

Conclusion:

In our region, implementation of an EMS protocol for rapid access to PCI significantly reduced time to reperfusion for patients with STEMI.
A prospective study of students’ and instructors’ opinions on Advanced Cardiac Life Support course teaching methods
Authors: Stempien James , Betz Martin
Published: July 2016

Introduction:

The American Heart Association (AHA) revises the Advanced Cardiac Life Support (ACLS) course approximately every 5 years, citing the scientific literature for any changes to content and management recommendations. With ACLS 2005, the AHA also revised the methods used to teach course content. The AHA cited no evidence in making these changes. The ACLS 2005 course, distributed in early 2007, makes greater use of videos to teach students. This prospective study surveyed opinions of both students and instructors in an effort to determine the level of satisfaction with this method of teaching.

Methods:

During 16 consecutive ACLS courses, all students and instructors were asked to complete a questionnaire. The students provided demographic information, but completed the survey anonymously. Four questions probed the participants' opinions about the effectiveness of videos in learning ACLS skills. Experienced participants were asked to compare the new teaching methods with previous courses. Opinions were compared among several subgroups based on sex, occupation and previous experience.

Results:

Of the 180 students who participated, 71% felt the videos were unequivocally useful for teaching ACLS skills. Fewer first-time students were unequivocally positive (59%) compared with those who had taken 2 or more previous courses (84%). A small proportion of students (13%) desired more hands-on practice time. Of the 16 instructors who participated, 31% felt that the videos were useful for teaching ACLS skills. No differences were found between doctors and nurses, or between men and women.

Conclusion:

The use of standardized videos in ACLS courses was felt by the majority of students and a minority of instructors to be unequivocally useful. First-time students had more doubts about the effectiveness of videos.
Glycyrrhizic acid toxicity caused by consumption of licorice candy cigars
Authors: Johns Christine
Published: July 2016

A 49-year-old female physician presented with peripheral edema, weight gain and relative hypertension caused by the consumption of licorice candy cigars containing glycyrrhizic acid (GZA) found in natural licorice extract. Although the patient's response to GZA resolved spontaneously, emergency physician awareness of the toxic effects of natural licorice extract may avert symptom progression in early-identified cases. The benefits of natural licorice extract as a flavour enhancer and herbal medicine are recognized worldwide. The Canadian public is likely not generally aware of the toxic potential of GZA, or that it may be present in the following commonly consumed products: black licorice, chewing gum, herbal teas, soft drinks, tobaccos and herbal remedies for cough, stomach ailments and constipation. Emergency physicians should inquire about the consumption of products that may contain natural licorice extract when patients present with unexplained hypertension, hypokalemia, edema, rhabdomyolysis or myoglobinuria.
Emergency medicine preclerkship observerships: evaluation of a structured experience
Authors: Penciner Rick
Published: July 2016

Objective:

Medical students are expected to make residency and career decisions early in their undergraduate medical education. In medical school curricula, there is limited exposure to emergency medicine (EM) in the preclerkship years. The purpose of this study was to evaluate a structured EM observership program for preclerks by surveying the students’ perceptions and attitudes about the program following their participation.

Methods:

A structured observership program was developed and implemented at the University of Toronto Medical School in February 2007. All first- and second-year students were eligible to participate on a voluntary basis. Nine emergency department (ED) teaching sites were enlisted, with each site recruiting interested preceptors. The observership consisted of two 4-hour shifts with 1 preceptor at 1 site. Specific expectations were provided to the students at the start of the observership. A convenience sample was used for the period between Feb. 26 and Nov. 4, 2007, to conduct an anonymous online survey about the students' experience after the ob servership.

Results:

During the study period, 82 students completed 99 observerships at 9 sites with 54 different preceptors. Of the 82 students who completed the observerships, 70 students completed the survey. Overall, all the students (70/70) found the experience to be worthwhile. Most students (68/70) viewed the preceptors as good role models. As a result of the observership, 47 of 70 students reported that their attitudes about and interest in EM had changed and most (59/70) planned on exploring other opportunities in EM (e.g., electives).

Conclusion:

Structured EM observerships are viewed by medical students to be worthwhile. These observerships can change attitudes about and interest in EM and allow students to make more informed career choices.
Erythroderma: a dermatologic emergency
Authors: Bruno Tony F. , Grewal Parbeer
Published: July 2016

Erythroderma is a potentially fatal dermatologic emergency that is often mistaken for infection. Indeed, the fact that it is difficult to diagnosis is the main contributor to its significant mortality rate, as treatment is readily available. We present a case of a 36-year-old man who was incorrectly diagnosed and treated for 2 months. We review the etiologies, initial work-up and management of this disease. In our case, the patient was ill, had lost 11.3 kg and developed systemic inflammatory response syndrome. Without proper treatment he was at risk of developing full-blown sepsis. Although there are many causes of erythroderma, prompt initial treatment directed at the underlying etiology typically results in a rapid remission.
Temporal lobe seizures from a posterior cerebral artery aneurysm presenting as memory flashbacks
Authors: Peera Mohamed A. , LoCurto Michael
Published: July 2016

Memory flashbacks are usually attributed to recreational drugs or psychiatric conditions. The differential diagnosis for memory flashbacks is diverse and challenging; moreover, management is influenced by the working diagnosis. We describe the case of a 35-year-old man who presented with memory flashbacks secondary to temporal lobe seizures from an unruptured aneurysm of the posterior cerebral artery. To our knowledge, a case of this nature has not been previously reported. This case demonstrates the need to recognize that, on rare occasions, a complaint of memory flashbacks can be the result of an organic etiology. We also discuss the challenging presentations of temporal lobe seizures, as they can easily be misdiagnosed as a psychiatric condition.