bluuebunny/crossref_metadata_2025 huggingface dataset:
Development of the Canadian Emergency Department Diagnosis Shortlist
Authors: Unger Bernard , Afilalo Marc , Boivin Jean François , Bullard Michael , Grafstein Eric , Schull Michael , Lang Eddy , Colacone Antoinette , Soucy Nathalie , Xue Xiaoqing , Segal Eli
Published: July 2016

Objective:

Managers of emergency departments (EDs), governments and researchers would benefit from reliable data sets that characterize use of EDs. Although Canadian ED lists for chief complaints and triage acuity exist, no such list exists for diagnosis classification. This study was aimed at developing a standardized Canadian Emergency Department Diagnosis Shortlist (CED-DxS), as a subset of the full International Classification of Diseases, 10th revision, with Canadian Enhancement (ICD-10-CA).

Methods:

Emergency physicians from across Canada participated in the revision of the ICD-10-CA through 2 rounds of the modified Delphi method. We randomly assigned chapters from the ICD-10-CA (approximately 3000 diagnoses) to reviewers, who rated the importance of including each diagnosis in the ED-specific diagnosis list. If 80% or more of the reviewers agreed on the importance of a diagnosis, it was retained for the final revision. The retained diagnoses were further aggregated and adjusted, thus creating the CED-DxS.

Results:

Of the 83 reviewers, 76% were emergency medicine (EM)–trained physicians with an average of 12 years of experience in EM, and 92% were affiliated with a university teaching hospital. The modified Delphi process and further adjustments resulted in the creation of the CED-DxS, containing 837 items. The chapter with the largest number of retained diagnoses was injury and poisoning (n= 292), followed by gastrointestinal (n= 59), musculoskeletal (n= 55) and infectious disease (n= 42). Chapters with the lowest number retained were neoplasm (n= 18) and pregnancy (n= 12).

Conclusion:

We report the creation of the uniform CED-DxS, tailored for Canadian EDs. The addition of ED diagnoses to existing standardized parameters for the ED will contribute to homogeneity of data across the country.
Noncompletion of referrals to outpatient specialty clinics among patients discharged from the emergency department: a prospective cohort study
Authors: Friedman Steven Marc , de Dios Jennifer Vergel , Hanneman Kate
Published: July 2016

Objective:

We sought to characterize patients who are referred from the emergency department (ED) to specialty clinics but do not complete the referral, and to identify reasons for their failure to follow up.

Methods:

A prospective cohort study was carried out over 3 months of patients who were discharged from the ED of a teaching hospital with referral to internal medicine, cardiology or neurology clinics, but who did not complete the referral. Information on demographics, barriers to care and reasons for not completing the referral was obtained through a standardized telephone interview.

Results:

Of 171 ED referrals, 42 (24.6%) were not completed. Interviews were completed for 71.4% (30 patients). Of the nonattenders, 80% were functional in English and most had high school (73.1%) or university (60.7%) education. Virtually all (93.0%) interviewees could get to hospital by themselves or have someone take them. Only 42.9% (12 patients) understood why the emergency physician (EP) requested consultation, and 42.9% (12 patients) described EP instructions as poor or fair. Primary reasons for noncompletion of consult were patient choice (46.7%, 95% confidence interval [CI] 27.1%–66.2%), physical or social barriers (13.3%, 95% CI 0.0%–27.2%), communication failure (20%, 95% CI 4.0%–36.0%) and consultant's refusal of the consultation (20% [95% CI 4.0%–36.0%]). All consultant refusals were from one internal medicine clinic, representing 42% (8/19) of ED referrals to that clinic. None of the 6 patients interviewed who were declined consultation was aware that their consultation had been refused.

Conclusion:

Patients discharged by the EP with referral to specialty clinics frequently do not complete the consultation. Causes for failure to follow up relate to patient decision, inadequate or poorly understood discharge information, and system factors. Institutional audits of patients who fail to complete follow-up may reveal unanticipated barriers to care.
Incorporating simulation into a residency curriculum
Authors: Takayesu James K. , Nadel Eric S. , Bhatia Kriti , Walls Ron M.
Published: July 2016

The integration of simulation into a medical postgraduate curriculum requires informed implementation in ways that take advantage of simulation's unique ability to facilitate guided application of new knowledge. It requires review of all objectives of the training program to ensure that each of these is mapped to the best possible learning method. To take maximum advantage of the training enhancements made possible by medical simulation, it must be integrated into the learning environment, not simply added on. This requires extensive reorganization of the resident didactic schedule.

Simulation planning is supported by clear learning objectives that define the goals of the session, promote learner investment in active participation and allow for structured feedback for individual growth. Teaching to specific objectives using simulation requires an increased time commitment from teaching faculty and careful logistical planning to facilitate flow of learners through a series of simulations in ways that maximize learning. When applied appropriately, simulation offers a unique opportunity for learners to acquire and apply new knowledge under direct supervision in ways that complement the rest of the educational curriculum. In addition, simulation can improve the learning environment and morale of residents, provide additional methods of resident evaluation, and facilitate the introduction of new technologies and procedures into the clinical environment.
Profound metabolic acidosis from pyroglutamic acidemia: an underappreciated cause of high anion gap metabolic acidosis
Authors: Green Thomas J. , Bijlsma Jan Jaap , Sweet David D.
Published: July 2016

The workup of the emergency patient with a raised anion gap metabolic acidosis includes assessment of the components of “MUDPILES” (methanol; uremia; diabetic ketoacidosis; paraldehyde; isoniazid, iron or inborn errors of metabolism; lactic acid; ethylene glycol; salicylates). This approach is usually sufficient for the majority of cases in the emergency department; however, there are many other etiologies not addressed in this mnemonic. Organic acids including 5-oxoproline (pyroglutamic acid) are rare but important causes of anion gap metabolic acidosis. We present the case of a patient with profound metabolic acidosis with raised anion gap, due to pyroglutamic acid in the setting of malnutrition and chronic ingestion of acetaminophen.
Low-impact pelvic fractures in the emergency department
Authors: Dodge Greg , Brison Rob
Published: July 2016

Objective:

We examined the records of patients presenting to the emergency department (ED) with low-impact pelvic fractures. We describe frequency, demographics, management and patient outcomes in terms of ambulatory ability, living independence and mortality.

Methods:

Patients treated for a pelvic fracture over a 2-year period in Kingston, Ont., were identified. We performed a retrospective hospital record review to distinguish high- versus low-impact injury mechanisms, and to characterize the injury event, ED management and outcomes for patients with low-impact fractures.

Results:

Of 132 pelvic fractures identified, 77 were low-impact fractures. Patients were predominantly women (82%) with a mean age of 81 years; 96% had some pre-existing medical comorbidity. The pubic rami were most commonly involved (86%). The median length of stay in the ED was 9.4 hours. Twenty-five patients (32%) were admitted to hospital. Ten patients had surgical stabilization, mostly of the acetabulum. Five patients died in hospital, 4 from pneumonia and 1 from myocardial infarction. Eight additional patients died within 1 year of injury. At discharge, only 18% lived independently and 16% walked without aids versus 42% and 38%, respectively, before injury.

Conclusion:

Low-impact pelvic fractures affect predominantly elderly women with pre-existing comorbidities. A substantial amount of time and resources in the ED are used during the workup of these patients and while awaiting their disposition from the ED. These injuries are important because they affect independence and seem associated with an increased risk of death.
Emergency department discharge instructions comprehension and compliance study
Authors: Clarke Collin , Friedman Steven Marc , Shi Kevin , Arenovich Tamara , Monzon Jose , Culligan Christopher
Published: July 2016

Objectives:

To assess patient comprehension of emergency department discharge instructions and to describe other predictors of patient compliance with discharge instructions.

Methods:

Patients departing from the emergency department of an inner-city teaching hospital were invited to undergo a structured interview and reading test, and to participate in a follow-up telephone interview 2 weeks later. Two physicians, blinded to the other's data, scored patient comprehension of discharge information and compliance with discharge instructions. Inter-rater reliability was assessed using a kappa-weighted statistic, and correlations were assessed using Spearman's rank correlation coefficient and Fisher's exact test.

Results:

Of 106 patients approached, 88 (83%) were enrolled. The inter-rater reliability of physician rating scores was high (kappa = 0.66). Approximately 60% of subjects demonstrated reading ability at or below a Grade 7 level. Comprehension was positively associated with reading ability (r = 0.29, p = 0.01) and English as first language (r = 0.27, p = 0.01). Reading ability was positively associated with years of education (r = 0.43, p < 0.0001) and first language (r = 0.24, p = 0.03), and inversely associated with age (r = -0.21, p = 0.05). Non-English first language and need for translaor were associated with poorer comprehension of discharge instructions but not related to compliance. Compliance with discharge instructions was correlated with comprehension (r = 0.31, p = 0.01) but not associated with age, language, education, years in anglophone country, reading ability, format of discharge instructions, follow-up modality or association with a family physician.

Conclusions:

Emergency department patients demonstrated poor reading skills. Comprehension was the only factor significantly related to compliance; therefore, future interventions to improve compliance with emergency department instructions will be most effective if they focus on improving comprehension.
Emergency medicine teaching faculty perceptions about formal academic sessions: “What’s in it for us?”
Authors: Bandiera Glen W. , Morrison Laurie
Published: July 2016

Background:

Little is known about factors affecting emergency physician attendance at formal academic teaching sessions or what emergency physicians believe to be the benefits derived from attending these activities.

Objectives:

To determine what factors influence emergency medicine faculty attendance at formal academic rounds, what benefits they derive from attendance, and what differences in perceptions there are between full-time clinical and part-time clinical academic faculty.

Methods:

A survey was sent to all emergency physicians with academic appointments at one institution. Responses were tabulated dichotomously (yes/no) for checklist answers and analyzed using a 2-person grounded theory approach for open answers based on an a priori analysis plan. Differences between full-time and part-time faculty were compared using the chi-squared test for significance.

Results:

Response rate was 73.8% (48/65). Significant impediments to attendance included clinical responsibilities (75%), professional responsibilities (52.1%), personal responsibilities (33.3%), location (31.2%) and time (27.1%). Perceived benefits of attending rounds were: continuing medical education, social interaction, teaching opportunities, interaction with residents, comparing one's practice with peers, improving teaching techniques, and enjoyment of the format. There were no statistically significant differences between groups' responses.

Conclusions:

Emergency physicians in our study attend formal teaching sessions infrequently, suggesting that the perceived benefits do not outweigh impediments to attendance. The single main impediment, competing responsibilities, is difficult to modify for emergency physicians. Strategies to increase faculty attendance should focus on enhancing the main perceived benefits: continuing medical education, social interaction and educational development. Faculty learn from themselves and from residents during formal teaching sessions.
Acute pneumoperitoneum following coitus
Authors: Manchanda Ranjit , Refaie Ashraf
Published: July 2016

Vaginal rupture leading to pneumoperitoneum is well documented to occur after hysterectomy or surgery. However, it is extremely rare in a young woman following conventional intercourse. We report one such case. A 16-year-old woman presented to the accident and emergency department with a clinical picture of an acute abdomen. Results of radiography showed gas under the diaphragm, suggesting the possibility of bowel perforation. A detailed sexual history pointed toward the possibility of vaginal trauma. Diagnosis was confirmed on examination under anesthesia, and the tear repaired. A concomitant laparoscopy ruled out any other intra-abdominal injury. This case reminds us that acute peritoneum can occur after sexual intercourse and also reiterates the importance of a detailed sexual history and vaginal examination in young women presenting with an acute abdomen.
Patients who leave the emergency department without being seen by a physician: a control-matched study
Authors: Monzon Jose , Friedman Steven Marc , Clarke Collin , Arenovich Tamara
Published: July 2016

Objective:

To describe the socio-demographic characteristics and clinical outcomes of patients who leave the emergency department (ED) without being seen by a physician.

Methods:

This 3-month prospective study was conducted at a downtown Toronto teaching hospital. Patients who left the ED without being seen (LWBS) were matched with controls based on registration time and triage level. Subjects and controls were interviewed by telephone within 1 week after leaving the ED.

Results:

During the study period, 386 (3.57%) of 10 808 ED patients left without being seen. One-third of these had no fixed address or no telephone, and only 92 (23.8%) consented to a telephone interview. They cited excessive wait time as the most common reason for leaving the ED (in 36.7% of cases). Despite leaving the ED without being seen, they were no more likely than those in the control group to seek follow-up medical attention (70 % in both groups). Among those from both groups who did seek follow-up, the LWBS patients were more likely to do so the same day or the day after leaving the ED. The LWBS patients often lacked a regular physician (39.1% v. 21.7%;p= 0.01) and were more likely to attend an ED or urgent care clinic (34.8% v. 12.0%;p< 0.001). Controls were more likely to follow up with a family physician (37.0% v. 23.9%;p= 0.06). The LWBS and control groups did not differ in subjective health status at 48 hours after leaving the ED, nor in subsequent re-investigation in hospital.

Conclusions:

Patients who leave the ED without being seen have different socio-demographic features, methods of accessing the health care system, affiliations and expectations than the general ED population. They are often socially disenfranchised, with limited access to traditional primary care. These patients are generally low acuity, but they are at risk of important and avoidable adverse outcomes.
Myth: Atropine should be administered before succinylcholine for neonatal and pediatric intubation
Authors: Fleming Bethany , McCollough Maureen , Henderson Sean O.
Published: July 2016

Succinylcholine is often used to facilitate neonatal and pediatric rapid sequence intubation in the emergency department, and most relevant literature recommends administering atropine prior to succinylcholine to reduce the risk of bradycardia. Given the potential complications associated with combining these medications, we searched the published literature for evidence supporting this practice. Most studies recommending atropine premedication were undertaken in the operating room setting and pertained to repeated succinylcholine dosing. Furthermore, there is little published evidence to indicate that succinylcholine-related bradycardia is a clinically important side effect. Several authors have called for the practice to cease, but, to date, these calls have gone unheeded. We found no evidence supporting atropine's use in pediatric patients prior to single-dose succinylcholine. Atropine premedication for emergency department rapid sequence intubation is unnecessary and should not be viewed as a “standard of care.”
Non-operative management of a high-pressure water injection injury to the hand
Authors: Snarski Jaime T. , Birkhahn Robert H.
Published: July 2016

High-pressure injection injuries to the hand are work-related injuries that can take a devastating toll on the functionality of the affected extremity. Chemical injections are a surgical emergency. Injuries involving only water injection are rarer and have variable management strategies. We report a case of high-pressure injection hand injury due to water only. The patient was managed non-operatively with parenteral antibiotics, narcotics and elevation, with good outcome. We present a review of the literature on high-pressure injection injury.
Using local epidemiology to make a difficult diagnosis: a case of blastomycosis
Authors: Kesselman Edward W. , Moore Sean , Embil John M.
Published: July 2016

An otherwise well 21-year-old man from Northwestern Ontario presented to our emergency department in Winnipeg, Manitoba, with a 2-month history of cough, progressively increasing dyspnea, hemoptysis and a 15-kg weight loss. His symptoms were worsening despite antibiotic treatment for presumed bacterial pneumonia. His past history included work as a seasonal labourer clearing brush. He was not hypoxic on room air, but his chest radiograph revealed a miliary pattern and bilateral infiltrates. A Mantoux test for tuberculosis was non-reactive, and the sputum gram stain was unremarkable. Empiric therapy was initiated for blastomycosis and the diagnosis was confirmed with a calcofluor stain of the sputum. Although blastomycosis is rare in most regions in North America, there is an unusually high incidence of blastomycosis in Northwestern Ontario. This case highlights the intolerance and utility of knowledge of the local epidemiology in establishing difficult diagnoses of regional importance, such as fungal pneumonias.
Ability of neuron-specific enolase to predict survival to hospital discharge after successful cardiopulmonary resuscitation
Authors: Auer Johann , Berent Robert , Weber Thomas , Porodko Michael , Lamm Gudrun , Lassnig Elisabeth , Maurer Edwin , Mayr Herbert , Punzengruber Christian , Eber Bernd
Published: July 2016

Background:

Accurate prediction of survival to hospital discharge in patients who achieve return of spontaneous circulation after cardiopulmonary resuscitation (CPR) has significant ethical and socioeconomic implications. We investigated the prognostic performance of serum neuron-specific enolase (NSE), a biochemical marker of ischemic brain injury, after successful CPR.

Methods:

In-hospital or out-of-hospital patients with nontraumatic normothermic cardiac arrest who achieved return of spontaneous circulation (ROSC) following at least 5 minutes of CPR were eligible. Neuron-specific enolase levels were assessed immediately, 6 hours, 12 hours and 2 days after ROSC. Subjects were followed to death or hospital discharge.

Results:

Seventeen patients (7 men, 10 women) were enrolled during a 1-year period. Median (range) NSE levels in survivors and non-survivors respectively were as follows: immediately after ROSC: 14.0 μg/L (9.1–51.4 μg/L) versus 25.9 μg/L (10.2–57.5 μg/L); 6 hours after ROSC: 15.2 μg/L (9.7–30.8 μg/L) versus 25.6 μg/L (12.7–38.2 μg/L); 12 hours after ROSC: 14.0 μg/L (8.6–32.4 μg/L) versus 28.5 μg/L (11.0–50.7 μg/L); and 48 hours after ROSC: 13.1 μg/L (7.8–29.5 μg/L) versus 52.0 μg/L (29.1–254.0 μg/L). Non-survivors had significantly higher NSE levels 48 hours after ROSC than surivors (p = 0.04) and showed a trend toward higher values during the entire time course following ROSC. An NSE concentration of >30 μg/L 48 hours after ROSC predicted death with a high specificity (100%: 95% confidence interval [CI] 85%–100%), and a level of 29 μg/L or less at 48 hours predicted survival with a high specificity (100%: 95% CI 83%–100%).

Conclusions:

Serum NSE levels may have clinical utility for the prediction of survival to hospital discharge in patients after ROSC following CPR over 5 minutes in duration. This study is small, and our results are limited by wide confidence intervals. Further research on ability of NSE to facilitate prediction and clinical decision-making after cardiac arrest is warranted.
Atlanto-occipital dislocation: case report and discussion
Authors: McKenna David A. , Roche Clare J. , Lee W. Kit , Torreggiani William C. , Duddalwar Vinay A.
Published: July 2016

Atlanto-occipital dislocation (AOD) is a devastating condition that frequently results in prehospital cardiorespiratory arrest and accounts for 15% of fatal spinal trauma. Atlanto-occipital dislocation occurs 5 times more commonly in children than adults, and is believed to be caused by hyperextension. Because of improvements in prehospital resuscitation, more victims with AOD now survive to reach the emergency department. Neurologic injury is usually severe secondary to ligamentous disruption that allows the cranium to move with respect to the cervical spine, and associated facial and head injuries are common. There are, however, reports of survivors without neurologic deficits. We present the case of a 46-year-old woman who suffered an AOD after a motor vehicle crash and we discuss the diagnosis of this condition. The signs of AOD are often subtle, and the possibility of this diagnosis must be kept in mind in all patients with a neck injury, even in the absence of neurologic signs. A systematic approach to assessing the cranio-cervical relationship on the lateral cervical x-ray and the appropriate use of CT scanning is essential to identifying AOD. Through this case report we hope to familiarize clinicians with mechanisms of injury and appropriate imaging interpretation that will assist in the diagnosis of AOD.
Procedural sedation and analgesia in a Canadian adult tertiary care emergency department: a case series
Authors: Campbell Sam G. , Magee Kirk D. , Kovacs George J. , Petrie David A. , Tallon John M. , McKinley Robert , Urquhart David G. , Hutchins Linda
Published: July 2016

Objectives:

To examine the safety of emergency department (ED) procedural sedation and analgesia (PSA) and the patterns of use of pharmacologic agents at a Canadian adult teaching hospital.

Methods:

Retrospective analysis of the PSA records of 979 patients, treated between Aug. 1, 2004, and July 31, 2005, with descriptive statistical analysis. This represents an inclusive consecutive case series of all PSAs performed during the study period.

Results:

Hypotension (systolic blood pressure ≤ 85 mm Hg) was documented during PSA in 13 of 979 patients (1.3%; 95% confidence interval [CI] 0.3%–2.3%), and desaturation (Sao2≤ 90) in 14 of 979 (1.4%; CI 0.1%–2.7%). No cases of aspiration, endotracheal intubation or death were recorded. The most common medication used was fentanyl (94.0% of cases), followed by propofol (61.2%), midazolam (42.5%) and then ketamine (2.7%). The most frequently used 2-medication combinations were propofol and fentanyl (P/F) followed by midazolam and fentanyl (M/F), used with similar frequencies 58.1% (569/979) and 41.0% (401/979) respectively. There was no significant difference in the incidence of hypotension or desaturation between the P/F and M/F treated groups. In these patients, 9.1% (90/979) of patients received more than 2 different drugs.

Conclusions:

Adverse events during ED PSA are rare and of doubtful clinical significance. Propofol/fentanyl and midazolam/fentanyl are used safely, and at similar frequencies for ED PSA in this tertiary hospital case series. The use of ketamine for adult PSA is unusual in our facility.
Myth: Blood transfusion is effective for sickle cell anemia—associated priapism
Authors: Merritt Andrew L. , Haiman Christopher , Henderson Sean O.
Published: July 2016

Objective:

Priapism is a recognized complication of sickle cell anemia (SCA). When initial conventional treatments fail, simple or exchange blood transfusion has been advocated as a secondary intervention. However, recent literature suggests this may not be an effective therapy and may have significant neurologic sequelae. This paper reviews and summarizes the effectiveness and risks of blood transfusion compared with conventional priapism therapy.

Methods:

All relevant papers identified from a MEDLINE search were systematically examined for data related to the use of blood transfusion in the setting of priapism due to SCA. The effectiveness of conventional therapy was compared with transfusion therapy using the outcome of “time to detumescence” (TTD). In addition, papers documenting adverse neurologic sequela were reviewed and summarized.

Results:

Forty-two case reports were identified containing complete information with regard to patient age and TTD. The mean TTD was 8.0 days with conventional therapy (n= 16) and 10.8 days with blood transfusion therapy (n= 26). Adverse neurologic sequelae from blood transfusion therapy was described in 9 cases, with long term outcomes ranging from complete resolution to severe residual deficits.

Conclusion:

The current literature does not support the contention that blood transfusion is an effective therapy in the treatment of priapism due to SCA, as defined by an acceleration of TTD. In fact, numerous reports suggest that serious neurologic sequelae may result from this treatment. We feel the routine use of this therapy cannot be recommended.
Ovarian torsion in a 20-year-old patient
Authors: Martin Chris , Magee Kirk
Published: July 2016

Ovarian torsion is an uncommon gynecological emergency that requires prompt recognition and treatment. It may present with nonspecific signs and symptoms, and should be considered in any female with acute abdominal pain. The diagnosis is based on an awareness of the relevant risk factors, the clinical presentation, and a high index of suspicion. Timely investigation and management can make the difference between ovarian loss and salvage — an outcome of great importance in the population of reproductive age females.
Chest Pain in Emergency Department Patients: If the Pain is Relieved by Nitroglycerin, is it More Likely to be Cardiac Chest Pain?
Authors: Steele Robert , McNaughton Timothy , McConahy Melissa , Lam John
Published: July 2016

Introduction:

It is often believed that chest pain relieved by nitroglycerin is indicative of coronary artery disease origin.

Objective:

To determine if relief of chest pain with nitroglycerin can be used as a diagnostic test to help differentiate cardiac chest pain and non-cardiac chest pain.

Design:

Prospective observational cohort study with a 4-week follow-up of patients enrolled.

Setting:

Academic tertiary care hospital, with 60 000 visits/year.

Inclusion criteria:

Adult patients presenting to the emergency department with active chest pain who received nitroglycerin and were admitted for chest pain.

Exclusion criteria:

Patients with acute myocardial infarction diagnosed after obtaining an ECG, patients whose chest pain could not be quantified, those for whom no cardiac work-up was done, or those who received emergent cardiac catheterization.

Results:

270 patients were enrolled. Nitroglycerin relieved chest pain in 66% of the subjects. The diagnostic sensitivity of nitroglycerin to determine cardiac chest pain was 72% (64%–80%), and the specificity was 37% (34%–41%). The positive likelihood ratio for having coronary artery disease if nitroglycerin relieved chest pain was 1.1 (0.96–1.34). Telephone follow-up at 4 weeks was performed, with a 95% follow-up rate.

Conclusions:

Relief of chest pain with nitroglycerin is not a reliable diagnostic test and does not distinguish between cardiac and non-cardiac chest pain.
All-terrain vehicle major injury patterns in children: a five-year review in Southwestern Ontario
Authors: Alawi Khalid , Lynch Tim , Lim Rod
Published: July 2016

Objective:

The aim of the study was to characterize the nature of the injuries sustained by children involved in all-terrain vehicle (ATV) crashes in Southwestern Ontario over a 5-year period.

Methods:

A retrospective chart review was conducted of children who sustained ATV-related trauma and who presented to the emergency department at the Children's Hospital of Western Ontario between Sept. 1, 1998, and Aug. 31, 2003, with an Injury Severity Score (ISS) ≥ 12. Patients were identified by the London Health Sciences Centre Trauma Program Registry. Patient charts were then retrieved and reviewed to record patient demographics, injuries, interventions and length of stay in hospital.

Results:

Seventeen patients, 14 male and 3 female, met inclusion criteria. Ages ranged from 8–17 years, with an average age of 13.7 years. Thirteen were <16 years of age. Overall there were 7 different systems injured in these 17 patients. Fourteen patients sustained an injury to more than 1 system. The average ISS was 22.8. The average length of hospital stay was 9.7 days. Six patients sustained significant head injuries; 4 of these 6 patients were not wearing helmets. Eight patients suffered splenic injuries, and 3 required a splenectomy. Thirteen patients sustained fractures.

Conclusions:

ATV trauma is a significant threat to the children in Southwestern Ontario. These results clearly support the Canadian Paediatric Society's recommendation that children <16 years of age should be prohibited from operating or riding on ATVs.
Acute myocardial infarction after administration of low-dose intravenous epinephrine for anaphylaxis
Authors: Shaver Kyle J. , Adams Christopher , Weiss Steven J.
Published: July 2016

This case describes a 29-year-old woman who presented with an acute severe anaphylactic reaction to penicillin. In addition to other medications administered in the emergency department, she received 0.1 mg intravenously of 1:10 000 epinephrine, after which she immediately developed severe chest pain. Her ECG showed ST elevations consistent with an anterior myocardial infarction, and her serum troponin level was elevated. A CT angiogram showed no signs of coronary artery disease or abnormal anatomy. This case is an example of vasospasm-induced myocardial injury and illustrates a potential danger of intravenous epinephrine use. The authors were able to identify only 2 other case reports where therapeutic doses of epinephrine have been reported to cause this phenomenon.
Hyperglycemia in acutely ill emergency patients — Cause or effect?
Authors: Henderson William R. , Chittock Dean R. , Dhingra Vinay K. , Ronco Juan J.
Published: July 2016

Objectives:

To clarify the benefits, risks and timing of glucose control and intensive insulin therapy in several groups, specifically the neurologic, cardiac and septic populations of patients, commonly seen in the emergency department.

Methods:

Electronic search of MEDLINE (1966–2005; once with PubMed and once with Ovid) and Embase (1980–2005) using the terms insulin and glucose combined with emergency medicine, intensive care, cardiology and emergency department.

Results:

There is considerable controversy in the literature surrounding the use of strict glucose control in cardiac, neurologic and septic patients. Much of this literature is non-randomized, and the timing of therapy is poorly investigated.

Conclusions:

Hyperglycemia is associated with adverse outcomes in acutely ill neurologic, cardiac and septic patients, but it remains unclear whether this is a causative association. Glucose control and intensive insulin therapy may be useful in some patient subgroups; however, controlled trials of aggressive glycemic control have provided insufficient evidence to justify subjecting patients to the real risks of iatrogenic hypoglycemia. We recommend a cautious approach to the control of glucose levels in acutely ill emergency department patients, with a target glucose of below 8 to 9 mmol/L.
Bowel perforation after single-dose activated charcoal
Authors: Green Jason P. , McCauley William
Published: July 2016

Patients presenting to the emergency department (ED) after medication overdose are often given activated charcoal initially for gastrointestinal decontamination. Complications of charcoal are rare, but do occur. The following case describes a patient with pre-existing undiagnosed diverticular disease who developed sigmoid perforation after a single dose of activated charcoal, given without cathartic for a drug overdose. A literature search revealed no other cases of bowel perforation associated with single-dose activated charcoal. This case report discusses adverse effects associated with activated charcoal and the role of cathartics in gastrointestinal decontamination.
Data collection on patients in emergency departments in Canada
Authors: Rowe Brian H. , Bond Kenneth , Ospina Maria B. , Blitz Sandra , Schull Michael , Sinclair Douglas , Bullard Michael
Published: July 2016

Objective:

Relatively little is known about the ability of Canadian emergency departments (EDs) and the federal, provincial and territorial governments to quantify ED activity. The objectives of this study were to determine the use of electronic patient data in Canadian EDs, the accessibility of provincial data on ED visits, and to identify the data elements and current methods of ED information system (EDIS) data collection nationally.

Methods:

Surveys were conducted of the following 3 groups: 1) all ED directors of Canadian hospitals located in communities of >10 000 people, 2) all electronic EDIS vendors, and 3) representatives from the ministries of health from 13 provincial and territorial jurisdictions who had knowledge of ED data collection.

Results:

Of the 243 ED directors contacted, 158 completed the survey (65% response rate) and 39% of those reported using an electronic EDIS. All 11 EDIS vendor representatives responded. Most of the vendors provide a similar package of basic EDIS options, with add-on features. All 13 provincial or territorial government representatives completed the survey. Nine (69%) provinces and territories collect ED data, however the source of this information varies. Five provinces and territories collect triage data, and 3 have a comprehensive, jurisdiction-wide, population-based ED database. Thirty-nine percent of EDs in larger Canadian communities track patients using electronic methods. A variety of EDIS vendor options are available and used in Canada.

Conclusion:

The wide variation in methods and in data collected presents serious barriers to meaningful comparison of ED services across the country. It is little wonder that the majority of information regarding ED overcrowding in Canada is anecdotal, when the collection of this critical health information is so variable. There is an urgent need to place the collection of ED information on the provincial and national agenda and to ensure that the collection of this information consistent, comprehensive and mandatory.
Pediatric appendicitis: pathophysiology and appropriate use of diagnostic imaging
Authors: Brennan Gerald D.G.
Published: July 2016

Evaluating children for appendicitis can be extremely difficult, and various strategies have been developed to improve the precision of preoperative diagnosis. Among these, ultrasound and computed tomography (CT) are now widely used but remain controversial. Although CT scanning is superior to ultrasound in terms of diagnostic accuracy for appendicitis, the large dose of ionizing radiation from CT and the risk of subsequent radiation-induced malignancy (RIM) are of particular concern in pediatric patients. This article reviews the literature on the pathophysiology, morbidity and mortality of appendicitis, summarizes the data regarding pediatric imaging in appendicitis, provides a practical approach to imaging for clinicians who evaluate pediatric patients, and makes recommendations for reducing the risk of RIM in pediatric patients.
What happens to my patients? An automated linkage between emergency department and mortality data
Authors: Maxwell David
Published: July 2016

A simple application linking mortality data from the Bureau of Vital Statistics with data from the emergency department information system is described. This application has been used to supplement the regular mortality review process, identify deaths of patients who left without being seen, and perform outcome studies looking at specified clinical conditions.
Hyperbaric oxygen therapy in the management of two cases of hydrogen sulfide toxicity from liquid manure
Authors: Belley Richard , Bernard Nicolas , Côté Mario , Paquet Francois , Poitras Julien
Published: July 2016

Hydrogen sulfide is a potent lethal gas. Supportive care, nitrite therapy and hyperbaric oxygen are the treatment modalities reported in the literature in cases of hydrogen sulfide exposure. We describe an industrial exposure in which 6 workers inhaled high concentrations of hydrogen sulfide when they entered a closed spreader tank partially filled with liquid swine manure. Five of the 6 lost consciousness, and 2 were agitated and poorly responsive on arrival to the emergency department despite having already received high-flow oxygen for nearly 1 hour. These 2 patients received nitrite therapy followed by orotracheal intubation and hyperbaric oxygen. All patients were discharged home without sequelae after short stays in hospital. The emergency management of hydrogen sulfide exposure is briefly reviewed.
Diagnostic uncertainty in a case of neuroleptic malignant syndrome
Authors: Seitz Dallas P.
Published: July 2016

Neuroleptic malignant syndrome (NMS) is a potentially life-threatening condition that has been associated with antipsychotic use. Most diagnostic criteria include fever and muscle rigidity, although NMS may present without either. Diagnostic uncertainty in such cases may result in delays in diagnosis and management, leading to adverse consequences for these patients. The differential diagnosis of NMS is broad and includes a number of neurological, medical and psychiatric conditions as well as substance and medication-induced disorders. A case is described that illustrates an atypical presentation of NMS and demonstrates some of the challenges in its diagnosis. Limitations of current NMS criteria are also examined, and suggestions for future criteria are presented.
Nail embolization to the femoral artery
Authors: Baw Bandar , Al-Salamah Majid A. , Al-Hodaib Abdullah , Wadams Heather
Published: July 2016

Modern air-nailing tools are known to cause penetrating trauma. We report the unusual case of a pneumatically fired carpenter's nail that penetrated the chest of a 30-year-old man and subsequently embolized from the heart to the left femoral artery without clinical evidence of having entered the heart. The nail was surgically removed, and the patient was discharged from hospital without sequelae after 10 days. This case and the relevant literature are discussed from the perspective of the emergency department investigation and care of such patients.
Brugada syndrome in a young patient with palpitations
Authors: Watrich Deanne G. , Woods Robert A. , Steiner Ivan P.
Published: July 2016

Brugada syndrome is a potentially lethal and eminently treatable entity that may present with palpitations or syncope. This article presents the case of a young patient with Brugada syndrome and reviews key features in the epidemiology, pathophysiology, diagnosis, treatment and prognosis of this condition.
Variations in monetary distribution among Ontario’s Alternative Funding Agreement workload model hospitals
Authors: Whyne Mitchell , Whyne Garrett , Rowe Brian H.
Published: July 2016

Objectives:

Alternative Funding Agreements (AFAs) were in place in 41 hospital emergency departments (EDs) in Ontario at the time of this survey (May to August 2005). Each of these 41 hospitals works with its own internal administrative model. The primary objective of this paper was to document the administrative models used in these Ontario EDs. The secondary objective was to inform current and future AFA EDs of the potential models.

Methods:

Telephone surveys were conducted with a member of each of the 41 AFA workload model hospitals.

Results:

All hospitals provided at least 1 emergency physician to answer the questionnaire. Although most AFA hospitals divide the AFA fund pool on an hourly basis, there is impressive variation on premium values awarded for day, evening, weekend and night shifts. Other variations included holdback of funds for bonuses, distribution of non-OHIP (Ontario Health Insurance Plan) dollars, on-call allowances, and different pay scales for the general practitioners and locums working in some departments.

Conclusions:

Allowing flexibility in distribution of AFA dollars to physicians in each group has helped make this program more acceptable. Many issues unrelated to funding remain to be resolved in order to stabilize ED recruitment and retention as well as improve work satisfaction. Further research on these latter topics is required to develop a fair and equitable funding arrangement that supports and enhances physician coverage in EDs across Canada.
Poisoning due to raw Gyromitra esculenta (false morels) west of the Rockies
Authors: Leathem Anne M. , Dorran Thomas J.
Published: July 2016

Vomiting with abdominal pain is a common presentation in the emergency department (ED). Without a careful history, unusual causes, such as toxic ingestion, may evade diagnosis. We report a case of an Asian couple who presented to the ED with vomiting and epigastric distress. They were discharged with no definite diagnosis, but on a return ED visit the following day were diagnosed with toxic ingestion ofGyromitra esculenta, commonly known as the western false morel. The patients were admitted and treated with intravenous hydration and pyridoxine. Both patients developed mild hepatotoxicity but went on to fully recover. This case demonstrates that the western false morel may cause significant toxicity and it highlights the importance of obtaining a complete history in patients who present with non-specific gastrointestinal symptoms.
Necrotizing pneumonia and septic shock: suspecting CA-MRSA in patients presenting to Canadian emergency departments
Authors: Vayalumkal Joseph V. , Whittingham Heather , Vanderkooi Otto , Stewart Thomas E. , Low Donald E. , Mulvey Michael , McGeer Allison
Published: July 2016

We report a case of fatal necrotizing pneumonia and sepsis caused by community-associated methicillin-resistantStaphylococcus aureus(CA-MRSA) in an otherwise well, 48-year-old Canadian man with type 2 diabetes mellitus who had travelled to Texas. Despite therapy that included intravenous antibiotics, intravenous immune globulin and other supportive measures, the patient succumbed to his illness. Recently, CA-MRSA pneumonia has been reported in several countries. The virulence of this organism may in part be related to its ability to produce toxins, such as Panton-Valentine leukocidin. As rates of CA-MRSA increase worldwide, physicians should be aware of the potential for MRSA to cause life-threatening infections in patients presenting to Canadian emergency departments (EDs). Necrotizing pneumonia caused by MRSA must be considered in the differential diagnosis of acute, severe respiratory illness. Early recognition of this syndrome in the ED may help physicians initiate appropriate antibiotic therapy in a timely manner.
Key indicators of overcrowding in Canadian emergency departments: a Delphi study
Authors: Ospina Maria B. , Bond Kenneth , Schull Michael , Innes Grant , Blitz Sandra , Rowe Brian H.
Published: July 2016

Objective:

To identify the level of consensus among a group of Canadian emergency department (ED) experts on the importance of a set of indicators to document ED overcrowding.

Methods:

A 2-round Delphi survey was conducted from February 2005 to April 2005, with a multi-disciplinary group of 38 Canadian experts in various aspects of ED operations who rated the relevance of 36 measures and ranked their relative importance as indicators of ED overcrowding.

Results:

The response rates for the first and second rounds were 84% and 87%, respectively. The most important indicator identified by the experts was the percentage of the ED occupied by in-patients (mean on a 7-point Likert-type scale 6.53, standard deviation [SD] 0.80). The other 9 indicators, in order of the importance attributed, were the total number of ED patients (mean 6.35, SD 0.75), the total time in the ED (mean 6.16, SD 1.04), the percentage of time that the ED was at or above capacity (mean 6.16, SD 1.08), the overall bed occupancy (mean 6.19, SD 0.93), the time from bed request to bed assignment (mean 6.06, SD 1.08), the time from triage to care (mean 5.84, SD 1.08) the physician satisfaction (mean 5.84, SD 1.22), the time from bed availability to ward transfer (mean 5.53, SD 1.72) and the number of staffed acute care beds (mean 5.53, SD 1.57).

Conclusion:

Ten clinically important measures were prioritized by the participants as relevant indicators of ED overcrowding. Indicators derived from consensus techniques have face validity, but their metric properties must be tested to ensure their effectiveness for identifying ED overcrowding in different settings.
Emergency medicine training demographics of physicians working in rural and regional southwestern Ontario emergency departments
Authors: Bhimani Munsif , Dickie Gordon , McLeod Shelley , Kim Daniel
Published: July 2016

Objectives:

We sought to determine the emergency medicine training demographics of physicians working in rural and regional emergency departments (EDs) in southwestern Ontario.

Methods:

A confidential 8-item survey was mailed to ED chiefs in 32 community EDs in southwestern Ontario during the month of March 2005. This study was limited to nonacademic centres.

Results:

Responses were received from 25 (78.1%) of the surveyed EDs, and demographic information on 256 physicians working in those EDs was obtained. Of this total, 181 (70.1%) physicians had no formal emergency medicine (EM) training. Most were members of the College of Family Physicians of Canada (CCFPs). The minimum qualification to work in the surveyed EDs was a CCFP in 8 EDs (32.0%) and a CCFP with Advanced Cardiac and Trauma Resuscitation Courses (ACLS and ATLS) in 17 EDs (68.0%). None of the surveyed EDs required a CCFP(EM) or FRCP(EM) certification, even in population centres larger than 50 000.

Conclusion:

The majority of physicians working in southwestern Ontario community EDs graduated from family medicine residencies, and most have no formal EM training or certification. This information is of relevance to both family medicine and emergency medicine residency training programs. It should be considered in the determination of curriculum content and the appropriate number of residency positions.