bluuebunny/crossref_metadata_2025 huggingface dataset:
Measures of association: an overview with examples from Canadian emergency medicine research
Authors: Worster Andrew , Rowe Brian H.
Published: July 2016

The authors of studies often report their results using abbreviated terms such as RR, OR, ARR, RRR and NNT. These terms are quantities that express the strength of association between the dependent and independent variables and are collectively referred to as measures of association. The similarity between these measures and the multiple terms by which each is referred can be confusing. The purpose of this article is to explain in a straightforward manner the purpose, derivation, and limitations of some of the more commonly used categorical measures of association, including relative risk, odds ratio, absolute and relative risk reduction and number needed to treat, using results from recent emergency medicine studies published by Canadian researchers.
Successful treatment of severe atenolol overdose with calcium chloride
Authors: O’Grady John , Anderson Scott , Pringle Derrick
Published: July 2016

Atenolol, a selective β1-adrenergic antagonist, is commonly used to treat hypertension, ischemic heart disease and cardiac dysrhythmias. Few cases of severe atenolol intoxication have been described, and only one of these reports discussed the use of calcium chloride as a treatment. We present a case of atenolol overdose associated with shock and first-degree heart block, in which administration of calcium chloride led to dramatic improvement after failure of conventional treatment. In addition, we discuss the pharmacokinetics, toxicology and management of β-blocker overdose, focusing on the possible role of calcium chloride.
Is propofol an optimal agent for procedural sedation and rapid sequence intubation in the emergency department?
Authors: Wilbur Kerry , Zed Peter J.
Published: July 2016

Objective:

We conducted a qualitative systematic review to evaluate the efficacy and safety of propofol for direct current cardioversion (DCC), rapid sequence intubation (RSI) and procedural sedation in adult emergency department (ED) patients.

Data source:

MEDLINE (1966 to September 2000), PubMed (to September 2000), EMBASE (1988 to September 2000), Database of Systematic Reviews (to September 2000), Best Evidence (1991 to September 2000) and Current Contents (1996 to September 2000) databases.

Study selection:

English-language, randomized, comparative evaluations of propofol for procedures routinely conducted in adults (>18 years) were included. Direct current cardioversion, RSI and procedural sedation were considered.

Data extraction:

Efficacy and safety endpoints were evaluated for all trials. For DCC and procedural sedation trials, efficacy measures included induction and recovery times, as well as the association for successful procedure. For the RSI trials, optimal intubating conditions were evaluated as the primary efficacy endpoint. Safety measures included hemodynamic changes, apnea rates and adverse effects.

Data synthesis:

In the setting of DCC, efficacy and safety outcomes were similar for propofol, thiopental, etomidate and methohexital. All of these agents provided markedly shorter induction and recovery times than midazolam. Patients who were pre-medicated with fentanyl exhibited prolonged recovery times and greater decreases in blood pressure. When used for RSI, propofol administration was associated with satisfactory intubating conditions that were comparable to those seen with thiopental and etomidate. Blood pressure reductions were seen in both DCC and RSI studies. Apneic episodes (>30 seconds) occurred in 23% of propofol recipients, 28% of thiopental recipients and 7% of etomidate and midazolam recipients. Apart from the DCC studies described, no procedural sedation studies met our predefined review eligibility criteria.

Conclusion:

The body of literature evaluating propofol for DCC and RSI in the ED is limited. There is evidence to support the use of propofol for DCC and RSI, but this evidence comes from stable patients in non-ED settings. Further ED-based randomized comparative trials should be conducted before propofol is adopted for widespread use in the ED.
Serotonin syndrome due to an overdose of moclobemide?
Authors: Ip Andrew , Renouf Tia
Published: July 2016

Serotonin syndrome, a triad of autonomic instability, altered mental status and neuromuscular abnormalities, is usually attributed to serotonergic overdoses. Moclobemide is a new selective monoamine oxidase inhibitor (MAOI) that generally causes mild, self-limited gastrointestinal and central nervous system effects after ingestion. We present a case of serotonin syndrome that occurred after moclobemide overdose, and discuss the recognition and treatment of this important condition. Serotonin syndrome may become increasingly common because of the liberal use of selective serotonin reuptake inhibitors, new MAOIs and other agents such as codeine and meperidine, which have the potential for harmful interaction.
The role of lumbar puncture in the diagnosis of subarachnoid hemorrhage when computed tomography is unavailable
Authors: Mann David
Published: July 2016

Subarachnoid hemorrhage (SAH) is an important but uncommon condition in the differential diagnosis of acute headache. Most authorities recommend that patients with suspected SAH undergo noncontrast computed tomography (CT) as a first diagnostic intervention. If the results of the CT scan are negative, a lumbar puncture should be performed. Many nonurban Canadian hospitals do not have CT scanners and must either transfer patients or consider performing lumbar puncture prior to CT. In selected patients, performing lumbar puncture first may be an option, but timing of the procedure and the interpretation of results is important.
Diagnosing streptococcal pharyngitis in the emergency department: Is a sore throat score approach better than rapid streptococcal antigen testing?
Authors: Rosenberg Paul , McIsaac Warren , MacIntosh Donald , Kroll Michael
Published: July 2016

Background:

Reducing the number of unnecessary antibiotic prescriptions given for common respiratory infections has been recommended as a way to limit bacterial resistance. This study assessed the validity of a clinical sore throat score in 2 community emergency departments (EDs) and its impact on antibiotic prescribing. We also attempted to improve on this approach by using a rapid streptococcal antigen test.

Methods:

A total of 126 patients with new upper respiratory tract infections accompanied by sore throat were assessed by a physician. Pharyngeal swabs were obtained for a rapid test and throat culture, and information was gathered to determine the sore throat score. The sensitivity and specificity of the score approach were compared with usual physician care based on the rapid test results.

Results:

Of the 126 cases of new upper respiratory infections with sore throat, physicians who followed their usual care routine, guided by the rapid test results, prescribed antibiotics for 46 patients. Of the 46 prescriptions, 18 were given to patients with culture-negative results for group A streptococcal (GAS) pharyngitis. Use of the sore throat score would not have reduced the number of prescriptions but would have missed only 1 patient with a positive culture result (p< 0.05). The rapid test was not as sensitive as throat culture.

Conclusions:

An explicit clinical score approach to the management of GAS pharyngitis is valid in a community ED setting and could improve the pattern of antibiotic prescribing. While the addition of a rapid streptococcal antigen test significantly decreased the sensitivity of detecting GAS infections, a combined approach consisting of the clinical score and throat culture for patients with negative results on the rapid test would decrease antibiotic prescribing and telephone follow-up without decreasing the sensitivity of detecting GAS infection.
Canadian C-Spine Rule study for alert and stable trauma patients: II. Study objectives and methodology
Authors: Stiell Ian G. , Wells George A. , McKnight R. Douglas , Brison Robert , Lesiuk Howard , Clement Catherine M. , Eisenhauer Mary A. , Greenberg Gary H. , MacPhail Iain , Reardon Mark , Worthington James , Verbeek Richard , Dreyer Jonathan , Cass Daniel , Schull Michael , Morrison Laurie , Rowe Brian , Holroyd Brian , Bandiera Glen , Laupacis Andreas ,   Canadian CT Head and C-Spine (CCC) Study Group
Published: July 2016

Clinical prediction rules are decision-making tools that incorporate three or more variables from the history, physical examination or simple tests. They help clinicians make diagnostic or therapeutic decisions by standardizing the collection and interpretation of clinical data. There is growing interest in the methodological standards for their development and validation. This article describes the methods used to derive the Canadian C-Spine Rule and provides a valuable reference for investigators planning to develop future clinical prediction rules.
Acute compartment syndrome: How long before muscle necrosis occurs?
Authors: Vaillancourt Christian , Shrier Ian , Vandal Alain , Falk Markus , Rossignol Michel , Vernec Alan , Somogyi Dan
Published: July 2016

Objectives:

Acute compartment syndrome (ACS) is a limb-threatening condition often first diagnosed by emergency physicians. Little is known about the rapidity with which permanent damage may occur. Our objective was to estimate the time to muscle necrosis in patients with ACS.

Methods:

This historical cohort analysis of all patients who had a fasciotomy for ACS was conducted in 4 large teaching hospitals. Diagnosis was confirmed clinically or by needle measurement of compartment pressure. Muscle necrosis was determined using pathology reports and surgeons’ operative protocols. We used descriptive statistics and estimated tissue survival probability using the Vertex exchange method for interval-censored data.

Results:

Between 1989 and 1997 there were 76 cases of ACS. Most cases occurred in young men (median age 32) as a result of a traumatic incident (82%). Forty-nine percent (37/76) of all patients suffered some level of muscle necrosis, and 30% (11/37) of those with necrosis lost more than 25% of the muscle belly. Necrosis occurred in 2 of 4 cases in which the patient had been operated on within 3 hours of the injury, and our exploratory survival analysis estimates that 37% (95% confidence interval, 13%-51%) of all cases of ACS may develop muscle necrosis within 3 hours of the injury.

Conclusions:

This is the largest cohort of ACS and the first clinical estimation of time to muscle necrosis ever published. Ischemia from ACS can cause muscle necrosis before the 3-hour period post-trauma that is traditionally considered safe. Further research to identify risk factors associated with the development of early necrosis is necessary.
Delayed diagnosis of splenic rupture following minor trauma: Beware of comorbid conditions
Authors: Peera Mohamed Ali , Lang Eddy S.
Published: July 2016

Although rare, spontaneous splenic rupture has been reported in cases of chronic lymphocytic leukemia (CLL). In contrast, there are no published reports of splenic injury resulting from minor trauma in CLL patients. We report the case of an 81-year-old woman with a history of CLL, who presented with minor trauma to her coccygeal region, and was found to have a splenic rupture. We briefly describe the incidence, pathogenesis, presentation, diagnosis, management and prognosis of splenic injury, especially in cases with a history of splenomegaly.
Accidental injection of epinephrine by a child: a unique approach to treatment
Authors: Sellens Catharine , Morrison Laurie
Published: July 2016

A 9-year-old girl accidentally injected her right thumb with an adult dose of epinephrine through an auto-injector syringe, delivering 0.3 mg of 1:1000 epinephrine. This injection caused immediate ischemic changes in the digit. This is the first reported case of accidental self injection by a child of an adult dose of epinephrine and its successful treatment with low-dose phentolamine simultaneously infiltrated directly into the puncture area and along the course of the digital artery. The use of phentolamine as a specific competitive alpha-adrenergic antagonist to epinephrine has been well documented in adults and animal models. This report compares the management of a pediatric case to that of all reported adult cases of accidental subcutaneous epinephrine injections. This case suggests a pattern of infiltration with low-dose phentolamine that may be the most effective form of treatment for this condition in a patient of any age.
African drumbeats: a first conference on emergency medicine
Authors: Dickinson Garth
Published: July 2016

Africa’s first conference on emergency medicine was held in October 1998 in Johannesburg, South Africa. Attended by 305 delegates from 13 countries, it was an important milestone in the development of Africa, emergency medicine’s last frontier. The violence of South Africa’s post-apartheid society was portrayed in mock scenario demonstrations of the private sector emergency medical services (EMS) system. Many of the presentations had a distinctly African flavour; they dealt with penetrating trauma and with making the best of extremely limited resources. A session reviewing the activities of traditional healers was not only terrifyingly revealing, it also upset and offended a segment of the African audience. The conference ended positively with the creation of the Emergency Medicine Society of South Africa, a step toward recognition of emergency medicine as a specialty in Africa.
A voice for future EM physicians
Authors: Frank Jason R.
Published: July 2016

Welcome to the first section on “Resident Issues” in our new journal. With this section, CAEP reaffirms its commitment to the future of Canadian emergency medicine and future leaders in our specialty. Resident Issues will focus on work by and about future emergency physicians in Canada. The overall goal of this section is to promote
Career planning … international EM?
Authors: Cheng Ivy
Published: July 2016

An informal discussion of the possibilities of combining emergency medicine and international work during a residency program. A brief summary of emergency medicine related illness in the international setting is presented. An example of a successful combination of international work during residency is given. A list of tips and a starter’s list of resources are provided.
Emergency medicine training in Canada
Authors: Moore Kieran , Lucky Cindy-Ann
Published: July 2016

Canada is the only country with two colleges governing emergency medicine (EM) certification. Does this serve us well or does it divide us and our resources? If most CCFP(EM) graduates practise strictly EM, with no family or rural practice, then reform in the certification process may be necessary. At the same time, FRCPC residencies seem excessively long and lack the numbers to develop “critical mass.” Shortening the length of training would allow more residency positions to be created, thus advancing the goal of optimum emergency care for the Canadian public. Canadians deserve one standardized, certified, accredited EM training program that produces the highest quality emergency physicians.
Commentary: Chest pain evaluation in the emergency department
Authors: Allen Tim
Published: July 2016

In this issue, Dr. David Mutrie illustrates both the utility of departmental care protocols and the caution we must take in drawing conclusions from them. The latter point is particularly important if one wishes to apply these conclusions to other institutions.

The Thunder Bay Regional Hospital (TBRH), in Ontario, established simple guidelines for the management of patients with chest pain. Following the implementation of these guidelines, Mutrie reports shorter chest pain assessment times and reduced admission rates for non-myocardial infarction and non-unstable angina patients, without any obvious increase in inappropriate discharge of patients with ischemic disease. Can we therefore conclude that the guidelines were responsible for these improvements and that this set of guidelines would similarly improve performance in other emergency departments? The answer, unfortunately, is No. The fact is, the establishment of any organized approach to a clinical problem tends to improve performance. This is perhaps a sad reflection on “individual” practice patterns, but it is true nonetheless.
Prehospital emergency medical services’ ethical dilemma with do-not-resuscitate orders
Authors: Sherbino Jonathan , Guru Veena , Verbeek P. Richard , Morrison Laurie J.
Published: July 2016

Objective:

Our primary objectives were to estimate how frequently emergency medical technicians with defibrillation skills (EMT-Ds) are forced to deal with prehospital do-not-resuscitate (DNR) orders, to assess their comfort in doing so, and to describe the prehospital care provided to patients with DNR orders in a system without a prehospital DNR policy (i.e., where resuscitation is mandatory).

Methods:

Using Dillman methodology, the authors developed a 13-item survey and mailed it to 382 of 764 EMT-Ds in the metropolitan Toronto area. Responses were evaluated using 5-point Likert scales, limited-option and open-ended questions. Narrative responses were categorized. Two authors independently categorized narrative responses from 20 surveys, and kappa values for agreement beyond chance were determined.

Results:

Among 382 EMT-Ds surveyed, 236 (62%) responded, of whom 221 (94%) answered the questionnaire. Overall, 126 of 219 (58%) indicated that they were called to resuscitate patients with DNR orders “sometimes,” “frequently,” or “all the time.” In such situations, 22 of 207 (11%) stated they would honour the DNR order and 55 of 207 (27%) would honour the order but appear to provide basic resuscitation, in order to adhere to mandatory resuscitation regulations. Willingness to honour a DNR order did not vary by years of emergency medical service. EMT-Ds cited concern for the family and the patient, fear of repercussions and conflict with personal ethics as key factors contributing to this ethical dilemma. If legally allowed to honour DNR orders, 212 of 221 (96%) respondents would be comfortable with a written order and 137 of 220 (62%) with a verbal order.

Conclusion:

Prehospital DNR orders are common, and a significant number of EMT-Ds disregard current regulations by honouring them. EMT-Ds would be more comfortable with written than verbal DNR orders. An ethical prehospital DNR policy should be developed and applied.
Review of the selective COX-2 inhibitors celecoxib and rofecoxib: focus on clinical aspects
Authors: Loewen Peter S.
Published: July 2016

The selective cyclooxygenase-2 (COX-2) inhibitors celecoxib and rofecoxib were designed to have similar efficacy but less gastrointestinal toxicity than traditional nonsteroidal anti-inflammatory drugs (NSAIDs). Their efficacy has been demonstrated in the treatment of osteoarthritis, rheumatoid arthritis, ankylosing spondylitis, postoperative dental pain and dysmenorrhea. These agents produce fewer endoscopic ulcers, symptomatic ulcers and gastrointestinal bleeds than traditional NSAIDs; although the absolute benefit is small and the gastropreserving effect is negated by concurrent use of low-dose aspirin for cardiovascular risk reduction. Nephrotoxicity and hyptertension remain concerns with COX-2 inhibitors, as they are with traditional NSAIDs. COX-2 inhibitors may be safe alternatives to traditional NSAIDs for patients with aspirin-sensitive asthma.
On a wing and a prayer: medical emergencies on board commercial aircraft
Authors: Drummond Robert , Drummond Alan J.
Published: July 2016

Medical emergencies sometimes arise in the isolated and confined environment of a commercial aircraft. Because a physician passenger may be on board in 40% to 90% of all commercial flights, it follows that this physician may be asked to render assistance to an acutely ill passenger. Although data suggest that the incidence of such emergencies is low, the potential for serious events necessitates a degree of familiarity with the nature of emergencies in the air and with the options available to the travelling physician.
Clinical teaching in a busy emergency department: strategies for success
Authors: Penciner Rick
Published: July 2016

Clinical teaching is an integral part of emergency medical practice. With the growing number of medical students and residents in the emergency department there are increasing expectations for clinicians to teach. But there are many challenges and obstacles to overcome when teaching in a busy department. By incorporating diverse strategies and techniques, we can become more effective and efficient emergency medicine teachers.
Evaluation of prehospital insertion of the laryngeal mask airway by primary care paramedics with only classroom mannequin training
Authors: Murray Michael J. , Vermeulen Marian J. , Morrison Laurie J. , Waite Tim
Published: July 2016

Introduction:

The laryngeal mask airway (LMA™ airway) provides adequate ventilation and offers a suitable alternative for airway management in patients with cardiac arrest if primary care paramedics do not have intubation skills or are unable to intubate. Training in the use of the LMA usually occurs in the operating room.

Objective:

To describe the use of the LMA by paramedics in prehospital adult non-traumatic cardiac arrest patients after classroom mannequin training. The study took place in a suburban rural emergency medical service.

Methods:

This is a 2-phase observational study of the effect of paramedic training for LMA insertion using a mannequin and the success rate in the prehospital setting. All paramedics successfully completed classroom mannequin training. All subsequent prehospital adult non-traumatic cardiac arrest patients from mid-February 1999 to Mar. 31, 2000, were eligible. Subjective assessment of chest expansion, ease of ventilation and auscultation defined adequacy of ventilation. Data collected included the number of insertion attempts, reasons for failure, ease of insertion, adverse events and reasons for not attempting intubation. Statistical analysis comprised descriptive frequencies, chi-squared tests for comparison of categorical variables and analysis of variance for continuous variables.

Results:

208 paramedics (100%) successfully completed training. The mean number of attempts was 1, and only 4 (2.1%) paramedics required a second attempt with a mannequin. The paramedics’ perception of ease of use comparing the LMA with a bag valve mask (BVM) was evenly distributed across the 3 descriptors: 70 (39%) scored the LMA as easier to use, 57 (31%) as more difficult, and 54 (30%) stated there would be no difference. Of the 291 arrests during the study period, insertion of the LMA was attempted in 283 (97.3%) and was successful in 199 (70%) patients. The LMA became dislodged in 5 (2.5%) cases and was removed in 12 (6%) to clear vomit from the airway. The overall success rate was 182 (64%). The incidence of regurgitation prior to attempted insertion of the LMA was 28% (79 patients). Success rates did not vary significantly with the incidence of vomiting prior to insertion (p = 0.11). The majority of the paramedics evaluated LMA insertion as Very easy 49/220 (22.3%) or Easy 87/220 (39.6%). Paramedic evaluation of ease of use varied with success (p = 0.001).

Conclusions:

This study reports a 100% training success rate with a mannequin and a 64% success with LMA insertion and ventilation in the field by paramedics among adult out-of-hospital non-traumatic cardiac arrest patients.
Disaster Medicine Online: evaluation of an online, modular, interactive, asynchronous curriculum
Authors: Lund Adam , Lam Kenneth , Parks Paul
Published: July 2016

Canada has no formal training program in disaster medicine for health care professionals. The University of Alberta’s Division of Emergency Medicine has developed a means to fill the gap. Disaster Medicine Online (DMO) is an Internet-based, interactive, facilitator-guided distance-learning course on the fundamentals of disaster medicine. The 3-week pilot of DMO was offered in March 2002 and taken by a multidisciplinary group of 22 health care professionals, including resident and attending physicians, paramedics and nurses. Evaluation of the learning materials and educational methodology by experts and learners demonstrated a high degree of satisfaction with the Web interface, site usability, lesson content and format, and the interactive components of the online course. Learners reported spending a mean of 11.2 hours (range = 5–20) over the 3-week course period. Twenty of 22 learners completed the final assignment, and all 20 were successful in passing the course. Overall, 95% of learners said they would pursue another module if offered, and 100% would recommend DMO to their colleagues. DMO is a viable option for health care professionals who would like to pursue continuing medical education in this area without having to take time out of their personal and professional lives to travel to a face-to-face, traditional educational program.
Epinephrine in digital blocks: refuting dogma
Authors: Katis Peter G.
Published: July 2016

In the medical community there is a widely held belief that epinephrine should not be used with lidocaine when attempting a digital block because it will cause tissue gangrene. This belief is reinforced by several of the more prominent emergency textbooks, but a review of the medical literature fails to reveal a sound basis for this dogma.
Unusual case of acute onset abdominal pain: uses and limitations of medical imaging
Authors: Bandiera Glen , Poulin Eric
Published: July 2016

A 28-year-old male with atraumatic abdominal pain and transient hypotension was assessed using bedside emergency department (ED) ultrasonography and contrast enhanced helical computed tomography (CT). Both tests revealed free intraperitoneal fluid, but neither detected a splenic defect. The patient subsequently underwent splenectomy for a ruptured spleen. His serology for typical viral causes was negative. This article discusses spontaneous splenic rupture, the role of imaging in diagnosis, and the limitations of ED ultrasound and contrast enhanced helical CT.
Accuracy of clinical diagnosis versus the World Health Organization case definition in the Amoy Garden SARS cohort
Authors: Wong W.N. , Sek Antonio C.H. , Lau Rick F.L. , Li K.M. , Leung Joe K.S. , Tse M.L. , Ng Andy H.W. , Stenstrom Robert
Published: July 2016

Objectives:

To compare the diagnostic accuracy of emergency department (ED) physicians with the World Health Organization (WHO) case definition in a large community-based SARS (severe acute respiratory syndrome) cohort.

Methods:

This was a cohort study of all patients from Hong Kong’s Amoy Garden complex who presented to an ED SARS screening clinic during a 2-month outbreak. Clinical findings and WHO case definition criteria were recorded, along with ED diagnoses. Final diagnoses were established independently based on relevant diagnostic tests performed after the ED visit. Emergency physician diagnostic accuracy was compared with that of the WHO SARS case definition. Sensitivity, specificity, predictive values and likelihood ratios were calculated using standard formulae.

Results:

During the study period, 818 patients presented with SARS-like symptoms, including 205 confirmed SARS, 35 undetermined SARS and 578 non-SARS. Sensitivity, specificity and accuracy were 91%, 96% and 94% for ED clinical diagnosis, versus 42%, 86% and 75% for the WHO case definition. Positive likelihood ratios (LR+) were 21.1 for physician judgement and 3.1 for the WHO criteria. Negative likelihood ratios (LR–) were 0.10 for physician judgement and 0.67 for the WHO criteria, indicating that clinician judgement was a much more powerful predictor than the WHO criteria.

Conclusions:

Physician clinical judgement was more accurate than the WHO case definition. Reliance on the WHO case definition as a SARS screening tool may lead to an unacceptable rate of misdiagnosis. The SARS case definition must be revised if it is to be used as a screening tool in emergency departments and primary care settings.
Benign pneumatosis intestinalis: a cause of massive pneumoperitoneum in the adult
Authors: Liu David M. , Torreggiani William C. , Rowan Kevin , Nicolaou Savvas
Published: July 2016

Pneumatosis intestinalis (gas in the bowel wall) is often a benign condition, but it may mimic bowel ischemia or infarction and lead to unnecessary surgical intervention, especially when associated with pneumoperitoneum. We present a case of benign pneumatosis intestinalis with massive pneumoperitoneum and discuss various distinguishing features that may aid in its diagnosis.
Sentinel surveillance of HIV and hepatitis C virus in two urban emergency departments
Authors: Houston Stan , Rowe Brian H. , Mashinter Laura , Preiksaitis Jutta , Joffe Mark , Mackey Duncan , Galbraith John , Wiebe Natasha
Published: July 2016

Objectives:

This study was designed to determine the prevalence of HIV and hepatitis C virus (HCV) in a specific population, and to distinguish between known and previously unrecognized infections in the emergency department (ED) setting.

Methods:

Consecutive patients aged 15 to 54 years who had presented to the EDs of 2 urban hospitals during a 6-week period were enrolled in a prospective cross-sectional study if a complete blood count had been obtained as part of their care. The study patients were initially cross-referenced against local databases of known HIV and HCV seropositive patients. After removal of all personal identifiers, the study patients’ leftover blood was serotested for HIV and HCV, and seroprevalences were calculated. Univariate and multivariate analyses were performed to identify factors associated with HIV and HCV infection.

Results:

Of 3057 individuals whose files were analyzed, 1457 (48%) were male and 7% (213) were Aboriginal. Overall, 302 patients (10%; 95% confidence interval [CI], 9%–11%) were seropositive for HCV and, of these, only 132 (44%) were previously known to be. HCV seropositivity was associated with Aboriginal status, age, male gender, hospital site and HIV infection (allp< 0.001). In contrast, 39 patients (1%; 95% CI, 1%–2%) were HIV seropositive. Of these, 32 (82%) were previously known to be HIV positive, and 27 (69%) were HCV seropositive. HIV seropositivity was only associated with HCV infection (p< 0.001).

Conclusions:

The rate of previously undetected infections was relatively low for HIV but high for HCV. Emergency physicians in urban settings will frequently encounter patients not known to be HCV positive and not identified as such. These results emphasize the need for more effective preventive measures in the community and the importance of observing standard (universal) precautions in ED practice.
Screening urine for drugs of abuse in the emergency department: Do test results affect physicians’ patient care decisions?
Authors: Eisen Jeffrey S. , Sivilotti Marco L.A. , Boyd Kirsty U. , Barton Douglas G. , Fortier Christopher J. , Collier Christine P.
Published: July 2016

Background:

Drug abuse is a frequent factor in emergency department (ED) visits. Although commonly performed, qualitative testing of urine for drugs of abuse (u-DOA) is inherently limited in its ability to establish the identity, timing or dose of substances used. Previous studies have demonstrated these limitations, but their designs cannot be used to determine whether the results of u-DOA tests affect physicians’ patient care decisions. Our objective was to determine the impact of u-DOA testing on the care of patients who present to the ED.

Methods:

All adults 18 years of age or older who had u-DOA testing in 2 urban teaching EDs were eligible. Victims of vehicular trauma or sexual assault were excluded. Just prior to communicating the results of u-DOA testing for a patient, an investigator interviewed the ordering physician or consultant physician about the patient care plans for that patient. Test results were then revealed, and the questions immediately repeated. This design isolated the impact of knowledge of u-DOA test results on physicians’ patient care decisions. Any intended changes in patient care plans reported by the interviewed physician were compared to a priori criteria for substantive change and then subsequently reviewed by an independent expert to determine whether that change was justified.

Results:

Of the 110 u-DOA test results studied and the resultant 133 opportunities to influence physician management plans, there were 4 reported changes in management. One management change was judged to be substantive, but none of the 4 reported changes were considered by the independent expert reviewer to be justified. Urine-DOA testing thus led to a justified change in management in 0/133 instances (95% confidence interval 0%–2.3%).

Conclusions:

Urine-DOA is rarely helpful in guiding patient care decisions in the ED. The results of this study call into question the need for this test in the ED setting.
Need for bedside emergency department ultrasonography: case report of a ruptured ectopic pregnancy
Authors: Laviolette Eric
Published: July 2016

Ultrasonography is a useful tool for the immediate evaluation of patients with suspected ruptured ectopic pregnancy, abdominal aortic aneurysm, traumatic intra-abdominal hemorrhage or cardiac tamponade. The 1999 Canadian Association of Emergency Physicians position statement states that bedside emergency department ultrasonography should be available 24 hours per day. This case study illustrates how emergency physicians properly trained in emergency bedside ultrasonography can use this tool effectively to dramatically impact patient care.
When the MAGIC stops: magnesium in acute coronary syndromes — a lesson in medical humility
Authors: Patrick Shannon , Herbert Mel
Published: July 2016

There has been much debate as to whether magnesium, a well-tolerated, readily available and cheap therapy, should be used to treat patients with suspected myocardial infarction. Despite promising results from animal studies and small clinical trials conducted in the 1980s, two large recent trials have concluded that the once phenomenal treatment is ineffective. The story of magnesium for acute myocardial infarction is a lesson in medical humility.
Assessment of inter-observer reliability of two five-level triage and acuity scales: a randomized controlled trial
Authors: Worster Andrew , Gilboy Nicki , Fernandes Christopher M. , Eitel David , Eva Kevin , Geisler Rose , Tanabe Paula
Published: July 2016

Introduction:

The Emergency Severity Index (ESI©) is an initial measure of patient assessment in the emergency department (ED). It rates patients based on acuity and predicted resource intensity from Level 1 (most ill) to Level 5 (least resource intensive). Already implemented and evaluated in several US hospitals, ESI has yet to be evaluated in a Canadian setting or compared with the fivelevelCanadian Emergency Department Triage and Acuity Scale(CTAS).

Objective:

To compare the inter-observer reliability of 2 five-level triage and acuity scales.

Methods:

Ten triage nurses, who had all been trained in the use of CTAS, from 4 urban, academic Canadian EDs were randomly assigned either to training in ESI version 3 (ESI v.3) or to refresher training in CTAS. They independently assigned triage scores to 200 emergency cases, unaware of the rating by the other nurses.

Results:

Number of years of nursing practice was the only significant demographic difference found between the 2 groups (p= 0.014). A quadratically weighted kappa to measure the inter-observer reliability of the CTAS group was 0.91 (0.90, 0.99) and not significantly different from that of the ESI group 0.89 (0.88, 0.99). An inter-test generalizability (G) study performed on the variance components derived from an analysis of variance (ANOVA) revealed G(5) = 0.90 (0.82, 0.99). Conclusions: After 3 hours of training, experienced triage nurses were able to perform triage assessments using ESI v.3 with the same inter-observer reliability as those with experience and refresher training in using the CTAS.
Strategies for managing a busy emergency department
Authors: Campbell Samuel G. , Sinclair Douglas E. ,   The Canadian Association of Emergency Physicians Flow Management contributors
Published: July 2016

In a time of increased patient loads and emergency department (ED) exit block, the need for strategies to manage patient flow in the ED has become increasingly important. In March 2002 we contacted all 1282 members of the Canadian Association of Emergency Physicians and asked them to delineate strategies for enhancing ED patient flow and ED productivity without increasing stress levels, reducing care standards or compromising patient safety. Thirty physicians responded. Their suggested flow management strategies, which ranged from clinical decision-making to communication to choreography of time, space and personnel, are summarized here.
Lemierre syndrome in a child with recent pharyngitis
Authors: Busko Jonnathan Moore , Triner Wayne
Published: July 2016

A 14-year-old boy presented with fever and progressive respiratory distress, one week after an episode of pharyngitis. Although there was a concern about pulmonary embolism secondary to a lower extremity fracture, his presentation was most consistent with Lemierre syndrome. This syndrome is an uncommon but potentially lethal complication of otolaryngological infections. Early recognition and aggressive antibiotic therapy are critical elements in reducing mortality. Emergency physicians should be aware of this syndrome because its incidence appears to be increasing.
Population-based study of medically treated self-inflicted injuries
Authors: Colman Ian , Yiannakoulias Niko , Schopflocher Don , Svenson Lawrence W. , Rosychuk Rhonda J. , Rowe Brian H. ,   ED Atlas Group
Published: July 2016

Objective:

Self-inflicted injury is commonly seen in emergency departments (EDs). It may be a precursor to death by suicide. The objective of this study was to examine the epidemiology of self-inflicted injury presentations to EDs in the province of Alberta.

Methods:

Self-inflicted injury records for the 3 fiscal years 1998/99 to 2000/01 were accessed from the Ambulatory Care Classification System, a database that captures all ED encounters in the province of Alberta. Available data for each case included demographic details, location and time of visit, diagnoses and procedures.

Results:

There were 22 396 self-inflicted injury presentations to Alberta EDs during the study period. Self-inflicted injury rates were higher in females, younger patients, those on social services and those with Aboriginal treaty status. There were higher rates of return visits in the year following the self-inflicted injury than in other patient groups. Data showed regional variation. Trends could be seen in the timing of self-inflicted injury presentations by hour of day, day of week, and month of year.

Conclusions:

Self-inflicted injury is common, with particularly high rates demonstrated among marginalized populations. This study provides comprehensive data on those who present with self-inflicted injuries, and can be used to guide further treatment, research and evaluation for this population.
Compliance with guidelines for emergency management of asthma in adults: experience at a tertiary care teaching hospital
Authors: Krym Valerie F. , Crawford Brent , MacDonald Russell D.
Published: July 2016

Objectives:

Despite evidence-based clinical practice guidelines for the emergency management of asthma, substantial treatment variation exists. Our objective was to assess compliance with the Canadian Association of Emergency Physicians (CAEP) / Canadian Thoracic Society (CTS) Asthma Advisory Committee’s “Guidelines for the emergency management of asthma in adults” in the emergency department (ED) of a university-affiliated tertiary care teaching hospital.

Methods:

This retrospective study was conducted in a Canadian inner city adult ED. Investigators reviewed all ED records for the period from Jan. 1, 2001, to Dec. 31, 2001, and identified adult patients (i.e., >18 years of age) with a primary ED diagnosis of asthma. Hospital records were then reviewed to document compliance with the CAEP/CTS asthma guidelines. Descriptive statistics, including means, standard deviations and frequencies were used to summarize information.

Results:

Overall compliance with the guidelines was 69.6%, (95% confidence interval, 64.7%–74.5%), but compliance ranged from 41.4% for severe asthma, 67.1% for moderate asthma, and 88.6% for mild asthma. Interobserver reliability for compliance assessment was excellent.

Conclusions:

Despite publication and dissemination of evidence-based guidelines for the management of acute asthma in adults, guideline compliance at a university-affiliated, inner city, tertiary care teaching hospital ED is suboptimal.
Intravenous magnesium for acute benign headache in the emergency department: a randomized double-blind placebo-controlled trial
Authors: Frank Leonard R. , Olson Carin M. , Shuler Klaus B. , Gharib Salma F.
Published: July 2016

Background:

Magnesium deficiency may play a role in the pathogenesis of migraines and other headaches. Studies in outpatient clinics have found that magnesium administered intravenously (IV) reduces headache pain. We investigated the effectiveness of IV magnesium in patients with acute benign headache who presented to the emergency department (ED).

Methods:

This randomized double-blind placebo-controlled trial compared 2 g of IV magnesium versus placebo for the treatment of patients with acute benign headache who presented to the EDs of two teaching hospitals. Pre- and post-treatment pain scores were measured on a 100-mm visual analog pain scale.

Results:

Forty-two patients were randomized, 21 in each treatment group. Treatment groups had similar baseline characteristics. After treatment, placebo recipients reported an 8-mm median improvement in pain, and magnesium recipients had a 3-mm improvement (p = 0.63). We found no statistically significant difference between groups for any secondary outcomes; however, the patients who received magnesium had significantly (p = 0.03) more side effects than did those in the placebo group.

Conclusions:

We found no benefit to using IV magnesium to treat patients with acute benign headache who present to the ED.
Myth: Cool mist is an effective therapy in the management of croup
Authors: Colletti James E.
Published: July 2016

Croup is the most common infectious cause of acute airway obstruction in children between 1 and 6 years of age, accounting for 90% of cases of stridor. The majority of cases of croup are caused by parainfluenza and occur during the late fall and winter. Mist has been a mainstay for croup since the 19th century and, even today, many emergency departments (EDs) routinely begin cool mist therapy for patients with croup. Further therapy of croup typically includes nebulized racemic epinephrine and corticosteroids.
Test characteristics of neuroimaging in the emergency department evaluation of children for cerebrospinal fluid shunt malfunction
Authors: Mater Ahmed , Shroff Manohar , Al-Farsi Sami , Drake James , Goldman Ran D.
Published: July 2016

Objective:

Cerebrospinal fluid (CSF) shunt malfunction is one of the most common life-threatening neurosurgical conditions. In the emergency department (ED), imaging techniques to identify shunt malfunction include the shunt series (SS) and CT scanning of the head. We sought to determine the test characteristics of the SS and CT scan for identifying children with shunt malfunction.

Methods:

We retrospectively reviewed the medical records of children with a CSF shunt who presented to our tertiary care pediatric emergency department and received an SS during a 2-year period from Jan. 1, 2001, to Dec. 31, 2002. A pediatric neuroradiologist reviewed all SS and CT scans. We defined shunt malfunction as present if the child underwent operative shunt revision.

Results:

We identified 437 ED visits by 280 children. Forty-seven SS were read as abnormal. A CT scan was performed in 386 (88.3%) cases and 80 were abnormal. Shunt malfunction was identified in 131 (30.0%) children. Sensitivity, specificity, positive predictive value, negative predictive value, positive likelihood ratio and negative likelihood ratio of the SS for identifying cases of shunt malfunction were 30.0%, 95.8%, 72.3%, 75.1%, 7.1 and 0.7, respectively; for the CT scan, they were 61.0%, 82.7%, 64.5%, 80.5%, 3.5 and 0.5, respectively.

Conclusion:

Neuroimaging has a low sensitivity for identifying shunt malfunction. Neurosurgical consultation should be sought if shunt malfunction is clinically suspected, despite normal imaging.
Safety of a modification of the triage level for febrile children 6 to 36 months old using the Paediatric Canadian Triage and Acuity Scale
Authors: Gravel Jocelyn , Manzano Sergio , Arsenault Michael
Published: July 2016

Objective:

The Paediatric Canadian Triage and Acuity Scale (PaedCTAS) stipulates that febrile patients who are 3 to 36 months old should be triaged to the PaedCTAS 3 “urgent” category. To optimize resource use, we implemented a protocol enabling these children to be down-triaged to the PaedCTAS 4 “less urgent” category if there was no sign of toxicity. Our objective was to evaluate the safety of this triage protocol modification.

Methods:

This retrospective cohort study evaluated all patients triaged in an urban tertiary pediatric hospital during a 6-month period between November 22, 2005, and May 22, 2006. Data were retrieved from the emergency department (ED) database and rates of hospitalization and intensive care unit (ICU) admission were compared for 4 groups: all patients triaged as urgent (level 3), all febrile patients from 3 to 36 months old triaged as urgent (level 3), all patients triaged as less urgent (level 4) and all febrile patients aged 3 to 36 months old who were down-triaged to less urgent (level 4).

Results:

There were 36 285 total ED visits during the study period, including 3477 febrile children who were 3 to 36 months old. Nurses down-triaged 1869 febrile children (54%) to the level-4 (less urgent) category and left 1322 (38%) in the level-3 (urgent) category. Hospitalization rate for down-triaged febrile patients was similar to that seen for all PaedCTAS 4 patients (2.4% v. 2.8%, 95% confidence interval for difference –0.3% to 1.1%). Down-triaged patients had significantly lower admission rates than those remaining in the level-3 (urgent) category (absolute risk reduction 10.7% standard deviation 1.9%, p < 0.001). No down-triaged patient died or required ICU admission.

Conclusion:

Febrile children aged 6 to 36 months who have no signs of toxicity can safely be down-triaged, based on triage nurse clinical judgement, to the less urgent PaedCTAS 4 category. This modification would affect the triage level of approximately 5% of all pediatric ED visits.
Patient and family–centred care for pediatric patients in the emergency department
Authors: Brown Kathleen , Mace Sharon E. , Dietrich Ann M. , Knazik Stephen , Schamban Neil E.
Published: July 2016

Patient and family–centred care (PFCC) is an approach to health care that recognizes the integral role of the family and encourages mutually beneficial collaboration between the patient, family and health care professionals. Specific to the pediatric population, the literature indicates that the majority of families wish to be present for all aspects of their child's care and be involved in medical decision-making. Families who are provided with PFCC are more satisfied with their care. Integration of these processes is an essential component of quality care. This article reviews the principles of PFCC and their applicability to the pediatric patient in the emergency department; and it discusses a model for integrating PFCC that is modifiable based on existing resources.