bluuebunny/crossref_metadata_2025 huggingface dataset:
Take my breath away: a case of lactic acidosis in an asthma exacerbation
Authors: McGonigle Reid , Woods Robert A.
Published: July 2016

A 36-year-old male with a history of chronic asthma presented to an emergency department with shortness of breath consistent with an asthma exacerbation. He had persistent tachypnea following inhaled bronchodilator treatment; thus, the workup and differential diagnosis were expanded. He was found to have a mixed respiratory alkalosis and metabolic acidosis with elevated serum lactate without an obvious cause and was admitted to hospital. His case was reviewed, and the lactic acidosis was thought to be caused by inhaled β2-agonist use. Emergency physicians should be aware of the potential side effects of inhaled β2-agonists as lactic acidosis may complicate clinical assessment and management of asthma exacerbations and lead to unnecessary and potentially dangerous escalations in therapy.
Cardiac arrest in pregnancy and perimortem cesarean delivery: case report and discussion
Authors: Engels Paul T. , Caddy Sheila C. , Jiwa Gulnaz , Matheson J. Douglas
Published: July 2016

Cardiac arrest in pregnancy is a rare occurrence, particularly in the emergency department setting. The resuscitation of a pregnant patient in cardiac arrest is unique in a number of ways. Early identification and treatment of possible etiologies, appropriate response to the physiologic changes present in pregnancy, relief of potential vena cava obstruction by the gravid uterus, and expeditious preparation for possible cesarean delivery are important considerations for a successful resuscitation. We report and discuss the case of a pregnant patient with pulmonary edema and cardiac dysfunction who presented with severe hypoxemia and subsequent cardiac arrest and underwent a perimortem cesarean delivery and simultaneous fetal and maternal resuscitation in the emergency department.
Mass gathering medicine: a practical means of enhancing disaster preparedness in Canada
Authors: Lund Adam , Gutman Samuel J. , Turris Sheila A.
Published: July 2016

Background:

We explore the health care literature and draw on two decades of experience in the provision of medical care at mass gatherings and special events to illustrate the complementary aspects of mass gathering medical support and disaster medicine. Most communities have occasions during which large numbers of people assemble in public or private spaces for the purpose of celebrating or participating in musical, sporting, cultural, religious, political, and other events. Collectively, these events are referred to as mass gatherings. The planning, preparation, and delivery of health-related services at mass gatherings are understood to be within the discipline of emergency medicine. As well, we note that owing to international events in recent years, there has been a heightened awareness of and interest in disaster medicine and the level of community preparedness for disasters. We propose that a synergy exists between mass gathering medicine and disaster medicine.

Method:

Literature review and comparative analysis.

Results:

Many aspects of the provision of medical support for mass gathering events overlap with the skill set and expertise required to plan and implement a successful medical response to a natural disaster, terrorist incident, or other form of disaster.

Conclusions:

There are several practical opportunities to link the two fields in a proactive manner. These opportunities should be pursued as a way to improve the level of disaster preparedness at the municipal, provincial, and national levels.
The utility of the prehospital electrocardiogram
Authors: Davis Matthew T. , Dukelow Adam , McLeod Shelley , Rodriguez Severo , Lewell Michael
Published: July 2016

Objectives:

The 12-lead electrocardiogram (ECG) can capture valuable information in the prehospital setting. By the time patients are assessed by an emergency department (ED) physician, their symptoms and any ECG changes may have resolved. We sought to determine whether the prehospital electrocardiogram (pECG) could influence ED management and how often the pECG was available to and reviewed by the ED physician.

Methods:

A retrospective medical record review was conducted on a random sample of patients ≥ 18 years who had a prehospital 12-lead ECG and were transported to one of two tertiary care centres. Data were recorded onto a standardized data extraction tool. Three investigators independently compared the pECG to the first ECG obtained in the ED after patient arrival at the hospital. Any abnormalities not present on the ED ECG were adjudicated to ascertain whether they had the potential to change ED management.

Results:

Of 115 ambulance runs selected, 47 had no pECG attached to the ambulance call record (ACR) and another 5 were excluded (one ST elevation myocardial infarction, one cardiac arrest, three ACR missing). Of the 63 pECGs reviewed, 16 (25%) showed changes not apparent on the initial ED ECG (κ = 0.83; 95% CI 0.74–0.93), of which 12 had differences that might influence ED management (κ = 0.76; 95% CI 0.72–0.82). Only one hospital record contained a copy of the pECG, despite the current protocol that paramedics print two copies of the pECG on arrival in the ED (one copy for the ACR and one to be handed to the medical personnel). None of 110 ED charts documented that the pECG was reviewed by the ED physician.

Conclusion:

The pECG has the potential to influence ED management. Improvement in paramedic and physician documentation and a formal pECG handover process appear necessary.
Consensus on paramedic clinical decisions during high-acuity emergency calls: results of a Canadian Delphi study
Authors: Jensen Jan L. , Croskerry Pat , Travers Andrew H.
Published: July 2016

Objectives:

To establish consensus on the most important clinical decisions paramedics make during high-acuity emergency calls and to visualize these decisions on a process map of an emergency call. A secondary objective was to measure agreement among paramedics and medical director panel members.

Methods:

A multiround online survey of Canadian paramedics and medical directors. In round 1, participants listed important clinical decisions. In round 2, participants scored each decision in terms of its importance for patient outcome and safety. In rounds 3 and 4, participants could revise their scores. Consensus was defined a priori: 80% or more agreement that a decision was important or extremely important. The included decisions were plotted on a process map of a typical emergency call.

Results:

The panel response rates were as follows: round 1, 96%; round 2, 92%; round 3, 83%; and round 4, 96%. Consensus was reached on 42 decisions, grouped into six categories: airway management (n= 13); assessment (n= 3); cardiac management (n= 7); drug administration (n= 9); scene management (n= 4); and general treatment (n= 6). The on-scene treatment phase of the process map was found to have the highest decision density. Paramedics and medical directors differed in their scoring in 5 of 42 decisions (p< 0.05 or less).

Conclusion:

Consensus was reached among paramedics and medical directors on 42 decisions important for clinical outcome and patient safety. These decisions were visualized on a process map of an emergency call to learn more about where decision density exists during a typical call.
Deep vein thrombosis and bilateral pulmonary embolism following minor trauma to the popliteal fossa: could this have been avoided?
Authors: Orlik Jason , McVey Jennifer
Published: July 2016

Deep vein thrombosis (DVT) with subsequent pulmonary embolus (PE) is frequently fatal if untreated. Athletes may be susceptible to DVT following minor blunt trauma to the popliteal fossa. We report an adult male hockey player with no “classic” risk factors for DVT who presented with a DVT and bilateral PE following minor popliteal blunt trauma. This case report illustrates the utility of likelihood ratios when interpreting the results of diagnostic tests such as Doppler ultrasonography.
Bacterial contamination and cleanliness of emergency department ultrasound probes
Authors: Sanz Geoffrey E. , Theoret Jonathan , Liao Michael M. , Erickson Catherine , Kendall John L.
Published: July 2016

Objectives:

As ultrasonography is increasingly used in the emergency department (ED), ultrasound equipment has become a potential threat to infection control. Improperly cleaned ultrasound probes may serve as a vector for pathogens such as methicillin-resistant Staphylococcus aureus (MRSA). The primary objective of this study was to determine the prevalence of MRSA colonization on ultrasound probes used in a busy, urban ED. It was hypothesized that cultures of our ED ultrasound probes would yield a significant number of positive results for MRSA.

Methods:

In this observational study, 11 ED ultrasound probes were randomly sampled on 10 different occasions. Samples were taken using a RODAC plate method and were cultured for MRSA and methicillin-sensitive Staphylococcus aureus (MSSA). On half of the randomly assigned sampling occasions, a visual inspection of each ultrasound probe for general cleanliness was conducted and recorded. Data were stratified by ultrasound location in the ED and analyzed using the Fisher exact test, with p < 0.05 deemed to be statistically significant.

Results:

Of 110 samples, no isolates of MRSA were cultured. One probe yielded a positive culture for MSSA. Probes in the medicine, trauma, and pediatrics areas were found to be clean 65%, 33%, and 70% of the time, respectively. This variability in probe cleanliness by ED location was found to be statistically significant (p < 0.01).

Conclusions:

Contrary to our hypothesis, MRSA contamination of ultrasound probes was not found. This finding suggests that the spread of MRSA by ED ultrasound machines in a high-volume urban ED is unlikely. Further research at different centres with larger sample sizes is required before these results can be generalized.
Temporal artery thermometer use in the prehospital setting
Authors: Carleton Erica , Fry Brenda , Mulligan Ashlee , Bell Ali , Brossart Cory
Published: July 2016

Objectives:

Prehospital vital signs are an important and required component of patient assessment. We compared the temporal artery thermometer (TAT) to the digital thermometer currently used in our emergency medical service (EMS) system and then to the digital thermometer used in the emergency department. The primary objective of this study was to assess the usefulness of the TAT in the prehospital setting. Other outcomes of interest included whether extraneous factors or cold ambient temperatures affected the TAT readings and paramedic satisfaction with the TAT.

Methods:

This was a prospective, observational study. Patient temperature was taken by EMS personnel with both the digital thermometer and the TAT, and a chart review was conducted on a sample of these patients to compare the TAT to the emergency department digital thermometer.

Results:

A total of 818 patients had their temperatures taken with both thermometers in the prehospital setting. The relationship between the TAT and digital thermometer measurement was positive and moderate; however, there was poor agreement between the two devices. Sixty-nine charts were reviewed, and a positive correlation was found between the TAT and the emergency department digital thermometer, with good agreement between the two devices. No extraneous factors were found to have a noticeable effect on the temperature measurements; the TAT performed well in cold weather, and the EMS personnel reported it to be easy to use.

Conclusion:

The TAT appears to be a suitable alternative to digital thermometers currently used in many EMS systems. The paramedics involved in this study liked the TAT better than the in-ambulance digital thermometer and believed it to be more accurate. Further research on this topic is required.
Intra-articular lidocaine versus intravenous sedation for the reduction of anterior shoulder dislocations in the emergency department
Authors: Hames Heather , McLeod Shelley , Millard Wanda
Published: July 2016

Objective:

The objective was to compare intra-articular lidocaine (IAL) versus intravenous sedation (IVS) for the reduction of acute, anterior shoulder dislocations in the emergency department (ED) in terms of ED length of stay, rate of successful reductions, patient satisfaction, and complications.

Methods:

This was a prospective, randomized trial. Patients in the IAL group received 4 mg/kg (up to 200 mg) of 1% lidocaine injected into the glenohumeral joint using a lateral approach. Patients in the IVS group received medications for sedation as per the discretion of the treating physician. Follow-up was arranged within 2 weeks of the ED visit to assess for complications.

Results:

Forty-four patients (25 IAL, 19 IVS) were included. This trial was stopped early owing to a combination of unexpected findings in success, resource limitations, and difficulty in patient enrolment. Median time from first physician assessment to patient discharge was not different between the IAL (170 minutes) group and the IVS (145 minutes) group (Δ –25 minutes; 95% CI –32, 70;p= 0.46). There was a significantly lower rate (p< 0.001) of successful closed reduction in the IAL group (48%) compared to the IVS group (100%). Patient satisfaction and physician ease of reduction were higher in the IVS group compared to the IAL group (p< 0.05). There were no reported complications in either group at time of reduction or follow-up.

Conclusions:

There was no difference in ED length of stay between groups. There was a lower rate of successful reductions and lower satisfaction scores in the IAL group.
Evaluation of the incidence, risk factors, and impact on patient outcomes of postintubation hemodynamic instability
Authors: Green Robert S. , Edwards Janet , Sabri Elham , Fergusson Dean
Published: July 2016

Objective:

Postintubation hemodynamic instability (PIHI) is a potentially life-threatening adverse event of emergent endotracheal intubation. The objectives of this study were to determine the incidence, risk factors, and impact on patient outcomes associated with PIHI in intubations performed in emergency medicine.

Methods:

A structured chart audit was performed of all consecutive adult patients requiring emergent endotracheal intubations over a 16-month period at a tertiary care emergency department (ED). Data collection included medications, comorbidities, vital signs in the 30 minutes before and after intubation, hospital length of stay, and in-hospital mortality. PIHI was defined as a decrease in systolic blood pressure (SBP) to ≤ 90 mm Hg, a decrease in SBP of ≥ 20% from baseline, a decrease in mean arterial pressure to ≥ 65 mm Hg, or the initiation of any vasopressor medication at any time in the 30 minutes following intubation.

Results:

Overall, 218 patients intubated in the ED were identified, and 44% (96 of 218) developed PIHI. On multivariate analysis, increasing age (OR 1.03, 95% CI 1.01–1.05), chronic obstructive pulmonary disease (OR 3.00, CI 1.19–7.57), and pre–emergent endotracheal intubation hemodynamic instability (OR 2.52, 95% CI 1.27–4.99) were associated with the development of PIHI. The use of a neuromuscular blocking medication was associated with a decreased incidence of PIHI (OR 0.34, 95% CI 0.16–0.75).

Conclusions:

Based on our data, postintubation hypotension occurs in a significant proportion of ED patients requiring emergent airway control. Further investigation is needed to confirm the factors we found to be associated with PIHI and to determine if PIHI is associated with increased morbidity and mortality.
Bilateral occult hip fracture
Authors: Grad Willis B. , Desy Nicholas M.
Published: July 2016

One of the most common acute injuries seen in the emergency department is the hip fracture. This injury is usually diagnosed by plain radiographs, however these fractures are sometimes not obviously apparent. Occult hip fractures present a pitfall for emergency department physicians. We present a case of a patient who sustained bilateral occult hip fractures. We review the epidemiology of the condition, examine what diagnostic studies are available that may help the physician avoid missing the occult hip fracture and what the literature tells us about the utility of each of these modalities. The prognosis of the occult hip fracture along with options for treatment is also discussed.
The safety of ethanol infusions for the treatment of methanol or ethylene glycol intoxication: an observational study
Authors: Wedge Mary Kate , Natarajan Sabrina , Johanson Christel , Patel Rakesh , Kanji Salmaan
Published: July 2016

Background:

Methanol or ethylene glycol ingestion may result in significant morbidity or death without prompt treatment. Despite traditional and widespread use of intravenous ethanol as an antidote, its safety is not well described. An evaluation of the safety and ease of titrating ethanol infusions is necessary given the availability of an alternative antidote.

Objective:

To evaluate the safety and ease of titrating ethanol infusions for the treatment of methanol or ethylene glycol ingestion.

Methods:

We reviewed the hospital records of adults treated with ethanol at The Ottawa Hospital for methanol or ethylene glycol ingestion over a 9-year period. Using a standardized case report form, a single reviewer identified prespecified adverse events that developed after the start of ethanol therapy and classified dose adjustments during ethanol therapy as appropriate or inappropriate based on a priori criteria.

Results:

Forty-nine cases of methanol or ethylene glycol ingestion treated with ethanol were included in the analysis, of which 45 underwent hemodialysis, 38 were admitted to the intensive care unit, and 4 died. At least one adverse event was identified in 45 (92%) cases, including 35 (71%) with agitation requiring chemical or physical restraints and 10 (20%) with a depressed level of consciousness treated with intubation. The median number of ethanol concentration measurements per treatment course was 6 (range 0–24), of which only 27% were within the target range of 22 to 30 mmol/L and 47% were below. When measured concentrations were outside the target, the adjustment in ethanol dosing (or lack thereof) was deemed inappropriate 59% of the time, including 69% of the time during hemodialysis.

Conclusion:

Based on actual practice in a large academic centre, adverse events occur frequently with intravenous ethanol infusions, and ethanol titration is inefficient. The safety profile and therapeutic drug monitoring considerations for ethanol should be considered when choosing an antidote for methanol or ethylene glycol ingestion.
Antibiotic resistance in isolates recovered from women with community-acquired urinary tract infections presenting to a tertiary care emergency department
Authors: Filiatrault Lyne , McKay Rachel M. , Patrick David M. , Roscoe Diane L. , Quan Grahame , Brubacher Jeff , Collins Ken M.
Published: July 2016

Introduction:

We sought to determine the antibiotic susceptibility of organisms causing community-acquired urinary tract infections (UTIs) in adult females attending an urban emergency department (ED) and to identify risk factors for antibiotic resistance.

Methods:

We reviewed the ED charts of all nonpregnant, nonlactating adult females with positive urine cultures for 2008 and recorded demographics, diagnosis, complicating factors, organism susceptibility, and risk factors for antibiotic resistance. Odds ratios (ORs) and 95% confidence intervals (CIs) for potential risk factors were calculated.

Results:

Our final sample comprised 327 UTIs: 218 were cystitis, of which 22 were complicated cases and 109 were pyelonephritis, including 22 complicated cases.Escherichia coliaccounted for 82.3% of all UTIs, whereasStaphylococcus saprophyticusaccounted for 5.2%. In uncomplicated cystitis, 9.5% of all isolates were resistant to ciprofloxacin and 24.0% to trimethoprim-sulfamethoxazole (TMP-SMX). In uncomplicated pyelonephritis, 19.5% of isolates were resistant to ciprofloxacin and 36.8% to TMP-SMX. In UTI (all types combined), any antibiotic use within the previous 3 months was a significant risk factor for resistance to both ciprofloxacin (OR 3.34, 95% CI 1.16–9.62) and TMP-SMX (OR 4.02, 95% CI 1.48–10.92). Being 65 years of age or older and having had a history of UTI in the previous year were risk factors only for ciprofloxacin resistance.

Conclusions:

E. coliwas the predominant urinary pathogen in this series. Resistance to ciprofloxacin and TMP-SMX was high, highlighting the importance of relevant, local antibiograms. Any recent antibiotic use was a risk factor for both ciprofloxacin and TMP-SMX resistance in UTI. Our findings should be confirmed with a larger prospective study.
The SCRAP rule: The Derivation and Internal Validation of a Clinical Decision Rule for Computed Tomography of the Chest in Blunt Thoracic Trauma
Authors: Payrastre Julien , Upadhye Suneel , Worster Andrew , Lin Daren , Kahnamoui Kamyar , Patterson Heather , Sanaee Layli , Clayden Rob
Published: July 2016

Objective:

To derive and internally validate a clinical decision rule that will rule out major thoracic injury in adult blunt trauma patients, reducing the unnecessary use of chest computed tomographic (CT) scans.

Methods:

Data were retrospectively obtained from a chart review of all trauma patients presenting to a Canadian tertiary trauma care centre from 2005 to 2008, with those from April 2006 to March 2007 being used for the validation phase. Patients were included if they had an Injury Severity Score > 12 and chest CT at admission or a documented major thoracic injury noted in the trauma database. Patients with penetrating injury, a Glasgow Coma Scale (GCS) score ≤ 8, paralysis, or age < 16 years were excluded.

Results:

There were 434 patients in the derivation group and 180 in the validation group who met the inclusion criteria. Using recursive partitioning, five clinical variables were found to be particularly predictive of injury. When these variables were normal, no patients had a major thoracic injury (sensitivity 100% [95% CI 98.4–100], specificity 46.9% [95% CI 44.2–46.9], and negative likelihood ratio 0.00 [95% CI 0.00–0.04]). The five variables were oxygensaturation (< 95% on room air or < 98% on any supplemental oxygen),chest radiograph, respiratoryrate ≥ 25, chestauscultation, and thoracicpalpation (SCRAP). In the validation group, the same five variables had a sensitivity of 100% (95% CI 96.2–100%), a specificity of 44.7% (95% CI 39.5–44.7%), and negative likelihood ratio of 0.00 (95% CI 0.00–0.10).

Conclusions:

In major blunt trauma with a GCS score > 8, the SCRAP variables have a 100% sensitivity for major thoracic injury in this retrospective study. These findings need to be prospectively validated prior to use in a clinical setting.
The wire is really easy to see (WIRES): sonographic visualization of the guidewire by novices
Authors: Moak James H. , Rajkumar John S. , Woods William A.
Published: July 2016

Objective:

To determine whether novices can distinguish between properly and improperly placed guidewires in a vascular access model after only minimal training.

Methods:

This was a prospective study involving trainees with no previous training in sonographic guidewire visualization. A vascular access model was created with guidewires positioned inside or adjacent to simulated veins. Subjects were taught to scan each wire to determine its location. Afterward, participants scanned a test model of five vein-wire pairs and recorded their answers as “inside,” “outside,” or “unsure.” The test characteristics of sonographic guidewire localization were determined using actual wire location as the criterion standard.

Results:

Forty trainees (21 emergency medicine residents, 19 medical students) participated, and each examined five simulated veins. There were 156 true positives (intravascular wire correctly identified), 38 true negatives (extravascular wire correctly identified), 2 false negatives, 2 false positives, and 2 cases in which the participant marked “not sure,” which were reclassified as false negatives. Test characteristics were sensitivity 97.5% (95% CI 93.3–99.2) and specificity 95.0% (95% CI 81.8–99.1). The overall accuracy was 97.0%.

Conclusions:

Sonographic guidewire visualization, a step recommended for ensuring proper vessel cannulation during central venous access, can be accomplished by novices with a high degree of accuracy.
Central serous retinopathy: an unusual cause of acute visual loss
Authors: Chu Jennifer L. , Tyberg Jeffrey
Published: July 2016

Ophthalmologic complaints represent approximately 2% of emergency department (ED) visits. Acute vision loss is the most serious of such presentations and requires prompt assessment for a treatable cause. The differential diagnosis for acute vision loss includes retinal detachment, macular disorders, vaso-occlusive disorders, temporal arteritis, neuro-ophthalmologic disorders, and functional disorders. We report the case of a previously healthy 33-year-old man who presented to the ED with acute bilateral vision loss that was ultimately diagnosed as central serous retinopathy (CSR), an idiopathic, self-limited condition that typically affects males age 20 to 50 years. This condition is not mentioned in standard emergency medicine textbooks or the emergency medicine literature, and our hope is that our report will serve to illustrate a typical case of CSR and help prompt emergency physicians to consider this diagnosis in the appropriate circumstances.
Parents' willingness to have their child receive care by physician assistants in a pediatric emergency department
Authors: Doan Quynh , Sheps Sam , Wong Hubert , Singer Joel , Johnson David , Kissoon Niranjan
Published: July 2016

Objective:

To determine the willingness of parents of children visiting a pediatric emergency department to have a physician assistant (PA) assess and treat their child and the waiting time reduction sufficient for them to choose to receive treatment by a PA rather than wait for a physician.

Method:

After describing the training and scope of practice of PAs, we asked caregivers of children triaged as urgent to nonurgent if they would be willing to have their child assessed and treated by a PA on that visit: definitely, maybe, or never. We also asked the minimum amount of waiting time reduction they would want to see before choosing to receive treatment by a PA rather than wait for a physician.

Result:

We approached 320 eligible subjects, and 273 (85.3%) consented to participate. Regarding whether they would be willing to have their child receive treatment by a PA, 140 (51.3%) respondents answered definitely, 107 (39.2%) said maybe, and 26 (9.2%) said never. Most respondents (64.1%) would choose to have their child seen by a PA instead of waiting for a physician if the waiting time reduction were at least 60 minutes (median 60 minutes [interquartile range 60 minutes]). Respondents' perception of the severity of their child's condition was associated with unwillingness to receive treatment by a PA, whereas child's age, presenting complaint, and actual waiting time were not.

Conclusion:

Only a small minority of parents of children visiting a pediatric emergency department for urgent to nonurgent issues are unwilling to have their child treated by PAs.
Cardiopulmonary resuscitation and automatic external defibrillator training in schools: “Is anyone learning how to save a life?”
Authors: Hart Devin , Flores-Medrano Oscar , Brooks Steve , Buick Jason E. , Morrison Laurie J.
Published: July 2016

Objectives:

Bystander resuscitation efforts, such as cardiopulmonary resuscitation (CPR) and use of an automatic external defibrillator (AED), save lives in cardiac arrest cases. School training in CPR and AED use may increase the currently low community rates of bystander resuscitation. The study objective was to determine the rates of CPR and AED training in Toronto secondary schools and to identify barriers to training and training techniques.

Methods:

This prospective study consisted of telephone interviews conducted with key school staff knowledgeable about CPR and AED teaching. An encrypted Web-based tool with prespecified variables and built-in logic was employed to standardize data collection.

Results:

Of 268 schools contacted, 93% were available for interview and 83% consented to participate. Students and staff were trained in CPR in 51% and 80% of schools, respectively. Private schools had the lowest training rate (39%). Six percent of schools provided AED training to students and 47% provided AED training to staff. Forty-eight percent of schools had at least one AED installed, but 25% were unaware if their AED was registered with emergency services dispatch. Cost (17%), perceived need (11%), and school population size (10%) were common barriers to student training. Frequently employed training techniques were interactive (32%), didactic instruction (30%) and printed material (16%).

Conclusions:

CPR training rates for staff and students were moderate overall and lowest in private schools, whereas training rates in AED use were poor in all schools. Identified barriers to training include cost and student population size (perceived to be too small to be cost-effective or too large to be implemented). Future studies should assess the application of convenient and cost-effective teaching alternatives not presently in use.
Does the sedation regimen affect adverse events during procedural sedation and analgesia in injection drug users?
Authors: Scheuermeyer Frank Xavier , Andolfatto Gary , Qian Hong , Grafstein Eric
Published: July 2016

Objectives:

Injection drug users (IDUs) often undergo procedural sedation and analgesia (PSA) as part of emergency department (ED) treatment. We compared adverse events (AEs) using a variety of sedation regimens.

Methods:

This was a retrospective analysis of a PSA safety audit in two urban EDs. Consecutive self-reported IDUs were identified, and structured data describing comorbidities, vital signs, sedation regimens (propofol [P], propofol-fentanyl [PF], fentanyl-midazolam [FM], ketofol [1:1 ketamine:propofol, KF], and ketamine-propofol [KP]) and AEs were collected. The primary outcome was the proportion of patients in each sedation group having an AE; the secondary outcome was the proportion of patients having a cardiovascular or respiratory AE.

Results:

Data were collected on 276 IDUs (78 P, 82 PF, 65 FM, 25 KF, and 26 KP), and 18 patients had AEs (6.5%, 95% CI 4.0–10.3). The AE rates were 0.0%, 8.5%, 9.2%, 12.0%, and 7.6%, respectively, with propofol having a significantly lower rate (Pearson coefficient 14.9,p= 0.007). The cardiovascular/respiratory AE rates were significantly different as well, with P, KP, and KF having the lowest rates (Pearson coefficient 13.3,p= 0.01).

Conclusions:

For IDU PSA, the overall AE rate was 6.5%, and propofol appeared to have a significantly lower rate.
Unfavourable outcome for children leaving the emergency department without being seen by a physician
Authors: Gravel Jocelyn , Gouin Serge , Carrière Benoit , Gaucher Nathalie , Bailey Benoit
Published: July 2016

Objective:

To assess the prevalence of an unfavourable outcome among children leaving without being seen by a physician in the emergency department (ED).

Method:

This was a prospective cohort study conducted over a complete year in a pediatric tertiary care ED. A random sample of all children younger than 19 years of age who left without being seen by a physician was contacted by phone 4 to 6 days following the ED visit. The primary outcome was the occurrence of an unfavourable outcome prospectively defined using a Delphi method among 15 pediatric emergency physicians. An unfavourable outcome was defined as hospitalization, the need for an invasive procedure (intravenous or intramuscular medication, fracture reduction, bone casting, or surgical intervention), suicide attempt, or death in the 72 hours following leaving without being seen by a physician. As a secondary outcome, multiple potential predictors were evaluated. The first analysis evaluated the proportion of unfavourable outcomes among children who left without being seen by a physician. Then logistic regression identified predictors of unfavourable outcomes.

Results:

During the study period, 61,909 children presented to the ED, 7,592 (12%) left without being seen by a physician, and 1,579 were recruited. Thirty-eight (2.4%; 95% CI 1.7–3.2) patients fulfilled the criteria for an unfavourable outcome. On multiple logistic regression, chief complaints related to trauma and absence of nurse counseling had higher risks of unfavourable outcome.

Conclusions:

Approximately 2% of children who left without being seen by a physician at a tertiary care pediatric ED had an unfavourable outcome.
Assessment of consultation impact on emergency department operations through novel metrics of responsiveness and decision-making efficiency
Authors: Lee Patricia A. , Rowe Brian H. , Innes Grant , Grafstein Eric , Vilneff Renee , Wang Dongmei , van Rheenen Susan , Lang Eddy
Published: July 2016

Objectives:

Requests for specialty consultation are common in emergency departments (EDs) and often contribute to delays in throughput. Our objectives were to describe the contribution of the consultation process to total ED length of stay (LOS) through novel metrics and illustrate causes of delay.

Methods:

We conducted a prospective cross-sectional study at three Canadian tertiary care centres. Adult ED patients with requested medical/surgical consultations were enrolled. We created original metric intervals: total consultation time (TCT) defined as the interval from the initial consultation request to the disposition decision, consult response time (CRT) from the request to the consultant arrival, and decision-making interval (DMI) from arrival to the disposition decision. The consultation impact index (CII) was defined as the percentage of ED LOS consumed by the TCT. Reasons for delay were documented if time stamps exceeded preset benchmarks.

Results:

The median TCT for 285 patients was 138 minutes (interquartile range [IQR]: 82–239 minutes), whereas the median total ED LOS was 778 minutes (IQR 485–1,274 minutes). The median CRT was 55 minutes (IQR 21–115 minutes), and the median DMI was 58 minutes (IQR 25–126 minutes). The CII measured 26% (95% CI 23–28). Major contributors to consultation delay included urgent ward issues, simultaneous ED consultations, and the need for additional laboratory or radiographic investigations.

Conclusion:

The consultation process is highly variable and has an important impact on ED LOS. We describe novel measures related to consultation performance and provide an analysis of what causes delays. These results can be used to seek improvements in the consulting process.
Streptococcus pneumoniae–induced purpura fulminans in a woman with functional asplenia
Authors: Wojtowicz Jeremy M. , Jones Graham Longden
Published: July 2016

Purpura fulminans is a rare complication of septic shock, often associated withStreptococcus pneumoniae. Patients with anatomic or functional asplenia are at increased risk for infection because of impairment of their ability to defend against encapsulated pathogens. We report the case of a previously healthy, unimmunized 33-year-old female with functional asplenia who presented in septic shock and purpura fulminans and died in spite of maximal resuscitative measures. The clinical presentation, diagnosis, and management of purpura fulminans are reviewed. Purpura fulminans is a rare condition that requires early diagnosis and aggressive management by emergency physicians.
Teaching the RAPID approach at the start of emergency medicine clerkship: an evaluation
Authors: Woods Robert A. , Trinder Krista , D’Eon Marcel , McAleer Sean
Published: July 2016

Background:

The RAPID approach (Resuscitation, Analgesia and assessment, Patient needs, Interventions, Disposition) was developed as an approach to managing emergency department patients. It is a mental checklist to help trainees provide comprehensive care, addressing issues in priority. Its impact on trainee performance has not been assessed.

Methods:

Forty-two clerkship students were enrolled, with 21 students in each group. They received or did not receive the teaching intervention on an alternate basis. Students were assessed through daily encounter cards, a case presentation, a self-assessment form, a prerotation case (case E), and a sixcase short-answer exit examination (cases A to F) with case E repeated. Case E was designed specifically to assess students’ ability to provide comprehensive care. Fourteen students participated in focus groups.

Results:

Students in the intervention group had significantly higher exit examination case E scores (11.67 of 14 v. 10.26 of 14, p 5 0.008) and improvement in their case E scores from pre- to postrotation (1.82 v. 0.26, p 5 0.006). There were no significant differences in the other outcome measures. Intervention group students made positive comments around analgesia, addressing nonmedical needs and counseling on health promotion during focus groups.

Conclusions:

Students exposed to the RAPID approach at the start of their emergency medicine rotation performed better on the one component of the written examination for which it was designed to improve performance. Students found it to be a useful mental checklist for comprehensive care, possibly addressing the hidden curriculum. Emergency medicine educators should consider further study and careful implementation of the RAPID approach.
Socioeconomic status of emergency department users in Ontario, 2003 to 2009
Authors: Tozer April P. , Belanger Paul , Moore Kieran , Caudle Jaelyn
Published: July 2016

Objective:

Emergency department (ED) overcrowding in Canada is an ongoing problem resulting in prolonged wait times, service declines, increased patient suffering, and adverse patient outcomes. We explored the relationship between socioeconomic status (SES) and ED use in Canada's universal health care system to improve our understanding of the nature of ED users to both improve health care to the most deprived populations and reduce ED patient input.

Methods:

This retrospective study took information from the National Ambulatory Care Reporting System (NACRS) database for all ED visits in Ontario between April 1, 2003, and March 31, 2010. As there is no direct measure of SES available from ED visit records, a proxy measure of SES was used, namely a deprivation index (DI) developed from material and social factors from the 2006 Canadian census using the patient's residential neighbourhood. DI scores were assigned to ED visit records using Statistics Canada's Postal Code Conversion File, which links postal and census geography.

Results:

A total of 36,765,189 visits occurred during the study period. A cross-province trend was found wherein the most deprived population used EDs disproportionately more than the least deprived population (relative risk: 1.971 95% confidence interval 1.969–1.973,p< 0.0001). This trend was stable across the entire study period, although the divergence is attenuating.

Conclusion:

Social determinants of health clearly impact ED use patterns. People of the lowest SES use ED services disproportionately more than other socioeconomic groups. Focused health system planning and policy development directed at optimizing health services for the lowest SES populations are essential to changing ED use patterns and may be one method of decreasing ED overcrowding.
Familiarity with radiation exposure dose from diagnostic imaging for acute pulmonary embolism and current patterns of practice
Authors: Ahn Justin S. , Edmonds Marcia L. , McLeod Shelley L. , Dreyer Jonathan F.
Published: July 2016

Objective:

To assess the current level of knowledge and practice patterns of emergency physicians regarding radiation exposure from diagnostic imaging modalities for investigating acute pulmonary embolism (PE).

Methods:

An online survey was sent to adult emergency physicians working at two academic tertiary care adult emergency departments (EDs) to determine imaging choices for investigating PE in various patient populations and to assess their current knowledge of radiation doses and risks. A retrospective chart review was performed for all adult patients who underwent computed tomographic pulmonary angiography (CTPA) and/or ventilation-perfusion (V/Q) scanning in the same EDs.

Results:

The survey response rate was 72.1% (31 of 43 physicians). For patients < 30 years old, 83.9% of physicians chose V/Q scanning as their test of choice, regardless of gender. Although only a third of respondents knew the estimated radiation dose of a V/Q scan (37.5%) and a CTPA (32%), the majority were aware that V/Q scans involved less ionizing radiation than CTPAs. In the retrospective review, 663 charts were reviewed, including 201 CTPAs and 462 V/Q scans. V/Q scanning was the preferred modality in female patients (75.9% v. CTPA 24.1% [OR 2.1; 95% CI 1.5–2.9]) and in patients < 30 years old (87.9% v. CTPA 12.1% [OR 4.8; 95% CI 2.4–9.4]).

Conclusions:

Although surveyed physicians possessed limited knowledge of radiation doses of CTPA and V/Q scans, they preferentially used the lower radiation V/Q scans in younger patients, particularly females, in both the survey vignettes and in clinical practice. This may reflect efforts to reduce radiation exposures at our institution.
Holocord spinal epidural abscess in a pregnant patient presenting as premature labour: a rare presentation of an unusual diagnosis
Authors: Burton Kirsteen R. , Wang Xi , Dhanoa Deljit
Published: July 2016

Spinal epidural abscess (SEA) is a rare clinical entity. It is less common when the entire epidural space is involved, known as a holocord or panspinal SEA, and it is even less common in a pregnant patient. We report a case of methicillin-resistant Staphylococcus aureus holocord SEA in a 30-year-old female at approximately 22 weeks' gestational age who presented with lumbar pain and pelvic pressure and the urge to bear down. Magnetic resonance imaging of the spine demonstrated extensive SEA and meningitis from the foramen magnum to the lumbar spine that was treated both medically and surgically. The incidence of, clinical presentation of, and risk factors for developing SEA are discussed. If untreated, expanding SEAs produce sensory symptoms and signs, motor dysfunction, and, eventually, paralysis and death. The medical and surgical management of SEA is also discussed. SEA can have an insidious and atypical presentation despite
extensive involvement of the epidural space. Therefore, the diagnosis of SEA should always be considered in patients who present to the emergency department with back pain.
Preparedness of urban, general emergency department staff for neonatal resuscitation in a Canadian setting
Authors: Kester-Greene Nicole , Lee Jacques S.
Published: July 2016

Objectives:

The level of expertise and degree of training in neonatal resuscitation (NNR) of emergency physicians is not standardized and has not been measured. We sought to determine the self-reported comfort with, knowledge of, and experience with NNR of emergency department (ED) staff in a general ED prior to the opening of a new neonatal intensive care unit (NICU) and to explore factors associated with NNR comfort.

Methods:

Using Dillman methodology, we electronically surveyed full-time emergency physicians and nurses. Participants rated knowledge, comfort, and experience on 5-point Likert scales. We used logistic regression to explore factors associated with NNR comfort.

Results:

The response rate was 67.3% (n = 107). Only 4.2% of staff reported ever participating in a NNR, and only 38.7% reported any previous NNR training. Between 75 and 85% of participants rated their comfort level in caring for neonates, sense of preparedness, and knowledge of managing a sick neonate as poor or very poor. A recent neonatal clinical encounter was the strongest predictor of perceived comfort in NNR (OR = 22.2, 95% CI 5.0-98.7), as was completion of the Neonatal Resuscitation Provider (NRP) course (OR = 3.1, 95% CI 1.4-7.0).

Conclusions:

Perceived comfort with, knowledge of, and preparedness for NNR were poor in an urban, general ED prior to the opening of an NICU. Recent neonatal clinical encounter and participation in the NRP course were the strongest predictors of improved NNR comfort. In future work, we intend to assess the impact of simulation-based training on comfort with NNR among ED staff who primarily treat adults.
Point-of-care ultrasonography adoption in Canada: using diffusion theory and the Evaluation Tool for Ultrasound skills Development and Education (ETUDE)
Authors: Woo Michael Y. , Frank Jason R. , Lee A. Curtis
Published: July 2016

Objective:

Point-of-care ultrasonography (PoCUS) first appeared in the 1980s in North America, but the extent of the diffusion of its adoption is unknown. We characterized early PoCUS adoption by emergency physicians in Canada and its barriers to use using Rogers' diffusion of innovations theory.

Methods:

We developed a questionnaire based on a pilot study and literature review to assess past, current, and potential use of PoCUS and potential barriers to adoption. A Dillman technique for electronic surveys was used for dissemination. Using Rogers' diffusion of innovations theory, we developed and validated the Evaluation Tool for Ultrasound skills Development and Education (ETUDE). ETUDE scores allowed categorization of respondents into innovators, early adopters, majority, and nonadopters. Descriptive statistics, correlations, and x2statistics were used to analyze the data.

Results:

The 296 respondents (36.4% of 814 surveyed) had a median age of 40 and were 72.5% male. Adoption scores using ETUDE revealed nonadopters (18.8%), majority (28.7%), early adopters (34.5%), and innovators (18.0%). Respondents endorsed “always” using PoCUS currently and in the future for focused assessment with sonography in trauma (FAST) (current 41.8%/future 88.4%), first trimester pregnancy (current 23.3%/future 73.7%), suspected abdominal aortic aneurysm (current 32.7%/future 92.6%), basic cardiac indications (current 30.7%/future 87.5%), and central venous catheterization (current 17.0%/future 80.3%). Several barriers to PoCUS were identified for part-time emergency physicians and those working in inner-city/urban/suburban settings.

Conclusion:

This is the first study to determine the state of adoption and barriers to the introduction of PoCUS in Canadian emergency medicine practice. The novel validated ETUDE instrument should be used to evaluate the uptake of PoCUS over time.
Trends in use in a Canadian pediatric emergency department
Authors: Doan Quynh , Genuis Emerson D. , Yu Alvis
Published: July 2016

Introduction:

Emergency department (ED) crowding is a significant problem in Canada and has been associated with decreased quality of care in general and pediatric emergency departments (PEDs). Although boarding of admitted patients in the ED is the main contributor to adult ED overcrowding, factors involved in PED crowding may be different. The objective of this study was to report the trend in PED services use and to document the degree of overcrowding experienced in a Canadian PED.

Methods:

A retrospective cohort study was conducted using administrative data from a tertiary care PED from 2002 to 2011. The primary outcome was PED use (total volume of visits and case severity per triage levels using the Canadian Triage and Acuity Scale [CTAS] score and admissions). Secondary outcomes included measures of PED overcrowding, such as rates of patients leaving without being seen (LWBS) and length of stay (LOS).

Results:

Total volumes increased by 30% over the 10-year study period, whereas hospitalizations remained stable at approximately 10%. Trends in CTAS levels did not indicate meaningful changes in the severity of cases treated at our PED. LWBS proportions among CTAS 3, CTAS 4, and CTAS 5 groups and LOS for all CTAS groups progressively and statistically increased from year to year.

Conclusions:

Over the course of the study period, there was a substantial increase in PED visits,which likely contributed to the worsening markers of PED flow outcomes. Further study into the effects of PED crowding on patient outcomes is warranted.