bluuebunny/crossref_metadata_2025_split huggingface dataset:
Performance of emergency medicine residents on a novel practice examination using visual stimuli
Authors: Blouin Danielle , Dagnone Luigi Eugene , McGraw Robert 
Published: July 2016

ABSTRACT

Objectives:
In 2004, the format of the Royal College of Physicians and Surgeons of Canada certification exam in Emergency Medicine was modified to include an audiovisual session. Residents' performance on such stimuli is unknown. This study aims to determine the performance of Emergency Medicine postgraduate year 5 (PGY-5) on a novel practice examination using visual stimuli, in an effort to guide residents' preparatory study, and to help educators focus the teaching related to visual stimuli.

Methods:
In this prospective observational study, 30 PGY-5 residents from 12 Emergency Medicine programs across Canada participated in a practice examination in which they had to answer 133 questions related to 80 visual stimuli. The stimuli included electrocardiograms, medical imaging and clinical photographs. Three experienced faculty provided “reference standard” answers for the visual stimuli. For analysis purpose, stimuli were classified into 9 clinical domains, outlined in The Model of the Clinical Practice of Emergency Medicine.

Results:
Insufficient question numbers in 3 domains prevented reliable inferences. Correct answers were given for 65% of remaining questions, with the following domain distribution: 69% respiratory, 64% trauma, 73% cardiovascular, 62% head–eyes–ears–nose–throat (HEENT), 63% musculoskeletal and 69% cutaneous. Seventy-four percent of ECGs, 64% of imaging, and 62% of photograph-related questions were answered correctly. Incorrect answers were related to a lack of knowledge as well as imprecise or incomplete responses.

Conclusions:
PGY-5 subjects scored lowest in the HEENT and musculoskeletal domains. Medical educators should emphasize these domains in their teaching, and insist on precision and completeness of answers.
Turning a stroke into a TIA: curative thrombolysis with combined intravenous and intra-arterial tPA
Authors: Gladstone David J. , Aviv Richard I. , Jahromi Babak , Black Sandra E. , Baryshnik Devra , Caratao Rochelle , Fox Allan J. 
Published: July 2016

ABSTRACT
Intravenous tissue plasminogen activator (tPA) is standard treatment for eligible patients with acute ischemic stroke, but may be less effective for very severe strokes caused by proximal intracranial artery occlusions. We report the case of a woman with a devastating stroke who recovered completely following emergency revascularization of an occluded proximal middle cerebral artery using a novel treatment approach that combines both intravenous (IV) and intra-arterial (IA) tPA. This case illustrates the potential value of the combined IV–IA thrombolytic approach, which is an emerging investigational treatment strategy for selected patients with severe acute ischemic stroke.
Use of lidocaine and fentanyl premedication for neuroprotective rapid sequence intubation in the emergency department
Authors: Kuzak Nick , Harrison David W. , Zed Peter J. 
Published: July 2016

ABSTRACT

Introduction:
Autoregulation is dysfunctional in the injured brain. Increases in intracranial and arterial pressure may therefore result in extension of the primary injury. Rapid sequence intubation (RSI) is a well-known cause of surges in both arterial pressure and intracranial pressure. Neuroprotective agents, namely lidocaine and fentanyl, have the potential to minimize the pressure surges implicated in secondary brain injury. The purpose of this study was to determine the frequency with which neuroprotective agents were used for neuroprotective RSI in the emergency department.

Methods:
We conducted a retrospective chart review of all 139 patients intubated in the emergency department of Vancouver General Hospital between March and October 2003. Patients were eligible if there was an indication for neuroprotective agents defined as presumed intracranial pathology and a mean arterial pressure (MAP) &gt; 85 mm Hg. Contraindications to fentanyl included MAP &lt; 85 mm Hg or allergy to fentanyl.

Results:
Seventy-seven patients were intubated for primary neurological indications. Indication for intubation included non-traumatic causes (n = 37) (including cerebrovascular accident or intracranial hemorrhage) and closed head injury (n = 40). The mean age (± standard deviation) was 52.3 ± 20.4 years, and 31.4% were female. Fifty-seven (74.0%) patients had indications for neuroprotective agents, without contraindications. When neuroprotective agents were indicated, lidocaine was used in 84.2% (95% confidence interval [CI] 72.6%–91.5%) of patients while fentanyl was used in 33.3% (95%CI 22.4%–46.3%) of patients. Eleven percent of the intubations were performed with a fentanyl dose of Δ 2 mcg/kg, which is the lower limit considered effective.

Conclusions:
Despite the potential benefit of using lidocaine and fentanyl in appropriate patients undergoing neuroprotective RSI in the emergency department, our study identified a significant underutilization of optimal premedication. The identification of barriers to use and the implementation of strategies to optimize use are necessary.
Health promotion and disease prevention in the emergency department: a feasibility study
Authors: Cummings Garnet Edward , Francescutti Louis Hugo , Predy Gerald , Cummings Greta 
Published: July 2016

ABSTRACTBackground:Health promotion and disease prevention have been increasingly recognized as activities that may be within the scope of emergency medicine. The purpose of this feasibility study was to identify health risks and offer immediate interventions to adult patients who have drug and/or alcohol problems, incomplete immunization, are overdue for a Pap (Papanicolaou) smear, and/or are smokers.Methods:The study took place in a busy tertiary Emergency Department (ED) serving an inner-city population with a significant proportion of patients who are homeless, substance abusers, working poor, and/or recent immigrants. A convenience sample of patients completed a computer-based health-risk survey. Trained health promotion nurses offered appropriate interventions to patients following review and discussion of their self-reported data. Interventions included counseling for problem drinking, substance abuse, and smoking cessation, screening for cervical cancer, and immunization.Results:From October 20, 2000 to June 30, 2003, we enrolled 2366 patients. One thousand and eleven subjects (43%) reported substance abuse and 1095 (46%) were smokers. Of the 158 smokers contacted in follow-up, 19 (12%) had quit, 63 (40%) had reduced the number of cigarettes/day and 76 (48%) reported no change. Of 1248 women surveyed, 307 (25%) were overdue for a Pap smear and 54 (18%) received this intervention. Forty-four percent of subjects were overdue for at least one immunization and of those, 414 (40%) were immunized in the ED.Conclusion:At-risk patients can be identified using a computer-based screening tool, and appropriate interventions can be given to a proportion of these patients in a busy inner city ED without increasing wait time.
Impact of A Pressure-Responsive Flow-Limiting Valve on Bag–valve–mask Ventilation in an Airway Model
Authors: M. Busko Jonnathan , Blackwell Thomas H. 
Published: July 2016

ABSTRACT

Objective:
Using a simulated airway model, we compared ventilation performance by emergency medical services (EMS) providers using a traditional bag–valve–mask (Easy Grip®) resuscitator to their performance when using a new device, the SMART BAG® resuscitator, which has a pressure-responsive flow-limiting valve.

Methods:
We recruited EMS providers at an EMS educational forum and performed a randomized, non-blinded, prospective crossover comparison of ventilation with 2 devices on a non-intubated simulated airway model. Subjects were instructed to ventilate a Mini Ventilation Training Analyzer® as they would an 85-kg adult patient in respiratory arrest. After being randomized to order of device use, they performed ventilation for 1 minute with each device. Primary outcomes were ventilation rates and peak airway pressures. We also measured average tidal volume, gastric inflation volume, minute ventilation and inspiratory:expiratory (I:E) ratio, and compared our results to the American Heart Association standards (2005 edition).

Results:
We observed statistically significant differences between the SMART BAG® and the traditional bag–valve–mask for respiratory rate (12 v. 14 breaths/min), peak airway pressure (15.6 v. 18.9 cm H2O), gastric inflation (239.6 v. 1598.4 mL), minute ventilation (7980 v. 8775 mL), and I:E ratio (1.3 v. 1.1). Average tidal volume was similar with both devices (679.6 v. 672.2 mL).

Conclusion:
The SMART BAG® provided ventilation performance that was more consistent with American Heart Association guidelines and delivered similar tidal volumes when compared with ventilation with a traditional bag–valve–mask resuscitator.
Safety and effectiveness of intravenous regional anesthesia (Bier block) for outpatient management of forearm trauma
Authors: Mohr Bruce 
Published: July 2016

ABSTRACT

Objective:
To assess the safety and effectiveness of intravenous regional anesthesia (Bier block) in the management of forearm injuries (i.e., forearm, wrist or hand) by primary care physicians at a diagnostic and treatment facility.

Methods:
A retrospective review was conducted of all patients at a single centre who underwent a Bier block for forearm injuries between September 2000 and March 2005.

Results:
1816 Bier blocks were performed on 1804 patients (64% male) during the study period. Patient age ranged from 4–70 (mean 25) years. Wrist fractures requiring reduction were the most common diagnosis. Adverse events were recorded in 9 cases (0.50%, 95% confidence interval 0.23%–0.94%): 1 case of medication error (0.06%); 3 of improper cuff inflation (0.17%); and 5 of inadequate analgesia (0.28%). None of the adverse events resulted in failure to complete the procedure or in serious morbidity or mortality.

Conclusion:
Bier block anesthesia is a safe, effective and reliable technique in an outpatient primary care setting. This technique is a useful modality for physicians who manage acute upper-extremity injuries.
Potential impact of N-terminal pro-BNP testing on the emergency department evaluation of acute dyspnea
Authors: Murray Heather , Cload Bruce , Collier Christine P. , Sivilotti Marco L.A. 
Published: July 2016

ABSTRACTObjectives:Measurement of the serum B-type natriuretic peptide (BNP) level and more recently its precursor,N-terminal proBNP (NT-proBNP), has been advocated to facilitate the diagnosis of heart failure in the emergency department (ED). We sought to determine the potential impact of adding NT-proBNP testing to the routine evaluation of emergency patients with acute dyspnea.Methods:This prospective cohort study enrolled a convenience sample of acutely dyspneic patients at a tertiary care ED. We excluded trauma patients and those under 30 years of age. Patients underwent standard evaluation, including radiography when indicated. At the point of final diagnosis and blinded to the NT-proBNP result, physicians documented the likelihood that heart failure accounted for the patient's acute dyspnea on a 7-point Likert scale, the data from which was subsequently collapsed to 3 categories for analysis purposes. The primary outcome was the agreement between clinical impression and the NT-proBNP assay classified using manufacturer-recommended, age-specific cut-offs. Newly proposed cut-offs from a recent study were also evaluated.Results:One hundred and twenty-nine patients making 139 ED visits were enrolled (median age 76 years; 59% admitted). The serum NT-proBNP assay was positive in 119 (86%, 95% confidence interval [CI] 80%–91%) cases, including 75% (43/57, 95% CI 62%–86%) of the cases that the treating physician felt were not caused by heart failure, and 86% (25/29, 95% CI 68%–96%) where the treating physician was unsure. The median NT-proBNP concentration was higher in patients clinically believed to have heart failure rather than pneumonia or chronic obstructive pulmonary disease; however, the ranges of these values overlapped extensively (median 4361 pg/mL; interquartile range [IQR] 2386–10877 v. 1651 pg/mL; IQR 370–4745, respectively).Conclusions:There is high discordance between the clinical impression of treating physicians and NT-proBNP concentrations, notably in patients who are believed not to have heart failure. Although the reference standard of ED diagnosis is imperfect, the broad overlap in NT-proBNP concentrations suggests poor specificity in this target patient population. The introduction of routine ED NT-proBNP testing using the current cut-offs would be expected to result in substantial indirect costs from further diagnostic testing. It remains unclear whether the introduction of this diagnostic test would have a positive impact on clinically relevant patient outcomes.
Adequacy of antidote stocking in British Columbia hospitals: The 2005 Antidote Stocking Study
Authors: Wiens Matthew O. , Zed Peter J. , Lepik Katherine J. , Abu-Laban Riyad B. , Brubacher Jeffrey R. , Gorman Sean K. , Kent Debra A. , Purssell Roy A. 
Published: July 2016

ABSTRACTBackground:Inadequate hospital stocking and the unavailability of essential antidotes is a worldwide problem with potentially disastrous repercussions for poisoned patients. Research indicates minimal progress has been made in the resolution of this issue in both urban and rural hospitals. In response to this issue the British Columbia Drug and Poison Information Centre developed provincial antidote stocking guidelines in 2003. We sought to determine the compliance with antidote stocking in BC hospitals and any factors associated with inadequate supply.Methods:A 2-part survey, consisting of hospital demographics and antidote stocking information, was distributed in 2005 to all acute care hospital pharmacy directors in BC. The 32 antidotes examined (21 deemed essential) and the definitions of adequacy were based on the 2003 BC guidelines. Availability was reported as number of antidotes stocked per hospital and proportion of hospitals stocking each antidote. For secondary purposes, we assessed factors potentially associated with inadequate stocking.Results:Surveys were completed for all 79 (100%) hospitals. A mean of 15.6 ± 4.9 antidotes were adequately stocked per hospital. Over 90% of hospitals had adequate stocks ofN-acetylcysteine, activated charcoal, naloxone, calcium salts, flumazenil and vitamin K; 71%–90% had adequate dextrose 50% in water (D50W), ethyl alcohol or fomepizole, polyethylene glycol electrolyte solution, protamine sulfate, and cyanide antidotes; 51%–70% had adequate folic acid, glucagon, methylene blue, atropine, pralidoxime, leucovorin, pyridoxine, and deferoxamine; and &lt;50% had adequate isoproterenol and digoxin immune Fab. Only 7 (8.9%) hospitals sufficiently stocked all 21 essential antidotes. Factors predicting poor stocking included small hospital size (p &lt; 0.0001), isolation (p = 0.01) and rural location (p &lt; 0.0001).Conclusion:Although antidote stocking has improved since the implementation of the 2003 guidelines, essential antidotes are absent in many BC hospitals. Future research should focus on determining the reasons for this situation and the effects of corrective interventions.
Penetrating chest trauma secondary to a composite hockey stick injury
Authors: Kennedy Joel , Green Robert S. , Henteleff Harry 
Published: July 2016

ABSTRACTHockey is enjoyed by millions of people around the world and is a sport in which aggression is encouraged and injuries are common. Although body-checking is the most common cause of injury in hockey today, hockey sticks are associated with up to 14% of injuries. We report a case of chest trauma requiring surgical intervention secondary to the penetration of a composite hockey stick into a player's thoracic cavity.
Treatment failure in emergency department patients with cellulitis
Authors: Murray Heather , Stiell Ian , Wells George 
Published: July 2016

ABSTRACTObjective:To identify the rate of treatment failure in emergency department patients with cellulitis.Methods:This prospective observational convenience study enrolled adult patients with uncomplicated cellulitis. Physicians performed a standardized assessment prior to treatment. To calculate the interrater reliability of the assessment, duplicate data collection forms were completed on a small subsample of patients. Treatment failure was defined as the occurrence of any one of the following events after the initial emergency department visit: incision and drainage of abscess; change in antibiotics (not due to allergy/intolerance); specialist consultation; or, hospital admission. Comparison of means and proportions between the 2 groups was performed with univariate associations, using parametric or non-parametric tests where appropriate.Results:Seventy-five patients were enrolled; 57% were male, the mean age was 48 (standard deviation 19), 71 (95%) patients had extremity cellulitis and 10 (13%) had abscess with cellulitis. Fourteen episodes (18.7%, 95% confidence interval [CI] 11%–28%) were classified as treatment failures, with an oral antibiotic failure rate of 6.8% (95% CI 2%–22%) and an emergency department-based intravenous antibiotic failure rate of 26.1% (95% CI 16%–40%). Patients with treatment failure were older (mean age 59 yr v. 46 yr,p= 0.02) and more likely to have been taking oral antibiotics at enrolment (50% v. 16.4%,p= 0.01). Patients with a larger surface area of infection were also more likely to fail treatment (465.1 cm2v. 101.5 cm2,p&lt; 0.01). Interrater agreement was high for the presence of fever (kappa 1.0) and the size of surface area of infection (intraclass correlation coefficient 0.98), but low for assessments of both severity (kappa 0.35) and need for admission (kappa 0.46).Conclusions:The treatment of cellulitis with daily emergency department–based intravenous antibiotics has a failure rate of more than 25% in our centre. Cellulitis patients with a larger surface area of infection and previous (failed) oral therapy are more likely to fail treatment. Further research should focus on defining eligibility for treatment with emergency department-based intravenous antibiotics.
Comparison views to diagnose elbow injuries in children: a survey of Canadian non-pediatric emergency physicians
Authors: Dowling Shawn , Farion Ken , Clifford Tammy 
Published: July 2016

ABSTRACT

Objectives:
Elbow injuries in children are a common presenting complaint to the emergency department. Although radiography is a valuable tool in the diagnosis of this injury, x-rays of the injured elbow are inherently difficult to interpret. As a result, comparison views of the uninjured arm have traditionally been recommended to provide an anatomically “normal” radiograph. Recent studies have questioned the use of comparison views in the pediatric emergency department. The primary objective of this study was to determine current practices of non-pediatric emergency physicians in the use of comparison views for the diagnosis of elbow injuries in children.

Methods:
A self-administered mail survey was sent to 300 randomly selected emergency physicians, using the Canadian Association of Emergency Physicians database.

Results:
Two hundred and forty-two (81%) responses were received; 26 were excluded based on pre-determined criteria. Of eligible respondents, 95% ordered comparison views selectively and 64% of these physicians ordered comparison views infrequently. Eighty-eight percent found the comparison views to be “rarely” to “sometimes” useful. Forty-seven percent of respondents stated that they were only “somewhat” confident when interpreting x-rays of a child's elbow.

Conclusion:
This survey demonstrates that non-pediatric emergency physicians are using comparison views selectively for elbow injuries in children, despite being only “somewhat” confident in interpreting the x-rays.
Variation in emergency department visits for conditions that may be treated in alternative primary care settings
Authors: Altmayer Chris A. , Ardal Sten , Woodward Graham L. , Schull Michael J. 
Published: July 2016

ABSTRACTThe purpose of this report is to examine Ontario's geographic variation in emergency department (ED) visits for conditions that may be treated in alternative primary care settings. We studied all visits to Ontario EDs in 2002/03 and calculated county-specific age-standardized rates. Overall in Ontario, there were 3174 ED visits per 100 000 population aged 1-74 for conditions that could be treated in alternate primary care settings, but rates varied widely across counties. They were higher in rural counties with rates up to 7-fold higher than the provincial average. Urban counties had lower rates, some were less than one-third of the provincial average. Further research is needed to determine the relationship between ED utilization and primary care capacity.
Tunnelled central venous catheter–induced thrombosis: a rare case of superior vena cava syndrome
Authors: Aggarwal Sandeep K. , McCauley William 
Published: July 2016

ABSTRACTThrombotic venous obstruction in patients with a tunnelled central venous catheter is a cause of superior vena cava syndrome that is not routinely encountered by emergency physicians. Diagnosis requires identifying patients at risk (e.g., those under treatment for cancer and those who have a tunnelled central venous catheter), recognizing the signs and symptoms of superior vena cava syndrome, usually dyspnea and dilated neck or thoracic veins, and imaging the venous obstruction using computer tomography or sonography. Management involves anticoagulation and local thrombolytic administration. We report the case of a 28-year-old woman who presented with a 2-day history of face, chest and bilateral arm swelling who had been receiving maintenance chemotherapy for acute lymphoblastic leukemia through a Hickman® catheter. This case demonstrates the need to be vigilant for thrombus formation in patients with long-term, indwelling central venous catheters.
Faculty perceptions and practice impact of a faculty development workshop on emergency medicine teaching
Authors: Bandiera Glen , Lee Shirley , Foote John 
Published: July 2016

ABSTRACTBackground:Faculty development initiatives to improve emergency department (ED) teaching are compromised by the paucity of information about what behaviours and characteristics are desirable in an emergency medicine (EM) teacher.Objectives:To design and evaluate a learner-centred, interactive faculty development workshop based on original ED teaching research.Methods:Registrants for a university-based faculty development workshop on ED teaching completed a needs assessment and pre-workshop self-reflection exercise. Responses were grouped into 3 themes derived from the ambulatory teaching literature and a recent survey of expert clinical EM teachers and learners. Participants underwent a half-day workshop consisting of 1 large group interactive session and 3 small group sessions using role playing, practice reflection, real time review of hard copy resources, and brainstorming. Evaluation included a post-event ordinal scale questionnaire and a 4-month follow-up short answer survey, both measuring participants' perceptions of workshop effectiveness.Results:Fifteen faculty participated. The needs assessment identified “Common mistakes,” “Teaching efficiently” and “Dealing with the difficult learner” as themes. All 15 completed evaluations, rating the workshop as relevant (4.6/5), specific to their needs (4.4/5) and useful (4.5/5). At 4 months, 10 out of 10 respondents reported success at implementing new techniques and 8 reported greater confidence in teaching. The most common new techniques were: setting better learning objectives, giving better feedback, actively seeking teaching opportunities, and identifying a teaching point.Conclusions:Learner-centred faculty development meets perceived needs of faculty and can result in participants trying new teaching strategies.