bluuebunny/crossref_metadata_2025_split huggingface dataset:
Traumatic occurrence of chest wall tamponade secondary to subcutaneous emphysema
Authors: Perraut Michael , Gilday Daniel , Reed Gordon 
Published: July 2016

ABSTRACTSubcutaneous emphysema is a physical finding that itself is usually perceived as benign yet rarely may, in and of itself, be life-threatening. We present an unusual case of a 67-year-old woman who developed delayed severe subcutaneous emphysema and tension pneumothorax from a rib fracture subsequent to a fall. We review the pathophysiology, manifestations and management options of this disorder. In patients whose clinical condition allows it, chest tube placement prior to intubation should be considered. Furthermore, positive end-expiratory pressure should be minimized. We present a case that illustrates how subcutaneous emphysema itself can be a potential cause of respiratory failure and tamponade physiology. In our case, a patient with traumatic subcutaneous emphysema developed respiratory failure and clinical deterioration after the introduction of positive pressure ventilation. In such rare scenarios, care should be taken to consider the absolute need for positive pressure ventilation without surgical decompression.
Stable fracture of the pubic rami: a rare cause of life-threatening bleeding from the inferior epigastric artery managed with transcatheter embolization
Authors: Loffroy Romaric , Yeguiayan Jean-Michel , Guiu Boris , Cercueil Jean-Pierre , Krausé Denis 
Published: July 2016

ABSTRACT
Extraperitoneal bleeding from the inferior epigastric artery (IEA) and its branches is a rare complication of blunt pelvic trauma; however, it can result in life-threatening hemorrhage, even in cases of minimally displaced fractures of the pelvic ring. We report the case of a patient who had post-traumatic pelvic hematoma and cardiovascular collapse caused by avulsion of the right pubic branch of the IEA related to undisplaced fractures of the pubic rami. CT scanning followed by angiography showed leakage of contrast from the IEA. Transcatheter arterial embolization was performed to successfully control the hemorrhage. There have been very few previous reports of IEA injury related to stable fractures of the pubic rami successfully treated by transcatheter arterial embolization.
An interventional study to improve the quality of analgesia in the emergency department
Authors: Yanuka Michael , Soffer Dror , Halpern Pinchas 
Published: July 2016

ABSTRACTObjective:We sought to document the adequacy of acute pain management in a high-volume urban emergency department and the impact of a structured intervention.Methods:We conducted a prospective, single-blind, pre- and postintervention study on patients who suffered minor-to-moderate trauma. The intervention consisted of structured training sessions on emergency department (ED) analgesia practice and the implementation of a voluntary analgesic protocol.Results:Preintervention data showed that only 340 of 1000 patients (34%) received analgesia. Postintervention data showed that 693 of 700 patients (99%) received analgesia, an absolute increase of 65% (95% CI 61%–68%), and that delay to analgesia administration fell from 69 (standard deviation [SD] 54) minutes to 35 (SD 43) minutes. Analgesics led to similar reductions in visual analog pain scale ratings during the pre- and postintervention phases (4.5 cm, SD 2.0 cm, and 4.3 cm, SD 3.0 cm, respectively).Conclusion:Our multifaceted ED pain management intervention was highly effective in improving quality of analgesia, timeliness of care and patient satisfaction. This protocol or similar ones have the potential to substantially improve pain management in diverse ED settings.
Acute myocardial infarction in patients with syncope
Authors: McDermott Daniel , Quinn James V. , Murphy Charles E. 
Published: July 2016

ABSTRACT

Objective:
We sought to determine the incidence of acute myocardial infarction (AMI) in emergency department (ED) patients with syncope, the characteristics of these AMIs and how helpful the initial electrocardiogram (ECG) was in identifying these cases.

Methods:
In a prospective cohort of consecutive patients with syncope, the initial ECG was found to be abnormal using a prespecified definition (any nonsinus rhythm or any new or age-indeterminate abnormalities). Patients were then followed up to identify an AMI diagnosed within 30 days of presentation.

Results:
There were 1474 consecutive patient visits for syncope or near-syncope over a 45-month period spanning from Jul. 1, 2000, to Feb. 28, 2002, and Jul. 15, 2002, to Aug. 31, 2004, of which 46 (3.1%) were diagnosed with AMI. The majority of the AMI patients (42) had no ST segment elevation. The initial ECG was abnormal in 37 out of 46 cases. The diagnostic performance of the initial ECG was sensitivity 80% (95% confidence interval [CI] 67%–89%), specificity 64% (95% CI 61%–67%), negative predictive value 99% (95% CI 98%–100%), positive predictive value 7% (95% CI 6%–8%), positive likelihood ratio 2.2 (95% CI 1.6–2.5) and negative likelihood ratio 0.3 (95% CI 0.2–0.5).

Conclusion:
The incidence of AMI in patients presenting with syncope is low. A normal ECG has a high negative predictive value, although its sensitivity is limited.
Penetrating spinal cord injuries with retained canal fragments
Authors: Williams David T. , Chang Danny L. , DeClerck Matthieu P. 
Published: July 2016

Case 1: A previously healthy 15-year-old boy was brought by paramedics to the emergency department (ED) after suffering multiple penetrating gunshot wounds (GSWs) to the lower extremities and a single entry to the left suprascapular region. Vital signs were within normal limits upon presentation.
Case 2: A previously healthy 19-year-old man was brought by paramedics to the ED after suffering multiple stab wounds to the back. The patient was hypoxic and in severe respiratory distress upon arrival. A left thoracostomy tube was placed. Clinically the patient improved and vital signs returned to normal.
Acute postpartum pulmonary edema in a 23-year-old woman 5 days after cesarean delivery
Authors: Dunne Caitlin , Meriano Antonio 
Published: July 2016

ABSTRACT
The presentation of acute dyspnea after pregnancy is rare, but should bring a number of important conditions to the mind of the attending physician. Pulmonary embolism, amniotic fluid embolism, pneumonia, aspiration and pulmonary edema are some of the potentially devastating causes that must be considered. The percentage of pregnancies that are complicated by acute pulmonary edema has been estimated to be 0.08%. The most common contributing factors include the administration of tocolytic agents, underlying cardiac disease, iatrogenic fluid overload and preeclampsia. No matter what the underlying pathology, prompt administration of appropriate resuscitation is always the first priority. Only after the patient has been stabilized can attention be turned to diagnosis and specific treatment. This case examines one such presentation and reviews some of the diagnostic possibilities.
Chemical, biological, radiological and nuclear preparedness training for emergency medical services providers
Authors: Kollek Daniel , Welsford Michelle , Wanger Karen 
Published: July 2016

ABSTRACTObjective:We assessed the self-reported theoretical and practical preparedness training of Canadian emergency medical services (EMS) providers in chemical, biological, radiological and nuclear (CBRN) events.Methods:We designed an online survey to address the theoretical and practical CBRN training level of prehospital providers. Emergency medical services staff in British Columbia and Ontario were invited to participate.Results:Of the 1028 respondents, 75% were male, and the largest demographic groups were front-line personnel with more than 15 years of experience. Only 63% of respondents indicated they had received either theoretical or practical training to work in a contaminated environment, leaving 37% who indicated they had received neither type of training. Of those that had received any training, 61% indicated they had received “hands-on” or practical training and 82% indicated they had received some training in identification of a possibly contaminated scene. Only 42% had received training for symptoms of nerve agents, 37% had received training for symptoms of blister agents and 46% had received training for symptoms of asphyxiants. Thirty-two percent had received training for the treatment of patients exposed to nerve agents, and 30% had received training for the treatment of patients exposed to blister agents. Only 31% of all respondents had received training for detecting radiation.Conclusion:CBRN events involve unique hazards and require specific education and training for EMS providers. A large proportion of Canadian EMS providers report not having received the training to identify and work in contaminated environments.
Effectiveness of a novel training program for emergency medicine residents in ultrasound-guided insertion of central venous catheters
Authors: Woo Michael Y. , Frank Jason , Lee A. Curtis , Thompson Calvin , Cardinal Pierre , Yeung Marianne , Beecker Jennifer 
Published: July 2016

ABSTRACT

Objective:
Insertion of central venous catheters (CVCs) is an essential competency for emergency physicians. Ultrasound-guided (USG) insertion of CVCs has been shown to be safer than the traditional landmark technique. There is no clear consensus on effective methods for training physicians in USG insertion of CVCs. We developed and evaluated a novel educational training program in the USG technique for insertion of CVCs.

Methods:
Sixteen emergency medicine residents volunteered for a pre- and postprogram evaluation study, which was approved by our research ethics board. After their previous experience was determined, each participant was videotaped inserting a USG CVC in the right internal jugular vein on models. Participants then reviewed a Web-based instructional module and had a practical session. Participants were again videotaped inserting a USG CVC. The primary outcome was the change in score before and after the training program, using an expert-validated performance evaluation tool used to review the videotaped performances in a blinded fashion. Participants also completed a questionnaire to measure their satisfaction with the training program and any change in their perceived competence.

Results:
Participants ranged from residency year 1 to 5. Thirteen of 16 (81%) had never attempted USG insertion of a CVC. Participants reported that the models were realistic. Performance scores (12/19 to 13.2/19) and global ratings assessments (3.5/7 to 5.5/7) improved significantly (p &lt; 0.01; the effect size, Cohen d = 1.12 before and 1.28 after) after the instruction. There was good interrater reliability between evaluators of the videotaped performances regarding performance scores (r = 0.68) and global rating scores (r = 0.75). All participants felt their confidence and technical skills were improved (p &lt; 0.01) and all felt satisfied with the training program.

Conclusion:
This brief innovative multimethod training program was effective in enhancing emergency medicine resident competence in USG insertion of CVCs.
Diagnostic accuracy and clinical utility of emergency department targeted ultrasonography in the evaluation of first-trimester pelvic pain and bleeding: a systematic review
Authors: McRae Andrew , Edmonds Marcia , Murray Heather 
Published: July 2016

ABSTRACTObjective:Emergency department targeted ultrasonography (EDTU) offers the possibility of rapid exclusion of ectopic pregnancy in patients with first-trimester pelvic pain or bleeding. We sought to systematically review the evidence describing the diagnostic accuracy and clinical utility of EDTU in the first trimester of pregnancy, and to generate a pooled estimate of the sensitivity and specificity of EDTU for the detection of intrauterine pregnancy (IUP).Methods:The literature search, abstract review and study selection were performed using predefined criteria. We abstracted the sensitivity and specificity of EDTU for IUP from included studies, and evaluated and summarized the evidence assessing the effect of EDTU use on time to diagnosis, time to treatment of ectopic pregnancy, emergency department (ED) length of stay and health care costs.Results:The specificity of EDTU for IUP in most studies exceeds 98%. The sensitivity in most studies exceeds 90%. Pooled estimates were not calculated because of statistical heterogeneity between studies. Published evidence indicates that EDTU use reduces the frequency of missed ectopic pregnancies, decreases time to surgery for ectopic pregnancy, shortens the length of stay for patients with normal pregnancies and may be more cost-effective than diagnostic strategies requiring formal ultrasonography.Conclusion:EDTU is highly specific for the identification of IUP. Patients who have an IUP identified with EDTU may be safely discharged from the ED with outpatient follow-up. The specificity of EDTU for IUP, along with the potential improvements in patient care that EDTU affords, justifies its adoption as routine ED care in evaluating first-trimester pain or bleeding.
The impact on patient flow after the integration of nurse practitioners and physician assistants in 6 Ontario emergency departments
Authors: Ducharme James , Alder Robert J. , Pelletier Cindy , Murray Don , Tepper Joshua 
Published: July 2016

ABSTRACTObjective:We sought to assess the impact of the integration of the new roles of primary health care nurse practitioners (NPs) and physician assistants (PAs) on patient flow, wait times and proportions of patients who left without being seen in 6 Ontario emergency departments (EDs).Methods:We performed a retrospective review of health records data on patient arrival time, time of initial assessment by a physician, time of discharge from the ED and discharge status.Results:Whether a PA or NP was directly involved in the care of patients or indirectly involved by being on duty, the wait times, lengths of stay and proportion of patients who left without being seen were significantly reduced. When a PA or NP were directly involved in patients' care, patients were 1.6 (95% confidence interval [CI] 1.3–2.1,p&lt; 0.05) and 2.1 (95% CI 1.6–2.8,p&lt; 0.05) times more likely to be seen within the wait time benchmarks, respectively. Lengths of stay were 30.3% (95% CI 21.6%–39.0%,p&lt; 0.01) and 48.8% (95% CI 35.0%–62.7%,p&lt; 0.01) lower when PAs and NPs, respectively, were involved. When PAs and NPs were not on duty, the proportion of patients who left without being seen were 44% (95% CI 31%–63%,p&lt; 0.01) and 71% (95% CI 53%–96%,p&lt; 0.05), respectively.Conclusion:The addition of PAs or NPs to the ED team can improve patient flow in medium-sized community hospital EDs. Given the ongoing shortage of physicians, use of alternative health care providers should be considered. These results require validation, as their generalizability to other locations or types of EDs is not known.
Prehospital triage and direct transport of patients with ST-elevation myocardial infarction to primary percutaneous coronary intervention centres: a systematic review and meta-analysis
Authors: Brooks Steven C. , Allan Katherine S. , Welsford Michelle , Verbeek P. Richard , Arntz Hans-Richard , Morrison Laurie J. 
Published: July 2016

ABSTRACT

Objective:
Percutaneous coronary intervention (PCI) appears to be superior to in-hospital fibrinolysis for most patients with ST-elevation myocardial infarction (STEMI). However, few hospitals have PCI capability. The optimal prehospital strategy for facilitating rapid coronary reperfusion in STEMI patients is unclear. We sought to determine whether direct transport of adult STEMI patients by emergency medical services to primary PCI centres improves 30-day all-cause mortality when compared with a strategy of transportation to the closest hospital.

Methods:
We systematically searched MEDLINE, EMBASE, Cochrane “CENTRAL” database (1980-July 2007) and several other electronic databases. Two authors independently assessed citations for relevance. Two authors independently abstracted data from included studies. We included studies that, 1) transported patients directly to a PCI-capable centre for primary PCI, 2) had a control group that was transported to the closest hospital and 3) reported outcomes of treatment time intervals, all-cause mortality, reinfarction rate, stroke rate or the frequency of cardiogenic shock. We used a random effects model to provide pooled estimates of relative risk (RR) when data allowed.

Results:
We identified 2264 citations with the search. Five studies, including 980 STEMI patients, met inclusion criteria, and were clinically heterogeneous and of variable quality. Most studies were European (3/5) and involved physician out-of-hospital care providers. There was a trend toward increased survival with direct transport to primary PCI but this was not statistically significant (RR 0.51, 95% confidence interval [CI] 0.24–1.10). One study reported nonsignificant reductions in reinfarction (RR 0.43, 95% CI 0.11–1.60) and stroke (RR 0.33, 95% CI 0.01–8.06) with direct transport for primary PCI.

Conclusion:
There is insufficient evidence to support the effectiveness of direct transport of patients with STEMI for primary PCI when compared with transportation to the closest hospital.
“I never hear what happens, even if they die”: a survey of emergency physicians about outcome feedback
Authors: Lavoie Curtis F. , Plint Amy C. , Clifford Tammy J. , Gaboury Isabelle 
Published: July 2016

ABSTRACT

Objective:
Emergency physicians (EPs) rarely find out what happens to patients after the patients leave their care, a process we call “outcome feedback.” Some suggest this hinders the practice of emergency medicine (EM); however, evidence is lacking. We sought to evaluate EPs' perception of the current and potential role of outcome feedback in EM.

Methods:
We surveyed practising French- and English-speaking EPs from emergency departments within 100 km of Ottawa, Ont., in the provinces of Ontario and Quebec. The main outcomes included the prevalence, role and effect of outcome feedback.

Results:
Of the 297 physicians surveyed, 231 (77.8%) responded. The sample contained good representation of language groups, practice settings, sexes and age groups. All participants indicated that knowing outcomes is “essential” (62.6%) or “beneficial” (37.4%) to gaining experience in EM. Participants reported currently receiving passive outcome feedback in 10.0% of all cases, and seeking out (active) outcome feedback in 7.5% of all cases. The great majority of participants (97.3%) stated that they would like to receive more outcome feedback and believed that this would improve diagnostic accuracy (97.3%), clinical efficiency (85.5%), treatment outcomes (95.6%) and job satisfaction (95.1%). When asked to indicate “any possible negative effects that might arise from increased outcome feedback,” 62.1% indicated none. However, 17.9% hypothesized negative emotional effects and 11.5% suggested increased time requirements.

Conclusion:
The overwhelming majority of EPs receive very little outcome feedback. Most would like more outcome feedback and believe it would improve the practice of EM.
Simulation-based training in critical resuscitation procedures improves residents' competence
Authors: Langhan Trevor S. , Rigby Ian J. , Walker Ian W. , Howes Daniel , Donnon Tyrone , Lord Jason A. 
Published: July 2016

ABSTRACTObjective:Residents must become proficient in a variety of procedures. The practice of learning procedural skills on patients has come under ethical scrutiny, giving rise to the concept of simulation-based medical education. Resident training in a simulated environment allows skill acquisition without compromising patient safety. We assessed the impact of a simulation-based procedural skills training course on residents' competence in the performance of critical resuscitation procedures.Methods:We solicited self-assessments of the knowledge and clinical skills required to perform resuscitation procedures from a cross-sectional multidisciplinary sample of 28 resident study participants. Participants were then exposed to an intensive 8-hour simulation-based training program, and asked to repeat the self-assessment questionnaires on completion of the course, and again 3 months later. We assessed the validity of the self-assessment questionnaire by evaluating participants' skills acquisition through an Objective Structured Clinical Examination station.Results:We found statistically significant improvements in participants' ratings of both knowledge and clinical skills during the 3 self-assessment periods (p&lt; 0.001). The participants' year of postgraduate training influenced their self-assessment of knowledge (F2,25= 4.91,p&lt; 0.01) and clinical skills (F2,25= 10.89,p&lt; 0.001). At the 3-month follow-up, junior-level residents showed consistent improvement from their baseline scores, but had regressed from their posttraining measures. Senior-level residents continued to show further increases in their assessments of both clinical skills and knowledge beyond the simulation-based training course.Conclusion:Significant improvement in self-assessed theoretical knowledge and procedural skill competence for residents can be achieved through participation in a simulation-based resuscitation course. Gains in perceived competence appear to be stable over time, with senior learners gaining further confidence at the 3-month follow-up. Our findings support the benefits of simulation-based training for residents.
Does outcome feedback make you a better emergency physician? A systematic review and research framework proposal
Authors: Lavoie Curtis F. , Schachter Howard , Stewart Aviva T. , McGowan Jessie 
Published: July 2016

ABSTRACT

Objective:
The organization of emergency medical care limits the ability of emergency physicians to know the outcomes of most of their patients after the patients leave the emergency department. This lack of outcome feedback may hinder the practice of emergency medicine (EM) by preventing “calibration” of the decision tools of practitioners. We sought to determine what is currently known about outcome feedback in EM, including its incidence, impact and modifiers.

Data source:
We searched the following databases: PreMED-LINE, MEDLINE, EMBASE, CINAHL, CENTRAL, PsycINFO, DARE, Health Technology Assessment Database and AMED. We performed manual searches on abstract databases, reference lists, various health information and research websites, and nonindexed journals.

Study selection:
Selection entailed a 2-step screening process to exclude articles not pertaining to outcome feedback in EM.

Data extraction:
Our search yielded 1128 bibliographic records, from which screening identified 7 relevant reports: 5 surveys, 1 system level evaluation and 1 intervention trial.

Data synthesis:
All studies were found to have “inadequate” or “unable to assess” reporting and study quality. Systems for outcome feedback to EM residents have been increasingly available since 1984, though they are perceived to be inadequate. Commonly used mechanisms for outcome feedback include automatic routing of discharge summaries, case conferences for admitted patients and telephone calls to patients or families for discharged patients. With respect to attending emergency physicians, no conclusions or clinical recommendations can be made given the level of available evidence.

Conclusion:
The potential importance of outcome feedback remains, at this time, underevaluated. We propose a research framework, and hypothesize that increasing outcome feedback would increase emergency physician diagnostic accuracy, therapeutic outcomes, clinical efficiency and job satisfaction. Future research in this area should include surveys and focus groups, as well as simulated or real-world intervention trials.