bluuebunny/crossref_metadata_2025_split huggingface dataset:
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

ABSTRACT
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

ABSTRACT: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

ABSTRACTObjectives: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

ABSTRACTObjectives: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&lt; 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

ABSTRACT
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

ABSTRACT

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 &lt; 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 &lt; 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

ABSTRACTObjectives: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

ABSTRACTObjective: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&lt; 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&lt; 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

ABSTRACTObjective: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

ABSTRACTOne 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

ABSTRACT

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

ABSTRACTIntroduction: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

ABSTRACTObjective: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 &gt; 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 &lt; 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 (&lt; 95% on room air or &lt; 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 &gt; 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

ABSTRACTObjective: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.