bluuebunny/crossref_metadata_2025_split huggingface dataset:
Antidote stocking in British Columbia hospitals
Authors: Gorman Sean K. , Zed Peter J. , Purssell Roy A. , Brubacher Jeffrey , Willis Gillian A. 
Published: July 2016

ABSTRACT

Introduction:
Previous studies have demonstrated that antidotes are insufficiently stocked in Canadian and US health care facilities. The purpose of this study was to determine the adequacy of antidote stocking in British Columbia hospitals based on the current guidelines.

Methods:
A written survey was mailed to hospital pharmacy directors at all 93 acute care facilities in BC. Availability of 14 essential antidotes was classified as sufficient or insufficient based on the current guidelines. Facilities were stratified into small (&lt;50 beds), medium (50–250 beds) or large (&gt;250 beds); teaching or non-teaching; trauma or non-trauma, urban or rural, and isolated or non-isolated.

Results:
Complete responses were received from 75 (81%) of 93 hospitals. No hospital had adequate stock of all 14 antidotes. Overall, the average number (± standard deviation) of antidotes adequately stocked was 4.2 ± 2.9 per hospital. Urban hospitals had adequate stocks of 6.5 ± 2.6 antidotes while rural centres had adequate stocks of 2.6 ± 1.8 (p &lt; 0.001). Corresponding figures were 9.0 ± 1.8 for teaching hospitals vs. 3.7 ± 2.4 for non-teaching hospitals (p &lt; 0.001), 8.9 ± 2.0 for trauma centres vs. 3.8 ± 2.5 non-trauma centres (p &lt; 0.001), and 2.5 ± 2.1 for isolated hospitals vs. 4.6 ± 2.9 for non-isolated hospitals (p = 0.018). Small, medium, and large hospitals adequately stocked 2.3 ± 1.7, 5.7 ± 2.2, and 7.7 ± 3.0 antidotes, respectively (p &lt; 0.001). The 4 antidotes most adequately stocked were sodium bicarbonate (77%), N-acetylcysteine (64%), ethanol (49%) and naloxone (47%). Digoxin immune Fab fragments, glucagon, pyridoxine and rattlesnake antivenin were poorly stocked with sufficient supplies of 5%, 7%, 7% and 13%, respectively.

Conclusion:
BC hospitals do not have adequate antidote stocks. Provincial stocking guidelines and coordination of antidote purchasing and stocking are necessary to correct these deficiencies.
Neurologically normal survival after fibrinolysis during prolonged cardiac arrest: case report and discussion
Authors: Clark Kevin , Abu-Laban Riyad B. , Zed Peter J. , Graham Lois 
Published: July 2016

ABSTRACT
Cardiac arrest secondary to pulmonary embolism is a devastating condition with a high mortality rate. It is currently unclear whether fibrinolysis (thrombolysis) is beneficial in this setting. We report the case of a 28-year-old woman with a pulmonary embolism who developed return of pulses following the administration of tissue plasminogen activator after 38 minutes of pulseless electrical activity cardiac arrest. She went on to make a full neurologic and cardiopulmonary recovery. This case is discussed with reference to the current literature on the subject.
Wrist buckle fractures: a survey of current practice patterns and attitudes toward immobilization
Authors: Plint Amy , Clifford Tammy , Perry Jeff , Bulloch Blake , Pusic Martin , Lalani Amina , Ali Samina , Nguyen Bich Hong , Joubert Gary , Millar Kelly 
Published: July 2016

ABSTRACT

Objectives:
Buckle fractures are the most common wrist fractures in children, yet there is little literature regarding their management. This study examined the management of these fractures and attitudes toward their immobilization by pediatric emergency department (ED) physicians and pediatric orthopedic surgeons.

Methods:
A standardized survey was mailed to all pediatric orthopedic surgeons and pediatric ED physicians at 8 Canadian children’s hospitals.

Results:
Eighty-seven percent of physicians responded, including 33 of 39 pediatric orthopedic surgeons and 84 of 96 pediatric ED physicians. Sixty-four percent of respondents believe that wrist buckle fractures always need to be immobilized; pain control was most frequently cited for this belief. Physicians who did not believe that all buckle fractures need to be immobilized indicated that these fractures are inherently stable and have a low risk of refracture. Forty-eight percent of the orthopedic surgeons prefer below-elbow casts, 30% prefer a combination (splint and cast) and 12% prefer backslabs. Sixty percent of ED physicians “usually or always” use casts and 31% “usually or always” use backslabs. Although there was variation among the orthopedic surgeons regarding the recommended length of immobilization, most (70%) recommended 2 to 4 weeks, although some (12%) treated only until pain free. ED physicians showed greater diversity regarding length of immobilization.

Conclusions:
Although many physicians believe that wrist buckle fractures need to be immobilized, a significant number do not. There is substantial variability in the type and length of immobilization used. This variability suggests that the optimal management strategy for wrist buckle fractures is unclear and should be determined in future prospective studies.
Medical myth: Bimanual pelvic examination is a reliable decision aid in the investigation of acute abdominal pain or vaginal bleeding
Authors: Brown Todd , Herbert Mel E. 
Published: July 2016

ABSTRACTReliance on the accuracy of the pelvic examination is upheld in many medical textbooks, but review of the literature does not support the accuracy or reproducibility of this examination. That this “test” is useful for ruling out serious disease will be exposed for the myth that it is.
Bronchiolitis: Can objective criteria predict eligibility for brief hospitalization?
Authors: Brown Lance , Reiley David G. , Jeng Aaron , Green Steven M. 
Published: July 2016

ABSTRACTObjective:To determine if 3 objective criteria – pulse oximetry, respiratory syncytial virus (RSV) testing, and age – could be used to predict which children hospitalized with bronchiolitis will have brief (&lt;36 hour) hospitalizations and therefore be potential candidates for admission to short-stay observation units.Methods:This was a retrospective medical record review of medically uncomplicated children 3 to 24 months of age with emergency department and hospital discharge diagnoses consistent with bronchiolitis who were admitted to a general pediatric ward in our university-based, tertiary care hospital between Jan. 1, 1992, and Nov. 12, 2002. Multiple logistic regression was used to assess the predictor variables.Results:Our study consisted of 225 patients (45% female) with a median age of 7 months (interquartile range [IQR], 4–11 mo; range, 3–22 mo). Median pulse oximetry value was 94% (IQR 91%–96%; range 76%–100%), and 71% of the patients tested positive for RSV. Thirty children (13%) had brief hospitalizations &lt;36 hours, and the median hospital length of stay for the entire study group was 70 hours (IQR 46–108 h; range 6–428 h). None of the 3 predictor variables were independently associated with brief hospitalization.Conclusions:Pulse oximetry, RSV testing and age do not predict which children will have brief hospitalizations and are appropriate candidates for admission to short-stay observation units.
Hypoglycemia in bacterial septicemia
Authors: Preyra Ian , Worster Andrew 
Published: July 2016

ABSTRACT
In the emergency department (ED), the typical manifestation of impaired glucose homeostasis seen in patients with severe bacterial infections is hyperglycemia. Severe hypoglycemia is generally not a presenting feature of sepsis in children in the emergency setting, and thus may lead to delayed diagnosis and management. We present a case of a 14-year-old boy who attended the ED with constitutional symptoms and severe hypoglycemia as the initial presentation of overwhelming meningococcal sepsis and discuss the impairment of glucose homeostasis in patients with sepsis.
Off-service residents in the emergency department: the need for learner-centredness
Authors: Carter Alix J.E. , McCauley William A. 
Published: July 2016

ABSTRACT

Objectives:
Standard learning objectives enable residency directors to develop effective programs and evaluate residents based on key goals and parameters. While standards are important for ensuring basic competence, the usual process has little flexibility to address the unique needs and desires of a given resident. Our objective was to determine whether the expectations of off-service residents rotating through an emergency department (ED) rotation were being met.

Methods:
We developed a 144-item questionnaire using a 5-point Likert scale and surveyed 25 off-service residents at the beginning and end of their ED rotation. The survey was divided into 3 sections: presentations, skills and diagnoses.

Results:
The results demonstrate that certain expectations are consistently underachieved while others represent individual variations.

Conclusion:
We propose a learner-centred approach to ensure an optimal emergency educational experience for all trainees.
Acute allergic reaction due to the administration of fibrinolytic therapy for ST-segment elevation myocardial infarction: case report and discussion
Authors: Mills Geoff C. , Arntfield Robert T. , Sedran Robert J. 
Published: July 2016

ABSTRACT
Although a rare phenomenon, acute allergic reactions to fibrinolytic and heparin therapy have been described in the literature. We report the case of a 63-year-old woman who experienced a severe anaphylactic reaction while undergoing fibrinolytic therapy with tissue plasminogen activator for an ST-segment elevation myocardial infarction. Overall outcome was successful, but patient morbidity was increased because of the reaction and the subsequent therapy administered.
Conflict in the emergency department: Retreat in order to advance
Authors: Ahuja Jan , Marshall Pam 
Published: July 2016

ABSTRACT
Conflict that exists within a team providing services in an emergency department has the potential to be destructive to clinical care and professional relationships. A collaborative approach involving members of the team guided by a neutral facilitator can be effective in addressing important issues and creating solutions that are acceptable to the individuals and the group. By working together in such a facilitated setting, relationships between the team members can be strengthened while problems are being solved.
Can troponin I measurement predict short-term serious cardiac outcomes in patients presenting to the emergency department with possible acute coronary syndrome?
Authors: Hill Stephen A. , Devereaux P.J. , Griffith Lauren , Opie John , McQueen Matthew J. , Panju Akbar , Stanton Eric , Guyatt Gordon H. 
Published: July 2016

ABSTRACTObjective:To determine the ability of troponin I (TnI) measurement to predict the likelihood of a serious cardiac outcome over the subsequent 72 hours in patients presenting to the emergency department (ED) with symptoms suggestive of an acute coronary syndrome.Methods:This prospective observational study enrolled consecutive patients presenting to 2 urban tertiary care hospital EDs over a 5-week period. Eligible patients included those for whom a TnI test was ordered within 24 hours of arrival and in whom no serious cardiac outcome occurred before the test result was available. Patients were followed for 72 hours and serious cardiac outcomes documented; these included cardiovascular death, myocardial infarction, congestive heart failure, serious arrhythmia and refractory pain. We calculated likelihood ratios (LRs) to describe the association of the TnI result with serious cardiac outcomes.Results:Of the 352 enrolled patients, 20 had a serious cardiac outcome within 72 hours of ED presentation. The derived LRs (and 95% confidence interval [CI]) were 0.5 (0.3–0.9) for TnI values &lt;0.5 µg/L, 1.6 (0.4–6.5) for TnI values from 0.5 to 2.0 µg/L, 5.8 (1.7–19.5) for TnI values from &gt;2.0 to 10.0 µg/L and 14.4 (4.8–42.9) for TnI values &gt;10.0 µg/L.Conclusions:TnI values &gt;2.0 µg/L are associated with an increased probability of serious cardiac outcomes within 72 hours. TnI values between 0.5 and 2.0 µg/L are weakly positive predictors. TnI values &lt;0.5 µg/L have LRs in the range of 0.5 and thus are weakly negative predictors, not substantially decreasing the likelihood of serious cardiac outcomes, particularly in patients with a moderate or high pretest probability.
Paradoxical embolism: a rare life- and limb-threatening emergency
Authors: Tang Christine E. 
Published: July 2016

ABSTRACT
This article presents a case of a 43-year-old man with paradoxical embolism. The patient had simultaneous deep venous thrombosis, pulmonary embolism and bilateral limb-threatening arterial occlusions. The unifying diagnosis was paradoxical embolism through a previously undetected atrial septal defect. Suggestions for the evaluation and emergency management of paradoxical embolism are outlined, and the literature is briefly reviewed.
Root cause analysis of laboratory turnaround times for patients in the emergency department
Authors: Fernandes Christopher M.B. , Worster Andrew , Hill Stephen , McCallum Catherine , Eva Kevin 
Published: July 2016

ABSTRACTIntroduction:Laboratory investigations are essential to patient care and are conducted routinely in emergency departments (EDs). This study reports the turnaround times at an academic, tertiary care ED, using root cause analysis to identify potential areas of improvement. Our objectives were to compare the laboratory turnaround times with established benchmarks and identify root causes for delays.Methods:Turnaround and process event times for a consecutive sample of hemoglobin and potassium measurements were recorded during an 8-day study period using synchronized time stamps. A log transformation (ln [minutes + 1]) was performed to normalize the time data, which were then compared with established benchmarks using one-samplettests.Results:The turnaround time for hemoglobin was significantly less than the established benchmark (n= 140,t= –5.69,p&lt; 0.001) and that of potassium was significantly greater (n= 121,t= 12.65,p&lt; 0.001). The hemolysis rate was 5.8%, with 0.017% of samples needing recollection. Causes of delays included order-processing time, a high proportion (43%) of tests performed on patients who had been admitted but were still in the ED waiting for a bed, and excessive laboratory process times for potassium.Conclusions:The turnaround time for hemoglobin (18 min) met the established benchmark, but that for potassium (49 min) did not. Root causes for delay were order-processing time, excessive queue and instrument times for potassium and volume of tests for admitted patients. Further study of these identified causes of delays is required to see whether laboratory TATs can be reduced.
Blunt traumatic rupture of the pericardium with cardiac herniation
Authors: Rippey James C.R. , Rao Sudhakar , Fatovich Daniel 
Published: July 2016

ABSTRACT
Traumatic rupture of the pericardium with cardiac herniation is rare. Clinicians are often unfamiliar with the clinical and radiological manifestations of the injury, and the diagnosis is frequently missed preoperatively. This case report describes a patient with multiple trauma following a fall from a height, who developed this injury. The diagnosis was not made preoperatively despite suggestive clinical, electrocardiographic and radiological findings. Clinicians need to be aware of the presentation of this potentially fatal injury so that the diagnosis can be made and treatment instituted at an earlier stage. Pericardial rupture with cardiac herniation presents as cardiogenic shock, mimicking cardiac tamponade.
N-acetylcysteine for radiocontrast-induced nephropathy: Potential role in the emergency department?
Authors: Chong Elaine , Zed Peter J. 
Published: July 2016

ABSTRACT

Objective:
To systematically review the efficacy and safety of N-acetylcysteine (NAC) for the prevention of radiocontrast-induced nephropathy (RIN), and to discuss its potential role in the emergency department.

Methodology:
We conducted a search of MEDLINE (from 1966 to December 2003), PubMed (1966 to December 2003) and EMBASE (1988 to December 2003) for English-language, prospective, randomized, controlled trials in humans using the search terms N-acetylcysteine, acetylcysteine, radiopharmaceuticals, contrast media, and kidney failure (acute).

Results:
Five trials support and 4 trials refute the hypothesis that NAC helps prevent RIN. In 7 of 9 trials, oral NAC was administered twice daily for 2 days, on the day before and on the day of the radiocontrast study — a regime not feasible for emergent situations. More recent trials suggest that adequate hydration and lower volumes of radiocontrast, rather than NAC, are more effective ways to prevent RIN.

Conclusion:
Although further study may be indicated, current evidence does not suggest that NAC has a role in the emergency prevention of RIN.
Intramuscular ketamine to facilitate pediatric central vascular access
Authors: Denmark T. Kent , Hargrove Jenny R. , Brown Lance 
Published: July 2016

ABSTRACT

Objectives:
Obtaining prompt vascular access in young children presenting to the emergency department (ED) is frequently both necessary and technically challenging. The objective of our study was to describe our experience using intramuscular (IM) ketamine to facilitate the placement of central venous catheters in children presenting to our ED needing vascular access in a timely fashion.

Methods:
We performed a retrospective medical record review of all pediatric patients &lt;18 years of age who presented to our tertiary care pediatric ED between May 1, 1998, and August 7, 2003, and underwent the placement of a central venous catheter facilitated by the use of IM ketamine.

Results:
Eleven children met our inclusion criteria. Most of the children were young and medically complicated. The children ranged in age from 6 months to 8 years. The only complication identified was vomiting experienced by an 8-year-old boy. Emergency physicians successfully obtained central venous access in all subjects in the case series.

Conclusions:
The use of IM ketamine to facilitate the placement of central venous catheters in children who do not have peripheral venous access appears to be helpful. Emergency physicians may find it useful to be familiar with this use of IM ketamine.
Needs assessment and staff education to effect long-term change in emergency medicine in rural Nepal
Authors: Krym Valerie F. , MacDonald Russell D. 
Published: July 2016

ABSTRACT
Medical work in developing countries is challenging and rewarding. To make a lasting impact on the local community, a health care worker must be willing to listen to the needs of the people. The long-term impact of a needs assessment and staff education on emergency medicine at a rural hospital in Nepal is presented.
The Scheer Memorial Hospital is a 102-bed non-governmental, not-for-profit hospital in Banepa, Nepal. Nepalese and ex-patriot health care professionals staff the hospital. Medical supplies are obtained from local manufacturers or as donations from foreign organizations. The hospital waives fees for those who cannot afford care.
Two academic emergency physicians with expertise in international health undertook a needs assessment to assist in planning for long-term health care goals related to emergency medicine. The assessment focused on health care planning and education of the local health care staff. Based on interviews and objective assessments, a plan was developed and implemented to address 4 key areas: physical plant, equipment, staff training and essential tasks.
Sustainable positive change was accomplished by acknowledging local customs and standards of care, meeting the needs of local health care staff and using available resources.
Delayed presentation of a patient with a ruptured diaphragm complicated by gastric incarceration and perforation after apparently minor blunt trauma
Authors: Goh Brian K.P. , Wong Andrew S.Y. , Tay Khoon-Hean , Hoe Michael N.Y. 
Published: July 2016

ABSTRACTRupture of the diaphragm is almost always due to major trauma and is most commonly associated with road-traffic accidents. We report a case of delayed presentation of a 35-year-old woman with a ruptured diaphragm, 11 days following apparent minor blunt trauma. This case illustrates how the diagnosis of ruptured diaphragm can be missed and demonstrates the importance of considering this diagnosis in all cases of blunt trauma to the trunk. It also demonstrates the potential pitfall of misinterpreting the chest radiograph, and the value of repeat imaging after insertion of a nasogastric tube.
Pediatric wrist buckle fractures: Should we just splint and go?
Authors: Plint Amy C. , Perry Jeffrey J. , Tsang Jennifer L.Y. 
Published: July 2016

ABSTRACT:Objectives:The objective of this study was to evaluate the utility of circumferential casting in the emergency department (ED), orthopedic follow-up visits, and radiographic follow-up in the management of children with wrist buckle fractures.Methods:We performed a retrospective medical record review of all children &lt; 18 years of age who presented to our tertiary care children’s hospital between July 1, 2000, and June 30, 2001, and were diagnosed with a fracture of the wrist, radius or ulna. Based on the radiology reports, we identified buckle fractures of the distal radius, the distal ulna, or both bones. We excluded children who had other types of fractures.Results:We identified 840 children with fractures of the wrist, radius, or ulna. Of these, 309 met our inclusion criteria. The median age of our study cohort was 9.2 years. Emergency physicians immobilized 269 of these fractures in circumferential casts; of these, 30 (11%) had cast complications. Of the 276 subjects who had orthopedic follow-up visits and radiographs, 184 (67%) had multiple visits and 127 (46%) had multiple radiographs performed. No subjects had fracture displacement identified on follow-up.Conclusions:Orthopedic follow-up visits and radiographic follow-up may have minimal utility in the treatment of pediatric wrist buckle fractures. ED casting may pose more risk than benefit for these children. Splinting in the ED with primary care follow-up appears to be a reasonable management strategy for these fractures. A prospective study comparing ED splinting and casting for pediatric wrist buckle fractures is needed.
Lack of consensus on corneal abrasion management: results of a national survey
Authors: Calder Lisa , Balasubramanian Sowmya , Stiell Ian 
Published: July 2016

ABSTRACT:Objectives:Our objective was to determine the practice patterns of Canadian emergency physicians with respect to the management of traumatic corneal abrasions.Methods:After developing our instrument and pilot testing it on a sample of emergency residents, we randomly surveyed 470 members of the Canadian Association of Emergency Physicians, using a modified Dillman technique. We distributed a pre-notification letter, an 18-item survey, and appropriate follow-up surveys to non-responders. Those members with an email address (n= 400) received a Web-based survey, and those without (n= 70) received a survey by post. The survey focused on the indications and utilization of analgesics (oral and topical), cycloplegics, eye patches and topical antibiotics.Results:Our response rate was 64% (301/470), and the median age of respondents was 38 years. Most (77.7%) were male, 71.8% were full-time emergency physicians, 76.5% were emergency medicine certified, and 64.4% practised in teaching hospitals. Pain management preferences (offered usually or always) included oral analgesics (82.1%), cycloplegics (65.1%) and topical nonsteroidal anti-inflammatory drugs (NSAIDs) (52.8%). Only 21.6% of respondents performed patching, and most (71.2%) prescribed topical antibiotics, particularly for contact lens wearers and patients with ocular foreign bodies. Two-thirds of the respondents provided tetanus toxoid if a foreign body was present, and 46.2% did so even if a foreign body was not present. Most respondents (88.0%) routinely arranged follow-up.Conclusions:This national survey of emergency physicians demonstrates a lack of consensus on the management of traumatic corneal abrasions. Further study is indicated to determine the optimal treatment, particularly regarding the use of topical NSAIDs.