bluuebunny/crossref_metadata_2025_split huggingface dataset:
Quantifying delays in the recognition and management of acute compartment syndrome
Authors: Vaillancourt Christian , Shrier Ian , Falk Markus , Rossignol Michel , Vernec Alan , Somogyi Dan 
Published: July 2016

ABSTRACTObjective:To identify where most efforts should be made to decrease ischemia time and necrosis in acute compartment syndrome (ACS) and to determine the causes for late interventions.Methods:This was a multicentre, historical cohort study of patients who underwent fasciotomy for ACS within the McGill Teaching Hospitals between 1989 and 1997. Patients studied had a clinical diagnosis of ACS or compartment pressures greater than 30 mm Hg. In all cases, ACS was confirmed at the time of fasciotomy. Patients were stratified into traumatic and non-traumatic groups, and a step-by-step analysis was performed for each part of the process between injury and operation.Results:Among the 62 traumatic ACS cases, the longest delays occurred between initial assessment and diagnosis (median time 2h56, range from 0 to 99h20) and between diagnosis and operation (median 2h13, range 0h15–29h45). Among the 14 non-traumatic ACS cases, delays primarily occurred between inciting event and hospital presentation (median 9h19, range 0h04–289h29) and between initial assessment and diagnosis (median 8h18, range 0–104h15).Conclusions:ACS is a limb-threatening condition for which early intervention is critical. Substantial delays occur after the time of patient presentation. For traumatic and non-traumatic ACS, increased physician awareness and faster operating room access may reduce treatment delays and prevent disability.
Delayed salicylate toxicity following enteric-coated acetylsalicylic acid overdose: a case report and review of the literature
Authors: Drummond Robert , Kadri Nadine , St-Cyr Julie 
Published: July 2016

ABSTRACTSalicylates are widely available and potentially lethal. Clinical and laboratory findings associated with enteric-coated acetylsalicylic acid (ECASA) ingestion may be delayed more than 24 hours. When dealing with patients who have a history of significant ingestion, emergency physicians should consider initiating therapy regardless of initial salicylate levels. Prolonged observation may be necessary in cases of suspected ECASA overdose.
Severe methemoglobinemia from topical anesthetic spray: case report, discussion and qualitative systematic review
Authors: Abu-Laban Riyad B. , Zed Peter J. , Purssell Roy A. , Evans Kenneth G. 
Published: July 2016

ABSTRACTFew health care professionals realize that topical anesthetic spray can cause methemoglobinemia. We describe a 56-year-old woman who was transferred to our emergency department when severe cyanosis and chest pain developed after administration of topical oropharyngeal benzocaine and lidocaine during outpatient endoscopy. Investigations revealed a methemoglobin level of 51%. Despite rapid diagnosis and treatment with methylene blue, pulmonary edema consistent with adult respiratory distress syndrome developed, endotracheal intubation was required, and the patient suffered a lengthy course in the intensive care unit. This article presents a detailed discussion of the pathophysiology, diagnosis and treatment of methemoglobinemia, as well as a qualitative systematic review of the English literature on methemoglobinemia induced by topical anesthetic. The implications of this condition for emergency physicians are also outlined.
Emergency physicians’ attitudes toward a clinical prediction rule for the identification and early discharge of low risk patients with chest discomfort
Authors: MacGougan Cameron K. , Christenson James M. , Innes Grant D. , Raboud Janet 
Published: July 2016

ABSTRACTObjectives:To determine Canadian emergency physicians’ estimates regarding the safety and efficiency of chest discomfort management in their emergency department (ED), and their attitudes toward and perception of the need for a chest discomfort clinical prediction rule that identifies very low risk patients who are safe to discharge after a brief ED assessment.Methods:300 members of the Canadian Association of Emergency Physicians (CAEP) were randomly selected to receive a confidential mail survey, which invited them to provide information on current disposition of patients with chest discomfort and their opinions regarding the value of a clinical prediction rule to identify patients with chest discomfort who are safe to discharge after a brief (~2 hour) assessment.Results:Of the 300 physicians selected, 288 were eligible for the survey and 235 (82%) responded. Only 5% follow discharged patients to measure safe practice. Overall, 165 (70%) felt the proposed prediction rule would be very useful and 43 (18%) felt it would be useful. Almost all (94%) believed a prediction rule would be useful if it identified patients safe for discharge without increasing the current rate of missed acute myocardial infarction (estimated at 2%). Most respondents (59%) believed that a clinical prediction rule should suggest a course of action, while 30% felt it should convey a probability of disease.Conclusions:Canadian emergency physicians support the concept of a clinical prediction rule for the early discharge of patients with chest discomfort. Most believe that such a rule would be useful if it identified patients who are safe for discharge after a brief assessment, while maintaining current levels of safety. Future research should be aimed at deriving a clinical prediction rule to identify low risk patients who can be safely discharged after a limited emergency department evaluation.
Incidental findings during emergency sonographic examinations: a case series
Authors: Kendal John L. , Mandavia Diku 
Published: July 2016

ABSTRACTThe teaching of ultrasonography is rapidly being incorporated into emergency medicine (EM) training programs and clinical practice. Most literature focuses on appropriate indications for the performance of emergency ultrasonography, and most EM-related courses and programs limit their teaching to standard focused indications. Generally this will suffice; however, occasionally, incidental findings, which are beyond the realm of what is taught in these programs, have influenced patient care. In this paper we discuss 7 cases in which incidental findings were discovered during an emergency sonographic examination. In each case the findings changed the patient’s disposition, diagnosis and, potentially, outcome.
Recurrent bleeding in acute upper gastrointestinal hemorrhage: transfusion confusion
Authors: Ginn Jeffery L. , Ducharme James 
Published: July 2016

ABSTRACT

Objective:
Acute upper gastrointestinal (UGI) hemorrhage is a common, often serious condition encountered in the emergency department (ED). Previous research has suggested that transfusion of blood products may interfere with the hypercoagulable state induced by significant blood loss. Our objective was to determine whether the frequency of rebleeding is higher in patients with UGI bleeding who have received early blood transfusion.

Methods:
The study was a retrospective chart review of patients admitted to hospital through the ED with a diagnosis of UGI hemorrhage. Inclusion criteria limited analysis to patients presenting with hematemesis, melena, or bloody nasogastric aspirate, in whom a UGI lesion was confirmed endoscopically during admission.

Results:
A total of 214 charts were analyzed. Baseline demographic characteristics were similar in transfused and non-transfused patients. Presenting hemoglobin level was lower in the transfused group (86.5 v. 119.2 g/L, p &lt; 0.001). Recurrent bleeding occurred in 99 (46%) patients and was more common in transfused patients (67 [66%] v. 33 [29%], p &lt; 0.001). Logistic regression analysis revealed that transfusion and presenting hemoglobin level were the only variables with a statistically significant independent association with bleeding recurrence (p &lt; 0.001 and p &lt; 0.05 respectively).

Conclusions:
Our results support previous research suggesting that transfused UGI bleed patients have a higher rate of rebleeding. However, because of the retrospective design, causality cannot be inferred.
Impact of a prison triage system on injuries seen in emergency departments
Authors: Kuzak Nick , O’Connor Michael , Pickett William , O’Brien Terry , Reid Ken , Pearson Mary 
Published: July 2016

ABSTRACT

Objectives:
1) To describe injuries experienced by the male prisoner population in the Kingston, Ontario area, and to compare them with those observed in the general population; and 2) to compare the incidence and patterns of prisoner injuries seen in emergency departments (EDs) before and after the introduction of a prison injury triage system.

Design:
A chart review.

Setting:
The catchment area surrounding 2 hospital-based EDs in Kingston, Ontario, which includes 8 federal and provincial prisons for adult males.

Observations:
Injuries to male prisoners (ages 18–75 years) who were treated in the ED during 1996–98 were compared with injuries to the general male population of the same age range. An on-site emergency care triage system was introduced to area prisons in 1993. Prisoner injuries seen in the ED during 1996–98 were compared with those seen during a similar period prior to the introduction of the triage system (1981–84). Available comparators included patient demographics, disposition, intent and nature of injury, the need for surgery, and lengths of hospital stay.

Results:
148 prisoner injuries were identified for 1996–98. Prisoner injuries seen in the ED were relatively severe when compared with the general male population, as indicated by the higher frequency of fractures (31.8% prisoner vs. 13.4% general, p &lt; 0.001), blunt head injuries (10.1% vs. 2.2%, p &lt; 0.001), hospital admissions (42.6% vs. 4.1%, p &lt; 0.001) and deaths (2.7% vs. 0.6%, p &lt; 0.001). Since the introduction of the triage system there has been a reduction in the rate of prisoner injuries seen in local hospital EDs (6.1/100/yr [before] vs. 1.6/100/yr [after], p &lt; 0.001). There has been an increase in the relative severity of prisoner injuries seen in the EDs as indicated by the increased hospital admission rate (42.6% vs. 22.7%, p &lt; 0.001), increased rate of surgical intervention (27.7% vs. 12.1%, p &lt; 0.001), and increased length of hospital stay (4.0 days vs. 2.1 days, p &lt; 0.05). The mortality rate has remained low and unchanged (0.7% vs. 1.1%, p = 0.99).

Conclusions:
The introduction of the new triage system appeared to be associated with a decrease in the total number of ED visits by prisoners. The relative acuity of prisoner injuries seen in the EDs appeared to increase following introduction of the triage system.
Emergency medicine: A practice prone to error?
Authors: Croskerry Pat , Sinclair Douglas 
Published: July 2016

Abstract
The last decade has witnessed a rapidly growing public and academic interest in medical error, an interest that has culminated in the emergence of the science of error prevention in health care. The impact of this new science will be felt in all areas of medicine but perhaps especially in emergency medicine (EM). The emergency department’s unique operating characteristics make it a natural laboratory for the study of error. These characteristics, combined with the complex and myriad activities of EM, predict vulnerability to a multitude of errors. Overcrowding and other resource limitations impair continuous quality improvement, and many errors result from high decision density, excessive cognitive load and flawed thinking in the decision-making process. A large proportion of these errors have serious outcomes but an even higher proportion are preventable.
The historical practice of blaming individuals for errors needs to be replaced by root-cause analysis that identifies process and systemic weaknesses. Quantitative and qualitative methods are needed to detect, describe and classify error at all levels in the system. Research is needed into the processes that underlie EM error. Educational initiatives should be developed at all levels, for everyone from undergraduate trainees to practicing emergency physicians. Changes in societal attitudes will be an important component of the new culture of patient safety.
A nationwide reporting system is proposed to disseminate error information expediently. Canadian EM providers are in a pivotal position to provide leadership to the Canadian health care system in this important area.
Can peripheral venous blood gases replace arterial blood gases in emergency department patients?
Authors: Rang Louise C.F. , Murray Heather E. , Wells George A. , MacGougan Cameron K. 
Published: July 2016

ABSTRACTObjective:To determine if peripheral venous blood gas values for pH, partial pressure of carbon dioxide (PCO2) and the resultant calculated bicarbonate (HCO3) predict arterial values accurately enough to replace them in a clinical setting.Methods:This prospective observational study was performed in a university tertiary care emergency department from June to December 1998. Patients requiring arterial blood gas analysis were enrolled and underwent simultaneous venous blood gas sampling. The following data were prospectively recorded: age, sex, presenting complaint, vital signs, oxygen saturation, sample times, number of attempts and indication for testing. Correlation coefficients and mean differences with 95% confidence intervals (CIs) were calculated for pH,PCO2and HCO3. A survey of 45 academic emergency physicians was performed to determine the minimal clinically important difference for each variable.Results:The 218 subjects ranged in age from 15 to 90 (mean 60.4) years. The 2 blood samples were drawn within 10 minutes of each other for 205 (96%) of the 214 patients for whom data on timing were available. Pearson’s product–moment correlation coefficients between arterial and venous values were as follows: pH, 0.913;PCO2, 0.921; and HCO3, 0.953. The mean differences (and 95% CIs) between arterial and venous samples were as follows: pH, 0.036 (0.030–0.042);PCO2, 6.0 (5.0–7.0) mm Hg; and HCO3, 1.5 (1.3–1.7) mEq/L. The mean differences (± 2 standard deviations) were greater than the minimum clinically important differences identified in the survey.Conclusions:Arterial and venous blood gas samples were strongly correlated, and there were only small differences between them. A survey of emergency physicians suggested that the differences are too large to allow for interchangeability of results; however, venous values may be valid if used in conjunction with a correction factor or for trending purposes.
Inter-observer agreement using the Canadian Emergency Department Triage and Acuity Scale
Authors: Manos Daria , Petrie David A. , Beveridge Robert C. , Walter Stephen , Ducharme James 
Published: July 2016

ABSTRACTObjective:To determine the inter-observer agreement on triage assignment by first-time users with diverse training and background using the Canadian Emergency Department Triage and Acuity Scale (CTAS).Methods:Twenty emergency care providers (5 physicians, 5 nurses, 5 Basic Life Support paramedics and 5 Advanced Life Support paramedics) at a large urban teaching hospital participated in the study. Observers used the 5-level CTAS to independently assign triage levels for 42 case scenarios abstracted from actual emergency department patient presentations. Case scenarios consisted of vital signs, mode of arrival, presenting complaint and verbatim triage nursing notes. Participants were not given any specific training on the scale, although a detailed one-page summary was included with each questionnaire. Kappa values with quadratic weights were used to measure agreement for the study group as a whole and for each profession.Results:For the 41 case scenarios analyzed, the overall agreement was significant (quadratic-weighted κ = 0.77, 95% confidence interval, 0.76–0.78). For all observers, modal agreement within one triage level was 94.9%. Exact modal agreement was 63.4%. Agreement varied by triage level and was highest for Level I (most urgent). A reasonably high level of intra- and inter-professional agreement was also seen.Conclusions:Despite minimal experience with the CTAS, inter-observer agreement among emergency care providers with different backgrounds was significant.
Lateral canthotomy and cantholysis: a simple, vision-saving procedure
Authors: McInnes Gord , Howes Daniel W. 
Published: July 2016

ABSTRACTLateral canthotomy and cantholysis is a simple procedure that can be performed by emergency physicians. It has the potential to save vision, particularly in cases of blunt ocular trauma. The case of a 37-year-old man with blunt ocular trauma, a retrobulbar hemorrhage and rapidly increasing orbital pressure requiring an urgent lateral canthotomy and cantholysis is presented. Pathophysiology, indications, contraindications, procedure and follow-up care are described.
9/11 New York City: Canadians lend a hand
Authors: Travers Andrew , Irwin Kathryn , Anton Andy , Christenson Jim 
Published: July 2016

SOMMAIRE
Le 11 septembre 2001, les auteurs participaient à une rencontre sur des essais cliniques à New York. De concert avec leurs collègues chercheurs, ils ont participé à l’opération de sauvetage pendant les 16 premières heures suivant le pire acte de terrorisme de l’histoire moderne. Le présent article résume leur expérience.
Can body temperature be maintained during aeromedical transport?
Authors: Sookram Sunil M. , Barker Samantha , Kelly Karen D. , Patton William , Sosnowski Terry , Neilson Kevin , Rowe Brian H. 
Published: July 2016

ABSTRACTBackground:Aeromedical transport in northern areas may be associated with hypothermia. The objective of this study was to determine whether significant hypothermia (core temperature &lt;35ºC) occurs in severely injured or ill intubated patients during transport by rotary wing aircraft.Methods:In this prospective cohort study, all intubated patients over 16 years of age who were transported by rotary wing aircraft from rural hospitals or trauma scenes in northern Alberta to regional hospitals in Edmonton were eligible for study. Esophageal thermometers were used to measure core temperature at 10-minute intervals during transport.Results:Of 133 potentially eligible patients, 116 were enrolled; 69 (59%) had esophageal thermometers inserted, and 47 (41%) had other temperature measurements. Severe hypothermia occurred in only 1% to 2% of cases, but 28% to 39% of patients met criteria for mild hypothermia prior to transport. Core temperatures did not fall during transport, despite the fact that warming techniques were documented in only 38% of cases.Conclusions:During brief (&lt;225 km) rotary wing aeromedical transport of severely injured or ill patients, significant hypothermia is uncommon and body temperature is generally well maintained with the use of simple passive measures. These findings do not justify recommendations for more aggressive core temperature monitoring during this type of aeromedical transport.
A review of etomidate for rapid sequence intubation in the emergency department
Authors: Yeung Janice K. , Zed Peter J. 
Published: July 2016

ABSTRACTEtomidate is a sedative–hypnotic chemically unrelated to other induction agents. The pharmacological and safety profile of etomidate offers many advantages for induction during rapid sequence intubation (RSI) in the emergency department (ED). Its onset of action is within 5 to 15 seconds, and its duration of action is 5 to 15 minutes. Unlike thiopental, propofol, midazolam and, to a lesser extent, ketamine, etomidate has minimal respiratory or cardiovascular effects and can be safely used in patients with hemodynamic instability or cardiac ischemia. Etomidate is cerebroprotective, with the ability to decrease intracranial pressure and maintain cerebral perfusion, making it an ideal agent for patients with head injuries. Of the currently available induction agents, etomidate offers the most favourable safety profile and is the least likely to produce adverse effects in patients with unknown or untreated medical conditions. Etomidate may cause pain on injection, myoclonic movements on induction, hiccups, nausea and vomiting. Transient adrenal suppression has been reported, but not to a clinically significant degree, after single induction doses for ED RSI. Etomidate has been well studied in the ED and should be adopted for RSI in specific ED patient groups.
Fomepizole in the treatment of ethylene glycol poisoning
Authors: Hall Tammy L. 
Published: July 2016

ABSTRACT
The management of ethylene glycol poisoning is reviewed, with a focus on the use of the new antidote fomepizole. Ethylene glycol is a widely used industrial agent that is also easily obtained commercially, usually as radiator antifreeze. Ingestion of as little as 30 to 60 mL can result in death or serious permanent disability. Traditional management of poisoning includes the use of ethanol, with or without hemodialysis. Activated charcoal is not indicated, and gastric lavage may be beneficial only in the first hour after ingestion. Cofactors such as pyridoxine and thiamine may be beneficial in patients deficient in these vitamins. A new antidote, fomepizole, has recently been approved for use in Canada. Like ethanol, it is a competitive inhibitor of alcohol dehydrogenase. Potential benefits of fomepizole include its ease of administration and lack of serious adverse effects. Fomepizole may be recommended over ethanol in situations in which avoidance of ethanol-induced side effects is imperative or when ethanol is not readily available. Further studies are required to verify its comparative efficacy and cost-effectiveness compared to ethanol.
Analysis of factors influencing length of stay in the emergency department
Authors: Yoon Philip , Steiner Ivan , Reinhardt Gilles 
Published: July 2016

ABSTRACTObjectives:Length of stay (LOS) is a key measure of emergency department (ED) throughput and a marker of overcrowding. Time studies that assess key ED processes will help clarify the causes of patient care delays and prolonged LOS. The objectives of this study were to identify and quantify the principal ED patient care time intervals, and to measure the impact of important service processes (laboratory testing, imaging and consultation) on LOS for patients in different triage levels.Methods:In this retrospective review, conducted at a large urban tertiary care teaching hospital and trauma centre, investigators reviewed the records of 1047 consecutive patients treated during a continuous 7-day period in January 1999. Key data were recorded, including patient characteristics, ED process times, tests performed, consultations and overall ED LOS. Of the 1047 patient records, 153 (14.6%) were excluded from detailed analysis because of incomplete documentation. Process times were determined and stratified by triage level, using theCanadian Emergency Department Triage and Acuity Scale(CTAS). Multiple linear regression analysis was performed to determine which factors were most strongly associated with prolonged LOS.Results:Patients in intermediate triage Levels III and IV generally had the longest waiting times to nurse and physician assessment, and the longest ED lengths of stay. CTAS triage levels predicted laboratory and imaging utilization as well as consultation rate. The use of diagnostic imaging and laboratory tests was associated with longer LOS, varying with the specific tests ordered. Specialty consultation was also associated with prolonged LOS, and this effect was highly variable depending on the service consulted.Conclusions:Triage level, investigations and consultations are important independent variables that influence ED LOS. Future research is necessary to determine how these and other factors can be incorporated into a model for predicting LOS. Improved information systems will facilitate similar ED time studies to assess key processes, lengths of stay and clinical efficiency.