Introduction: Opioid overdoses (OODs) have become a public health emergency, yet little is known about their long-term outcomes following an OD. We determined the one-year all-cause mortality and associated risk factors in a cohort of patients treated in an urban emergency department (ED) for an OOD. Methods: We reviewed records of all patients who visited St. Paul's Hospital ED from January 2013 to August 2017 and had a discharge diagnosis of OOD or had received naloxone in the ED as per pharmacy records. Patients with a suspected OOD were identified on structured chart review. A patient's first visit for an OOD during the study period was used as the index visit, with subsequent visits excluded. The primary outcome was mortality during the year after the index visit. Mortality was assessed by linking patient electronic medical records with Vital Statistics data. Deaths that occurred in the ED on the index visit were excluded. Patients admitted to hospital following ED treatment were included in this study. We described patient characteristics, calculated mortality rates, and used Cox regression to identify risk factors. Results: A total of 2239 patients visited the ED for an OOD during the study period, with a median patient age of 37 years (IQR 29, 49). Males comprised 73% of patients, while 28% had no fixed address, and 21% received take-home naloxone at the index visit. In total, 137 patients (6.1%) died within 1 year of the index visit. Eighty-one deaths (3.6%) occurred within 6 months, including 24 deaths (1.1%) that occurred within 1 month. The highest mortality rate occurred in 2017, with 8.0% of patients entering the cohort that year dying within 1 year. Gender did not significantly impact mortality risk. A Cox regression analysis controlled for gender, housing status, and whether take-home naloxone was provided at the index visit indicated that advancing age (adjusted hazards ratio [AHR] 1.03; 95%CI: 1.01-1.04 for each year increase in age) and the index visit calendar year (AHR 1.30; 95%CI: 1.10-1.54 for each yearly increase in the study period) were significant factors for mortality within 1 year. Conclusion: The mortality rate following an opioid OD treated in the ED is high, with over 6% of patients in our study dying within 1 year. The rising mortality risk with increasing calendar year may reflect the growing harms of fentanyl-related OODs. Patients visiting the ED for an OOD should be considered high risk and offered preventative treatment and referrals prior to discharge.

Editor's note: CJEM has partnered with a small group of selected journals of international emergency medicine societies to share from each a highlighted research study, as selected monthly by their editors. Our goals are to increase awareness of our readership to research developments in the international emergency medicine literature, promote collaboration among the selected international emergency medicine journals, and support the improvement of emergency medicine world-wide, as described in the WAME statement at http://www.wame.org/about/policy-statements#Promoting%20Global%20Health. Abstracts are reproduced as published in the respective participating journals and are not peer reviewed or edited by CJEM.

Introduction: Point of care ultrasound has been reported to improve diagnosis in non-traumatic hypotensive ED patients. We compared diagnostic performance of physicians with and without PoCUS in undifferentiated hypotensive patients as part of an international prospective randomized controlled study. The primary outcome was diagnostic performance of PoCUS for cardiogenic vs. non-cardiogenic shock. Methods: SHoC-ED recruited hypotensive patients (SBP < 100 mmHg or shock index > 1) in 6 centres in Canada and South Africa. We describe previously unreported secondary outcomes relating to diagnostic accuracy. Patients were randomized to standard clinical assessment (No PoCUS) or PoCUS groups. PoCUS-trained physicians performed scans after initial assessment. Demographics, clinical details and findings were collected prospectively. Initial and secondary diagnoses including shock category were recorded at 0 and 60 minutes. Final diagnosis was determined by independent blinded chart review. Standard statistical tests were employed. Sample size was powered at 0.80 (α:0.05) for a moderate difference. Results: 273 patients were enrolled with follow-up for primary outcome completed for 270. Baseline demographics and perceived category of shock were similar between groups. 11% of patients were determined to have cardiogenic shock. PoCUS had a sensitivity of 80.0% (95% CI 54.8 to 93.0%), specificity 95.5% (90.0 to 98.1%), LR+ve 17.9 (7.34 to 43.8), LR-ve 0.21 (0.08 to 0.58), Diagnostic OR 85.6 (18.2 to 403.6) and accuracy 93.7% (88.0 to 97.2%) for cardiogenic shock. Standard assessment without PoCUS had a sensitivity of 91.7% (64.6 to 98.5%), specificity 93.8% (87.8 to 97.0%), LR+ve 14.8 (7.1 to 30.9), LR- of 0.09 (0.01 to 0.58), Diagnostic OR 166.6 (18.7 to 1481) and accuracy of 93.6% (87.8 to 97.2%). There was no significant difference in sensitivity (-11.7% (-37.8 to 18.3%)) or specificity (1.73% (-4.67 to 8.29%)). Diagnostic performance was also similar between other shock subcategories. Conclusion: As reported in other studies, PoCUS based assessment performed well diagnostically in undifferentiated hypotensive patients, especially as a rule-in test. However performance was similar to standard (non-PoCUS) assessment, which was excellent in this study.

Priapism is characterized by persistent penile erection in the absence of sexual arousal or desire that does not subside with orgasm. Although relatively uncommon, it is a genitourinary emergency that necessities prompt work-up and appropriate management, as there is a time-dependent relationship between total duration of erection and an increasing risk of permanent erectile dysfunction. Confirming the type of priapism is key to proper management, but the majority of cases presenting to the emergency department are ischemic in nature. Conservative management strategies for ischemic priapism are sparsely described in the literature but generally include ice pack application to the area, cold showers, masturbation and rarely, exercise. These strategies lack sound evidence, but the risks of attempting them are minimal as long as access to more definitive treatment is not delayed. Lower-limb exercise as a first-line treatment warrants further study in the undifferentiated emergency department priapism population. The case we present and discuss here illustrates the potential benefits of a trial of acute lower-limb exercise, specifically stair climbing, as a treatment for medication-induced priapism. If effective, this simple non-invasive management strategy may decrease the time to effective treatment, requires minimal resource utilization, and ultimately, avoids the need for more invasive treatment.

Introduction: There is an evidence-practice gap between guidelines for diagnosing pulmonary embolism (PE) and emergency physician practice. Computed tomography (CT) scanning is being overused to exclude PE in Canadian emergency departments (EDs) and current guidelines do not fit well with the ED model of patient care. There is a lack of research on patient opinions on PE testing, and a poor physician understanding of patient-specific goals in the ED. We are addressing this by conducting patient interviews to identify patient-specific values and opinions on PE testing in the ED. These will be used to develop patient-centered educational tools which physicians and patients can use to discuss the decision to order a CT PE scan. The aim of this study is to identify patient expectations and priorities on PE testing in the ED. Methods: This qualitative study uses constructivist grounded theory to analyze patient values and opinions on PE testing in ED patients from two hospitals. Participants are screened by monitoring the ED patient tracker. If a patient is being tested for PE, they are approached and consented by a researcher to take part in a 30-minute semi-structured interview. Each interview is transcribed verbatim and independently analyzed by four researchers using constant comparative coding. The researchers meet weekly to compare codes and agree on common coding terms. The codes are grouped into themes, and the interview script is modified to maximize information on emerging themes. From this, major themes with associated subthemes will be derived, each representing an opportunity, barrier or value which must be addressed in our new patient education tools. We have performed 23 interviews and expect to reach theme saturation at 30 interviews. Full results will be available by the 2019 CAEP conference. Results: From the patient interviews conducted so far, we have mapped four major themes: patient satisfaction comes from addressing their primary concern (for example, their pain); patients expect individualized care; patients prefer imaging over clinical examination when testing for PE; and patients expect 100% confidence from their ED physician when given a diagnosis. Conclusion: These four domains will be used to create a new patient-centered approach to PE testing in the ED which will include physician education, patient information and organizational changes to patient processing. This study incorporates evidence-based medicine with ethical and social implications to improve patient outcomes.

Editor's note: CJEM has partnered with a small group of selected journals of international emergency medicine societies to share from each a highlighted research study, as selected monthly by their editors. Our goals are to increase awareness of our readership to research developments in the international emergency medicine literature, promote collaboration among the selected international emergency medicine journals, and support the improvement of emergency medicine world-wide, as described in the WAME statement at http://www.wame.org/about/policy-statements#Promoting%20Global%20Health. Abstracts are reproduced as published in the respective participating journals and are not peer reviewed or edited by CJEM.

Infectious mononucleosis is typically a self-limited viral infection of adolescence and early adulthood that resolves in a period of weeks, causing no major sequelae. We describe a case of a healthy 18-year-old female diagnosed with infectious mononucleosis who also presented with right upper quadrant abdominal pain, moderate transaminitis, and cholestatic biochemistry. An ultrasound revealed acute acalculous cholecystitis, generally a condition seen in the context of critical illness. Further investigating emergency department patients with infectious mononucleosis is often not indicated, but may be important for those who present atypically.

Editor’s note: CJEM has partnered with a small group of selected journals of international emergency medicine societies to share from each a highlighted research study, as selected monthly by their editors. Our goals are to increase awareness of our readership to research developments in the international emergency medicine literature, promote collaboration among the selected international emergency medicine journals, and support the improvement of emergency medicine world-wide, as described in the WAME statement at http://www.wame.org/about/policy-statements#Promoting%20Global%20Health. Abstracts are reproduced as published in the respective participating journals and are not peer reviewed or edited by CJEM.

Introduction: Ureteral colic is a common painful disorder. Early surgical intervention is an attractive management option but existing evidence does not clarify which patients benefit. Based on lack of evidence, current national specialty guidelines provide conflicting recommendations regarding who is a candidate for early intervention. We compared treatment failure rates in patients receiving early intervention to those in patients offered spontaneous passage to identify subgroups that benefit from early intervention. Methods: We used administrative data and structured chart review to study consecutive patients attending one of nine hospitals in two provinces with an index emergency department (ED) visit and a confirmed 2.0-9.9 mm ureteral stone. We described patient, stone and treatment variables, and used multivariable regression to identify factors associated with treatment failure, defined as the need for rescue intervention or hospitalization within 60 days. Our secondary outcome was ED revisit rate. Results: Overall, 1168 (37.9%) of 3081 eligible patients underwent early intervention. Patients with small stones <5mm experienced more treatment failures (31.5% v. 9.9%) and more ED revisits (38.5% v. 19.7%) with early intervention than with spontaneous passage. Patients with large stones ≥7.0mm experienced fewer treatment failures (34.7% v. 58.6%) and similar ED revisit rates with early intervention. Patients with intermediate-sized 5.0-6.9mm stones had fewer treatment failures with intervention (37.4% v. 55.5%), but only if stones were in the proximal or middle ureter. Conclusion: This study clarifies stone characteristics that identify patients likely to benefit from early intervention. We recommend low-risk patients with uncomplicated stones <5mm generally undergo initial trial of spontaneous passage, while high-risk patients with proximal or middle stones >5mm, or any stone >7mm, be offered early intervention.