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With regionalized trauma care, medical transport times can be prolonged, requiring paramedics to manage patient care and symptoms. Our objective was to evaluate pain management during air transport of trauma patients.
We conducted a 12-month review of electronic paramedic records from a provincial critical care transport agency. Patients were included if they were ≥18 years old and underwent air transport to a trauma centre, and excluded if they were Glasgow Coma Scale score <14, intubated, or accompanied by a physician or nurse. Demographics, injury description, and transportation parameters were recorded. Outcomes included pain assessment via 11-point numerical rating scale, patterns of analgesia administration, and analgesia-related adverse events. Results were reported as mean ± standard deviation, [range], (percentage).
We included 372 patients: 47.0 years old; 262 males; 361 blunt injuries. Transport duration was 82.4 ± 46.3 minutes. In 232 (62.4%) patients who received analgesia, baseline numerical rating scale was 5.9 ± 2.5. Fentanyl was most commonly administered at 44.3 [25–60] mcg. Numerical rating scale after first analgesia dose decreased by 1.1 [-2–7]. Thereafter, 171 (73.7%) patients received 2.4 [1-18] additional doses. While 44 (23.4%) patients had no change in numerical rating scale after first analgesia dose, subsequent doses resulted in no change in numerical rating scale in over 65% of patients. There were 43 adverse events recorded, with nausea the most commonly reported (39.5%).
Initial and subsequent dose(s) of analgesic had minimal effect on pain as assessed via numerical rating scale, likely due in part to inadequate dosing. Future research is required to determine and address the barriers to proper analgesia.
Put simply, the sun should not set on an undiagnosed thunderclap headache.
A person presenting with a thunderclap headache is at high risk of a life-threatening condition – 4–5 times greater risk than those who are in the “rule-out MI” or “rule-out pulmonary embolism” category. Of those who do have a high-risk condition, 30–50 percent will not have a subarachnoid hemorrhage (SAH). Many emergency physicians discharge people with thunderclap headaches after a computed tomography (CT) and a lumbar puncture (LP) have ruled out an SAH, but this strategy needs to change and encompass consultation and additional imaging if that first series of investigations is negative. There are many other conditions that can present with a thunderclap headache. This chapter will review the differential diagnosis, and the signs and symptoms of each; it will conclude with recommendations on a comprehensive approach in the emergency department (ED) for someone presenting with a thunderclap headache.
We sought to conduct a major objective of the CAEP Academic Section, an environmental scan of the academic emergency medicine programs across the 17 Canadian medical schools.
We developed an 84-question questionnaire, which was distributed to academic heads. The responses were validated by phone by the lead author to ensure that the questions were answered completely and consistently. Details of pediatric emergency medicine units were excluded from the scan.
At eight of 17 universities, emergency medicine has full departmental status and at two it has no official academic status. Canadian academic emergency medicine is practiced at 46 major teaching hospitals and 13 specialized pediatric hospitals. Another 69 Canadian hospital EDs regularly take clinical clerks and emergency medicine residents. There are 31 full professors of emergency medicine in Canada. Teaching programs are strong with clerkships offered at 16/17 universities, CCFP(EM) programs at 17/17, and RCPSC residency programs at 14/17. Fourteen sites have at least one physician with a Master’s degree in education. There are 55 clinical researchers with salary support at 13 universities. Sixteen sites have published peer-reviewed papers in the past five years, ranging from four to 235 per site. Annual budgets range from $200,000 to $5,900,000.
This comprehensive review of academic activities in emergency medicine across Canada identifies areas of strengths as well as opportunities for improvement. CAEP and the Academic Section hope we can ultimately improve ED patient care by sharing best academic practices and becoming better teachers, educators, and researchers.
There are multiple recent reports of an association between anxious/depressed (A/D) symptomatology and the rate of cerebral cortical thickness maturation in typically developing youths. We investigated the degree to which anxious/depressed symptoms are tied to age-related microstructural changes in cerebral fiber pathways. The participants were part of the NIH MRI Study of Normal Brain Development. Child Behavior Checklist A/D scores and diffusion imaging were available for 175 youths (84 males, 91 females; 241 magnetic resonance imagings) at up to three visits. The participants ranged from 5.7 to 18.4 years of age at the time of the scan. Alignment of fractional anisotropy data was implemented using FSL/Tract-Based Spatial Statistics, and linear mixed model regression was carried out using SPSS. Child Behavior Checklist A/D was associated with the rate of microstructural development in several white matter pathways, including the bilateral anterior thalamic radiation, bilateral inferior longitudinal fasciculus, left superior longitudinal fasciculus, and right cingulum. Across these pathways, greater age-related fractional anisotropy increases were observed at lower levels of A/D. The results suggest that subclinical A/D symptoms are associated with the rate of microstructural development within several white matter pathways that have been implicated in affect regulation, as well as mood and anxiety psychopathology.
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).
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.
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 < 0.05) and 2.1 (95% CI 1.6–2.8, p < 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 < 0.01) and 48.8% (95% CI 35.0%–62.7%, p < 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 < 0.01) and 71% (95% CI 53%–96%, p < 0.05), respectively.
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.
This introduction discusses the nuances of becoming comfortable with treating pain, general principles of pain assessment, and pain management. The book provides the clinician with practical information on pain management that can be used while working. The Joint Commission on the Accreditation of Healthcare Organizations has mandated documentation of pain levels for eating disorder (ED) patients. If an ED has prolonged waiting times or excessive delays, protocols that allow pain management prior to physician assessment should be considered for patients with such diagnoses. Other indications for advanced pain management directives could include obvious fractures, burns or amputations. While initiation of analgesics is improving, we need to improve our rate of recurrent analgesic provision. We can see that pain management is like any aspect of medicine: physician knowledge, physician experience, and patient expectation must all be combined to ensure optimal care.
A 21-year-old man with Marfan syndrome and known aortic root aneurysm presented to our emergency department with symptoms suggestive of acute aortic dissection. The patient was hemodynamically stable and bilateral upper extremity blood pressures were similar. There was no mediastinal widening on portable chest radiograph. Both contrast CT and retrograde angiography of the aorta failed to identify dissection. Subsequent transesophageal echocardiography demonstrated a Stanford classification type A dissection. This case demonstrates the utility of multiple imaging modalities for identifying aortic dissection in high-risk patients.
To compare the results of urine cultures and reagent strip testing in 2 groups of elderly emergency department (ED) patients: an asymptomatic group unlikely to have urinary tract infection (UTI), and a group who had vague symptoms and were considered at risk for UTI.
We performed a prospective observational convenience study with 2 groups of 100 patients aged 65 or older. The asymptomatic group consisted of afebrile patients presenting to the ED with non-infectious complaints, while the symptomatic group included patients presenting with acute confusion, weakness or fever but no apparent urinary symptoms. We defined a positive urine culture as a single organism count greater than 100 000 CFU/mL in mid-stream specimens, or greater than 1000 CFU/mL in catheter specimens. We considered reagent strips positive if they demonstrated any reaction to the leukocyte-esterase assay, the nitrite assay or both.
Of the 33 positive cultures, 10 had negative reagent strips. Thirteen of the 14 positive nitrite tests were culture positive for a specificity of 92.8% and a sensitivity of 36.1%. Positive cultures did not infer a diagnosis of UTI. Of the 67 positive reagent strips, 41 (61.2%) were associated with negative cultures. Likelihood ratios (LRs) in both groups affirmed the inability of the reagent strips to help significantly in decision making, with positive and negative LR in the indeterminate range (control group: 2.8 and 0.31, symptomatic group: 2.7 and 0.46, respectively).
In the elderly, reagent testing is an unreliable method of identifying patients with positive blood cultures. Moreover, positive urine culture rates are only slightly higher in patients with vague symptoms attributable to UTI than they are in (asymptomatic) patients treated for non-urologic problems, which suggests that many positive cultures in elderly patients with non-focal systemic symptoms are false-positive tests reflecting asymptomatic bacteriuria and not UTIs. Blood cultures, regarded by many as the criterion standard for UTI, do not have sufficient specificity to confirm the diagnosis of UTI in elderly patients with non-specific symptoms.