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Proximal femoral fractures are characterized as one of the most common and most painful injuries sustained by patients of all ages and are associated with high rates of oligoanalgesia in the prehospital setting. Current treatments include oral and parenteral opiates and sedative agents, however regional anesthesia techniques for pain relief may provide superior analgesia with lower risk of side effects during patient transportation. The fascia iliaca compartment block (FICB) is an inexpensive treatment which is performed with minimal additional equipment, ultimately making it suitable in prehospital settings.
In adult patients sustaining proximal femoral fractures in the prehospital setting, what is the effect of the FICB on non-verbal pain scores (NVPS), patient satisfaction, success rate, and adverse events compared to traditional analgesic techniques?
A librarian-assisted literature search was conducted of the Cochrane Database, Ovid MEDLINE, PubMed, Ovid EMBASE, Scopus, and Web of Science indexes. Additionally, reference lists for potential review articles from the British Journal of Anesthesia, the College of Anesthetists of Ireland, the Journal of Prehospital Emergency Care, Annales Francaises d’Anesthesie et Réanimation, and the Scandinavian Journal of Trauma, Resuscitation, and Emergency Medicine were reviewed. Databases and journals were searched during the period from January 1, 1980 through July 1, 2022. Each study was scrutinized for quality and validity and was assigned a level of evidence as per Oxford Center for Evidence-Based Medicine guidelines.
Five studies involving 340 patients were included (ie, two randomized control trials [RCTs], two observational studies, and one prospective observational study). Pain scores decreased after prehospital FICB across all included studies by a mean of 6.65 points (5.25 - 7.5) on the NVPS. Out of the total 257 FICBs conducted, there was a success rate of 230 (89.3%). Of these, only two serious adverse events were recorded, both of which related to local analgesia toxicity. Neither resulted in long-term sequelae and only one required treatment.
Use of FICBs results in a significant decrease in NVPS in the prehospital setting, and they are ultimately suitable as regional analgesic techniques for proximal femur fractures. It carries a low risk of adverse events and may be performed by health care practitioners of various backgrounds with suitable training. The results suggest that FICBs are more effective for pain management than parenteral or oral opiates and sedative agents alone and can be used as an appropriate adjunct to pain management.
It is traditionally taught that the location to place an ultrasound probe to detect a pneumothorax with point-of-care ultrasound (POCUS) is the anterior chest, given the theory that air will collect at the least dependent area in the supine patient. There is a wide variety of scanning protocols with varying accuracy and completeness. We sought to assess the optimal area to scan for diagnosing pneumothorax by mapping the location of traumatic pneumothorax on computed tomography (CT).
Patients were selected after a retrospective cohort of adult patients who presented to a regional trauma center with a pneumothorax diagnosed on CT. Data were extracted using a standardized data collection tool, and 20% of charts were reviewed by two reviewers. Predefined zones were used to map the areas of pneumothoraces. Theoretical sensitivity and 95% confidence intervals (CIs) are reported.
A total of 203 traumatic pneumothoraces were reviewed from 2006 to 2016. The majority of the pneumothoraces were found in an area defined by the para-sternal border and the mid-clavicular line from the inferior aspect of the clavicle to the physiologic lung point (liver on the right, heart on the left). The theoretical sensitivity for pneumothorax of scanning this area was 91.6% (95% CI, 86.9–95%).
This study suggests any POCUS scanning protocol for traumatic pneumothorax should include an area from the inferior border of the clavicle at the parasternal border down to the liver or cardiac lung points and then the mid clavicular line down to the liver or cardiac lung points.
Emergency medical services (EMS) is called for a 65-year-old man with a 1-week history of cough, fever, and mild shortness of breath now reporting chest pain. Vitals on scene were HR 110, BP 135/90, SpO2 88% on room air. EMS arrives at the emergency department (ED). As the patient is moved to a negative pressure room, he becomes unresponsive with no palpable pulse. What next steps should be discussed in order to protect the team and achieve the best possible patient outcome?
One in four cases of acute aortic syndrome are missed. This national survey examined Canadian Emergency physicians’ opinion on risk stratification, the need for a clinical decision aid to risk stratify patients, and the required sensitivity of such a tool.
We surveyed 1,556 members of the Canadian Association of Emergency Physicians. We used a modified Dillman technique with a prenotification email and up to three survey attempts using electronic mail. Physicians were asked 21 questions about demographics, importance of certain high-risk features, investigation options, threshold for investigation, and if a clinical decision tool is required
We had a response rate of 32%. Respondents were 66% male, and 49% practicing >10 years, with 59% in an academic teaching hospital. A total of 93% reported a need for a clinical decision aid to risk stratify for acute aortic syndrome. A total of 99.6% of physicians were pragmatic accepting a non-zero miss-rate, two-thirds accepting <1%, and the remaining accepting a higher miss-rate.
Our national survey determined that emergency physicians would use a highly sensitive clinical decision aid to determine which patients are at low, medium, or high-risk for acute aortic syndrome. The majority of clinicians have a low threshold (<1%) for investigating for acute aortic syndrome, but accept that a zero miss-rate is not feasible.
Refractory ventricular fibrillation encountered during cardiac arrest has a mortality rate of 97%.1 As per the advanced cardiac life support (ACLS) guidelines, the management algorithm of ventricular fibrillation consists of chest compressions, epinephrine, defibrillation, and anti-arrhythmics.2 There have been reports describing the use of the fast-acting selective β-blocker, esmolol, and dual-sequential defibrillation in the management of ventricular fibrillation that is refractory to standard ACLS. We present a case of a 24-year-old male who had an out-of-hospital cardiac arrest, with refractory ventricular fibrillation despite high-quality cardiopulmonary resuscitation (CPR) and ACLS management. Along with standard ACLS, triple-sequential defibrillation was used to achieve return of spontaneous circulation (ROSC) after 82 minutes of downtime. An electrocardiogram (ECG) after ROSC showed an ST-elevation myocardial infarction (MI), and the patient underwent angiography showing a 100% occlusion of his left anterior descending artery. Following management of his coronary artery disease, he was discharged from the hospital 16 days later and was neurologically intact.
Acute aortic dissection (AAD) is a time sensitive, difficult to diagnose, aortic emergency. We sought to explore the quality of history taking in AAD and assess its impact on misdiagnosis.
We studied a retrospective cohort of patients >18 years old who presented to two tertiary care emergency departments from January 1st 2004 – December 31st 2012 and were diagnosed with an acute aortic dissection (AAD) on CT, MRI or TEE. Trained reviewers’ extracted data using a standardized data collection form. The definitions of 5 pain characteristics – character, onset, duration, quality, and radiation were defined a priori.
Data were collected for 194 cases of acute aortic dissection with a mean age of 65(SD 14.1) and 66.7% male, 34(17.6%) missed on initial presentation. Only 20(14.8%) patients were asked all 5 questions. The most common initial incorrect diagnosis were acute coronary syndrome (16, 47%), pulmonary embolism (5, 14.7%) and stroke (4, 11.7%). If <2 questions were asked 1 in 5 cases were missed, 4 times greater than if >2 were asked (P < 0.01).
Clinicians should ask and document the character, onset, duration, radiation and severity of pain in any patient presenting with chest, abdominal or flank pain. A focused history still remains the keystone to reducing misdiagnosis.
In 2011, Canada had a foreign-born population of approximately 6,775,800. They represented 20.6% of the total population. Immigrants possess characteristics that reduce the use of primary care. This is thought to be, in part, due to a lower education level, employment, and better health status. Our objective was to assess whether, in an immigrant population without a primary care physician, similar socioeconomic factors would also reduce the likelihood of using the emergency department compared to a non-immigrant population without primary care.
Data regarding individuals ≥ 12 years of age from the Canadian Community Health Survey from 2007 to 2008 were analysed (n=134,073; response rate 93%). Our study population comprised 15,554 individuals identified without a primary care physician who had a regular place for medical care. The primary outcome was emergency department as a regular care access point. Socioeconomic variables included employment, health status, and education. Covariates included chronic health conditions, mobility, gender, age, and mental health. Weighted logistic regression models were constructed to evaluate the importance of individual risk factors.
The sample of 15,554 (immigrants n=1,767) consisted of 57.3% male and 42.7% female respondents from across Canada. Immigrants were less likely than Canadian-born respondents to use the emergency department as a regular access point for health care (odds ratio=0.48 [95% CI 0.40 – 0.57]). Adjusting for health, education, or employment had no effect on this reduced tendency (odds ratio=0.47 [95% CI 0.38 – 0.58]).
In a Canadian population without a primary care physician, immigrants are less likely to use the emergency department as a primary access point for care than Canadian-born respondents. However, this effect is independent of previously reported social and economic factors that impact use of primary care. Immigration status is an important but complex component of racial and ethnic disparity in the use of health care in Canada.
Approximately 4.3 million Canadians are without a primary care physician, of which 13% choose the emergency department (ED) as their regular access point to health care. We sought to identify factors associated with preferential ED use over other health services. We hypothesized that socioeconomic barriers (i.e., employment, health status, education) to primary care would also prevent access to ED alternatives.
Data from the Canadian Community Health Survey, 2007 to 2008, were analysed (N=134,073; response rate 93.5%). Our study population comprised 14,091 individuals identified without a primary care physician. Socioeconomic variables included employment, health, and education. Covariates included chronic health conditions, immigrant status, gender, age, and mental health. Prevalence estimates and 95% confidence intervals (CIs) for each variable were calculated. Weighted logistic regression models were constructed to evaluate the importance of individual risk factors and their interactions after adjustment for relevant covariates.
The sample comprised 57.2% males from across Canada. Employment (OR 0.73 [95% CI: 0.59-0.90]), good health (OR 0.73 [95% CI 0.57-0.88]), and post-secondary education (OR 0.68 [95% CI 0.53-0.88]) reduced respondents use of the ED. The reduced odds of ED use were independent of chronic conditions, mental health, gender, poor mobility, province, and age.
Low socioeconomic status dictates preferential ED use in those without a primary care physician. Specific policy and system development targeting this at-risk population are indicated to alter ED use patterns in this population.