Introduction: Emergency medicine by its nature requires shift-work that often follows an erratic and unpredictable pattern. Faced with this ongoing challenge we hypothesized that many ED physicians may have taken steps to minimize their personal sleep deprivation through the use of a pharmacological sleep aid (PSA). The extent and nature of PSA use in this population is not well studied. We sought to describe the use of PSAs amongst practicing ED physicians in a Canadian tertiary-care setting. We also hoped to determine the specific substances being used, their frequency and predictive factors contributing to their use. Methods: A cross-sectional descriptive web-based survey was sent via e-mail to all practicing staff emergency physicians within the Calgary zone of Alberta Health Services. Participation was entirely voluntary and all responses were anonymous. Descriptive statistics were used to assess frequencies and summary measures. Logistic regression was used to explore associations between key variables. Results: Of the 198 eligible ED physicians, 144 (73%) completed the survey. 132 (92%) felt that shift-work negatively affected their ability to sleep and 121(84%) had experienced insomnia at some point in their medical career. 96(67%) ED physicians had used a PSA at some time in their career and 82(57%) were currently using a PSA with any frequency. The most frequent sleep aids currently being used were non-benzodiazepine hypnotics (65%), alcohol (31%) and melatonin (27%). 66(46%) respondents required a prescription for their PSA and 37(56%) of those had obtained a prescription from an ED physician colleague. Physician self-reporting of experience with insomnia was strongly associated with prior use of any PSA (OR 4.0; 95% CI 1.6-10.0) and prior use of non-benzodiazepine hypnotics (OR 14.4; 95% CI 3.2-64.2) There was no statistically significant association between current use of a PSA and physician age, physician gender, number of night shifts worked per month or co-habitation with children. None of the physicians who responded felt that their use of a PSA adversely affected their ability to provide quality patient care. Conclusion: Pharmacological sleep aid use among Canadian ED physicians may be more common than previously assumed. This could have implications for physician wellbeing and performance.

Introduction: Patients who are homeless and/or using substances rely heavily on emergency departments (ED) for medical care, and present with complex medical and social needs. Negative physician attitudes towards this population undermine the therapeutic relationship, compromising the quality of medical care provided. The objective of this study was to determine the attitudes of emergency physicians towards homeless and substance-using patients. Methods: Using a Modified Total Design approach, we conducted a cross-sectional survey of emergency physicians at five different healthcare locations in Calgary, Alberta, Canada. Attitudes were assessed using two validated measures, the Health Care Providers Attitudes Towards the Homeless Inventory (HPATHI), and the Short Understanding of Substance Use Scale (SUSS). Surveys were self-administered by respondents between March and December 2013. Results: A total of 117 physicians completed the survey (response rate 48%). 28% of respondents resented the amount of time it takes to see homeless patients, and 32% believed caring for homeless patients was not financially viable; 57% felt overwhelmed by the complexity of problems that homeless people have. Physicians with extra training in addiction medicine or health care for the homeless had more positive attitudes than physicians with no extra training; physician attitudes worsened over time towards both populations. Conclusion: Physicians feel overwhelmed when caring for patients who are homeless and/or substance using and negative attitudes worsened over time. Extra training in addiction medicine or healthcare for the homeless is associated with more positive attitudes. Possible strategies to improve attitudes should include a multifaceted approach addressing individual physician knowledge deficits, as well as expanded access to resources in the ED and community, designed to deal with the complex needs of these populations.

Introduction: The older adult population is growing. The consequences of minor trauma involving a head injury (MT-HI) in independent older adults are largely unknown. This study assessed the impact of a MT-HI on the functional and cognitive outcomes six months post injury of older adults who sustained a minor trauma. Methods: This multicenter prospective cohort study in eight sites included patients who were: aged 65 years or older, presenting to the emergency department (ED) within two weeks of injury with a chief complaint of a minor trauma, discharged within 48 hours, and independent for their basic activities of daily living prior to the ED visit. Participants underwent a baseline evaluation and a follow-up evaluation at six months post-injury. The main outcome was the functional decline measured with the Older Americans’ Resources and Services (OARS) scale six months after the trauma. Results: All 926 eligible patients were included in the analyses: 344 MT-HI patients and 582 without head injury. After six months, the functional decline was similar in both groups, 10.8% and 11.9% respectively (RR=0.79 [95% CI: 0.55-1.14]). The proportion of participants with mild cognitive disabilities was also similar, 21.7% and 22.8% respectively (RR=0.91 [95% CI: 0.71-1.18]). Furthermore, for the group of patients with a MT-HI, the functional outcome was not statistically different with or without the presence of a co-injury (RR= 1.35 [95% CI: 0.71-2.59]), or with or without the presence of a mTBI as defined by the WHO criteria (RR= 0.90 [95% CI: 0.59-1.13]). Conclusion: This study did not demonstrate that the occurrence of a MT-HI is associated with a worse functional or cognitive prognosis than other minor injuries without a head injury in an elderly population six months after injury.

Introduction: Recurrent admission to a hospital or trauma centre for separate incidents of traumatic injury is known as trauma recidivism. Although use of alcohol is a known risk factor for injury and associated with trauma recidivism, the scale of alcohol-related trauma recidivism has not been well described. The purpose of this review was to search the published literature for studies that evaluated the prevalence of alcohol use among trauma recidivists. Our primary objective was to determine the proportion of trauma recidivism related to alcohol use. The association between alcohol and trauma recidivism was evaluated as a secondary objective. Methods: Four electronic databases (MEDLINE, Embase, CINAHL, Web of Science) were searched from inception until December 2015 for all articles that might provide evidence on the proportion of trauma recidivism related to use of alcohol. After removal of duplicates, the search strategy yielded 2470 records for screening. Only primary studies that reported on repeated admissions to a hospital or trauma center for traumatic injuries specifically related to alcohol use were included. Descriptive statistics were used to assess study characteristics and the prevalence of trauma recidivism related to alcohol use. An aggregate weighted estimate of alcohol-related trauma recidivism was calculated. Results: A total of 12 studies met all inclusion criteria. Studies were published between 1989 and 2014. Overall, there were 3386 trauma recidivists among included studies. The proportion of trauma recidivists with evidence of alcohol use on admission ranged from 26.7% to 76.9% (median 46.4%). The aggregated sample produced a weighted estimate of 41.0% (1388/3386) for alcohol-related trauma recidivism. In four studies, the association between alcohol and trauma recidivism was examined; all four found a positive association between alcohol use and repeated admission for traumatic injury. Studies varied considerably in design, trauma populations, periods for evaluating recidivism, definitions for positive alcohol on admission, and methods used to determine alcohol use. Conclusion: Evidence from current literature suggests that 41.0% of trauma recidivism is related to use of alcohol. Due to methodological limitations among the studies included for review, this may underestimate the actual prevalence of alcohol-related trauma recidivism.

Introduction: It is estimated 15-50% of patients with a mild traumatic brain injury (MTBI) diagnosed in the emergency department (ED) will develop post-concussive syndrome (PCS). Although expert consensus recommends cognitive rest and graduated return to usual activities, these interventions are not based on prospective clinical evidence. The objective of this study was to determine if patients randomized to graduated return to usual activity discharge instructions had a decrease in their Post-Concussion Symptom Score (PCSS) 2 weeks after MTBI compared to patients who received usual care MTBI discharge instructions. Methods: This was a pragmatic, randomized trial of adult (18-64 years) patients presenting to an academic ED (annual census 65,000) with chief complaint ‘head injury’ occurring within 24 hours of ED visit. Patients were contacted by text message or phone 2 weeks post ED discharge and again at 4 weeks and asked to complete a validated, 22 item questionnaire to determine if there was a change in their PCSS. Secondary outcomes included change in PCSS at 4 weeks, number follow-up physician visits, and time off work/school. Results: 118 patients were enrolled in the study (58 in the control group and 60 in the intervention). Mean (SD) age was 35.2 (13.7) years and 43 (36.4%) were male. There was no difference with respect to change in PCSS at 2 weeks (10.5 vs 12.8; Δ 2.3, 95% CI: 7.0, 11.7) and 4 weeks post-ED discharge (21.1 vs 18.3; Δ 2.8, 95% CI: 6.9, 12.7) for the intervention and control groups, respectively. The number follow-up physician visits and time off work/school was similar when the groups were compared. Conclusion: Results from this study suggest graduated return to usual activity discharge instructions do not impact rate of resolution of MTBI symptoms 2 weeks after ED discharge. Given patients continue to experience low to moderate symptoms 2 weeks after MTBI, more investigation is needed to determine how best to counsel and treat patients with post-concussive symptoms.

Introduction: Oral sweet solutions have been accepted as effective analgesics for procedures in the neonatal population. However, there have been a limited number of trials in older infants. These studies have conflicting results. The objective of the study was to compare the efficacy of an oral sucrose solution versus placebo in reducing pain during urethral catheterization in infants 1 to 3 months old in the Emergency Department (ED). Methods: A randomized, double-blind clinical trial was conducted in a pediatric university-affiliated hospital ED. Infants, 1 to 3 months of age, were recruited and randomly allocated to receive 2 ml of 88% sucrose solution (SUC) or 2 ml of placebo solution (PLA) orally, 2 minutes before planned urethral catheterization. The primary outcome measure was the difference in pain scores as assessed by the Face, Legs, Activity, Cry and Consolability (FLACC) Pain Scale at 1 min post procedure. Secondary outcome measures were the difference in pain scores using the Neonatal Infant Pain Scale (NIPS), crying time and variations in heart rate. Results: Seventy-six participants were recruited and completed the study, 37 (group SUC) and 39 (group PLA) respectively. The mean difference in FLACC scores compared to baseline was 5.62 ± 1.32 (SUC) vs. 6.21 ± 1.15 (PLA) (p=.51) during catheterization, 2.70 ± 1.21 (SUC) vs. 2.26 ± 1.41 (PLA) at 1 min (p=.64) and 0.66 ± 1.32 (SUC) vs. 1.26 ± 1.00 (PLA) at 3 mins (p=.38). For the NIPS scores, it was 4.27 ± 1.06 (SUC) vs. 4.69 ± 0.92 (PLA) (p=.56) during procedure, 2.05 ± 0.91 (SUC) vs. 1.97 ± 1.19 (PLA) (p=.92) at 1 min and 0.49 ± 0.89 (SUC) vs. 0.89 ± 0.97 (PLA) (p=.54) at 3 mins. The difference in the mean crying time was not different between both groups: 99 ± 34 secs (SUC) vs. 100 ± 25 (PLA) (p=.99). No significant difference was found in participants’ heart rate variations during procedure 23 ± 8 BPM (SUC) vs. 26 ± 7 (PLA) (p=.60), after 1 min 19 ± 12 BPM (SUC) vs. 17 ± 7 (PLA) (p=.76) and after 3 mins -1 ± 12 BPM (SUC) vs. 3 ± 6 (PLA) (p=.53). Conclusion: In infants 1 to 3 months of age undergoing urethral catheterization in the ED, administration of an oral sweet solution did not statistically decrease pain scores as measured by the FLACC and NIPS scales. Participants’ heart rate variations and crying time were not significantly decreased when sucrose was provided.

Introduction: A novel bladder stimulation technique has been described for midstream urine (MSU) collection in well-feeding, inpatient newborns. We sought to determine the performance of this technique amongst infants presenting to the Emergency Department (ED). Methods: Our prospective ED-based study enrolled a convenience cohort of infants aged ≤ 90 days who required urine testing. Infants with significant feeding issues, moderate to severe dehydration, or critical illness were excluded. Bladder stimulation consisted of finger tapping on the lower abdomen with or without lower back massage while holding the child upright. Healthcare providers received standardized training in the technique. Primary outcome was the proportion of infants with successful MSU collection via the technique. Success was defined as adequate sample collection (≥ 1 mL urine) within 5 minutes of initiating stimulation. Secondary outcomes included the proportion of contaminated MSU samples, time required for MSU collection and full protocol completion, and patient discomfort as perceived by parent/guardian using a 100 mm visual analog scale [VAS]. Assuming success a priori in 50% of infants, a sample size of 115 allowed a 95% confidence interval of +/- 9.1% around the point estimate. Results: We enrolled 115 infants. Mean age was 53.0 days old (interquartile range [IQR] 26.7-68.0); 58.3% were male (69.2% uncircumcised). Midstream urine was successfully collected in 61 infants (53.0%; 95% CI 0.44,0.62). Thirty-one MSU samples (50.8%) were contaminated; uncircumcised males held the highest proportion (55.0%). Most contaminated samples (83.9%) were reported as “non-significant growth” or “growth of ≥ 3 organisms” and were easily identifiable as contaminants with minimal impact on clinical care. Only 4 (8.5%) of the 47 patients discharged home after successful MSU collection had a repeat ED visit for urine testing. Median stimulation time for MSU collection was 45 seconds (IQR 20-99 secs). Median time for full protocol completion was 30.83 minutes (IQR 24.42-46.83 mins). Mean VAS for infant discomfort was 20.2 mm (SD +/- 20.4 mm). Conclusion: Our pragmatic, ED-based study found the success rate of this bladder stimulation technique to be significantly lower (53%) than its published rate (86%). The contamination rate was high but most contaminated specimens were easily identifiable as such and had minimal clinical impact.

Introduction: Bronchiolitis is the most common lower respiratory tract infection among infants, characterized by wheeze and respiratory distress. Reliance on pulse oximetry has been associated with increased hospitalizations, prolonged hospital stay and escalation of care. The objectives were to determine if there is a difference in the proportion of unscheduled medical visits within 72 hours of emergency department discharge in infants with bronchiolitis who desaturate to <90% for at least one minute during home oximetry monitoring versus those without desaturations. Methods: This is a prospective cohort study from 2008 to 2013 enrolling 118 otherwise healthy infant aged 6 weeks to 12 months discharged home from a tertiary care pediatric emergency department with a diagnosis of acute bronchiolitis. The primary outcome was unscheduled medical visits for bronchiolitis, a visit to any health care provider due to concerns about respiratory symptoms, within 72 hours of discharge in infants with and without desaturations. Secondary outcomes included examination of the severity and duration of the desaturations, delayed hospitalizations within 72 hours of discharge and the effect of activity on desaturations. Results: During a mean monitoring period of 19 hours, 75/118 (64%) infants had at least one desaturation event (median continuous duration 3.4 minutes). 59/118 infants (50%) had at least 3 desaturations, 12 (10%) desaturated for >10% monitored time and 51(43%) had desaturations lasting ≥ 3 minutes continuously. 59/118 (50%) infants desaturated to ≤ 80% and 29 (24%) to ≤ 70% for ≥ 1 minute. A total 18/75 infants with desaturations (24.0%) had an unscheduled visit for bronchiolitis versus 11/43 of their non-desaturating counterparts (25.6%) [Difference - 1.6%; 95%CI -0.15 to ∞, p=0.66]. One of 75 desaturating infants (1.3%) and 2/43 (4.6%) of those without desaturations were hospitalized within 72 hours [Difference of -3.3%; 95% CI -0.04 to 0.10, p = 0.27]. Seventy seven percent of infants with desaturations experienced them during sleep or while feeding. Conclusion: The majority of infants with mild bronchiolitis experienced recurrent or sustained desaturations after discharge home. Children with and without desaturations had comparable rates of return for care, with no difference in unscheduled return medical visits and delayed hospitalizations.

Introduction: Survival to hospital discharge is better for PEA than asystole in out-of-hospital cardiac arrest. Point of care ultrasound (PoCUS) is widely used in cardiac arrest, although not mandated by ACLS guidelines. This study examines if initial PoCUS findings combined with cardiac rhythm are predictive of outcomes including return of spontaneous circulation (ROSC), survival to hospital admission (SHA), and hospital discharge (SHD). Methods: A database review was completed for patients arriving to a tertiary ED in asystole or PEA arrest from 2010 to 2014. Patients under 19y or with a previous DNR were excluded. Patients were grouped into those with cardiac activity on PoCUS and PEA on ECG (Positive group); those with no cardiac activity recorded on PoCUS and asystole on ECG (Negative group); and those with a mix of positive and negative findings (Indeterminate group). Data was analyzed for the frequency of ROSC, SHA, and SHD. Results: 186 patients met the study criteria, with 14 (8%) in the positive group, 134 (72%) in the negative group, and 38 (20%) in the indeterminate group. The positive group had significantly better initial outcomes than the negative group: ROSC: 78% (95% CI 49-95%) vs 17% (11-25%); OR 17.70 (4.57-168.5; p < 0.0001) and SHA: 29% (8-58%) vs 7% (3-12%); OR 5.56 (1.45-21.28; p = 0.022), and then the combined negative and indeterminate groups: ROSC: 22% (16-29%), OR 12.93 (3.43-48.73; p < 0.0001; SHA: 8% (5-13%); OR 4.51 (1.25-16.27; p = 0.033). There was no difference between the positive group and either the negative or combined groups for final outcome of SHD: 0% (0-23%) vs 1% (0-5%); OR 1.83 (0.08-39.97; p = 1.00; and vs 1% (0-5%); OR 1.67 (0.08-33.96; p = 1.00). The negative group had worse initial outcomes than the combined positive and indeterminate groups: ROSC 17% (11-25%) vs. 50% (36-64%) OR 0.21 (0.10-0.42; p < 0.0001); SHA 6% (3-12%) vs. 8% (5-13%) OR 0.34 (0.13-0.92; p = 0.0490). There was no difference in SHD: 1% (0-5%) vs. 1% (0-5%) OR 0.77 (0.07-8.71; p = 1.00). Conclusion: Our results suggest that although finding positive cardiac activity on ECG (PEA) and also on PoCUS is associated with greater ROSC and SHA, it does not identify patients with a final outcome of SHD.

Introduction: Tissue oximetry using near-infrared spectroscopy (NIRS) is a non-invasive monitor of cerebral oxygenation. This new technology has been used during cardiac arrest because of its ability to give measures in low blood flow situations. The aim of this systematic review was to assess the evidence regarding the association between NIRS values and resuscitation outcomes in patients undergoing cardiopulmonary resuscitation. We hypothesized that higher NIRS values would be associated with better outcomes and that the strength of that association would differ depending on the timing of the NIRS measurements. Methods: This review was registered (Prospero CRD42015017380) and is reported as per the PRISMA guidelines. Medline, Embase and CENTRAL were searched from their inception to September 18th, 2015 using a specifically designed search strategy. Grey literature was also searched using Web of Science and Google Scholar. NIRS manufacturers and authors of included citations were contacted to inquire on unpublished results. Finally, the references of all retained articles were reviewed in search of additional relevant studies. Studies reporting NIRS monitoring in adults during cardiac arrest were eligible for inclusion. Case reports and case series of fewer than five patients were automatically excluded. Two reviewers assessed the quality of included articles and extracted the data. Results: Out of 3275 unique citations, 19 non-randomized observational studies (15 articles and four conference abstracts) were included in this review, for a total of 2436 patients. Six studies were evaluated at low risk of bias, nine at intermediate risk and four at high risk. We found a stronger association between the return of spontaneous circulation (ROSC) and the highest NIRS value measured during resuscitation (standard mean deviation (SMD) 3.46 (95%CI 2.31-4.62)) than between ROSC and the mean NIRS measures (SMD 1.33 (95%CI 0.92-1.74)) which was superior to the one between ROSC and initial measures (SMD 0.45 (95%CI 0.02-0.88)). Conclusion: Patients with good outcomes have significantly higher NIRS value during resuscitation than their counterparts. The association between ROSC and NIRS measurements was influenced the timing of measurements during resuscitation.

Introduction: Point of care ultrasound has become an established tool in the initial management of patients with undifferentiated hypotension. Current established protocols (RUSH, ACES, etc) were developed by expert user opinion, rather than objective, prospective data. We wished to use reported disease incidence to develop an informed approach to PoCUS in hypotension using a “4 F’s” approach: Fluid; Form; Function; Filling. Methods: We summarized the incidence of PoCUS findings from an international multicentre RCT, and using a modified Delphi approach incorporating this data we obtained the input of 24 international experts associated with five professional organizations led by the International Federation of Emergency Medicine. The modified Delphi tool was developed to reach an international consensus on how to integrate PoCUS for hypotensive emergency department patients. Results: Rates of abnormal PoCUS findings from 151 patients with undifferentiated hypotension included left ventricular dynamic changes (43%), IVC abnormalities (27%), pericardial effusion (16%), and pleural fluid (8%). Abdominal pathology was rare (fluid 5%, AAA 2%). After two rounds of the survey, using majority consensus, agreement was reached on a SHoC-hypotension protocol comprising: A. Core: 1. Cardiac views (Sub-xiphoid and parasternal windows for pericardial fluid, cardiac form and ventricular function); 2. Lung views for pleural fluid and B-lines for filling status; and 3. IVC views for filling status; B. Supplementary: Additional cardiac views; and C. Additional views (when indicated) including peritoneal fluid, aorta, pelvic for IUP, and proximal leg veins for DVT. Conclusion: An international consensus process based on prospectively collected disease incidence has led to a proposed SHoC-hypotension PoCUS protocol comprising a stepwise clinical-indication based approach of Core, Supplementary and Additional PoCUS views.

Introduction: The use of cardiac point of care ultrasound (PoCUS) to assess cardiac arrest patients is widespread, although not mandated by advanced cardiac life support (ACLS) guidelines. This study aims to examine if the use of ultrasound is associated with a difference in the length of resuscitation and the frequency of interventions during ACLS in the emergency department (ED). Methods: A retrospective database and chart analysis was completed for patients arriving to a tertiary ED in cardiac arrest, between 2010 and 2014. Patients were excluded if aged under 19, or with a previous DNR order. Patients were grouped based on whether PoCUS was used during ACLS (PoCUS group) and those without PoCUS (control group). Multiple data were abstracted from charts using a standardized form. Data was analyzed for the length of resuscitation, frequency of common ACLS interventions such as endotracheal intubation, administration of epinephrine, and defibrillation, as well as initial cardiac activity findings on PoCUS. Results: 263 patients met the study inclusion criteria, with 51 (19%) in the control group, and 212 (81%) in the PoCUS group. In the PoCUS group 23 (11%) had cardiac activity (Positive PoCUS) and 189 (89%) had no cardiac activity recorded. Positive PoCUS patients had longer mean resuscitation times (26.13 min, 95% CI 17.80-34.46 min) compared to patients with no PoCUS cardiac activity (12.63 min, 95% CI 11.07-14.19 min, p < 0.05) as well as to the control group (14.20 min, 95% CI 10.30-18.09 min, p < 0.05). Positive PoCUS patients were more likely to receive endotracheal intubation (91%, 95% CI 72-99%), and epinephrine (100%, 95% CI 85-100%) than patients with no PoCUS cardiac activity (ET: 47%, 95% CI 40-54%, p < 0.0001; Epi: 81%, 95% CI 75-86%, p < 0.0172) and than the control group (ET: 65%, 95% CI 50-78%, p < 0.0227; Epi: 80%, 95% CI 67-90%, p < 0.0258). There was no difference in numbers receiving defibrillation between groups. Conclusion: Our results suggest emergency physicians may be making increased resuscitative effort for patients with positive cardiac activity findings on PoCUS compared to those with negative findings or when no PoCUS was performed.

Introduction: Emergency Department (ED) resuscitation is a complex, high-stakes procedure where positive outcomes depend upon effective interactions between the healthcare team, the patient, and the environment. To this end, resuscitation teams work in spaces designed to optimize workflows and ensure that necessary treatments and skillsets are available when required. However, systematic failures in this environment cannot always be adequately anticipated, exposing patients to opportunities for harm. As part of a new interprofessional education initiative, this prospective, observational study sought to characterize latent threats to patient safety (LST’s) identified during the delivery of in-situ, simulated resuscitations in two Canadian, tertiary care, academic Emergency Departments. Methods: In-situ simulation sessions were delivered on a monthly basis in the EDs of each hospital campus, during which a variety of simulated resuscitation scenarios were run with distinct teams of ED healthcare professionals. A research assistant was present throughout each session and documented LST’s identified by simulation facilitators and participants during the case and debriefing. Data were entered into a master table and grouped thematically for analysis. Results: After a pilot run-in, 10 in-situ simulation sessions were delivered, involving 27 cases and reaching 180 ED healthcare professionals (25 attending MD, 37 resident MD, 59 RN, 24 RT). 83 latent safety threats were identified through these sessions (mean 3.1 LSTs per case) of which 52 were determined to be “actionable”. Corrective mechanisms have been initiated in 72% of these cases (e.g., new education campaigns and in-servicing, equipment provisioning, equipment checklists). Conclusion: In-situ simulation, beyond its role as a training tool for developing Non-Technical and Crisis Resource Management skills, can be effectively used to identify systematic deficits and knowledge gaps that could expose critically ill patients to harm. Effective quality improvement and continuing education programs are essential to translate these findings into more resilient patient care.

Introduction: Point of care ultrasound (PoCUS) provides invaluable information during resuscitation efforts in cardiac arrest by determining presence/absence of cardiac activity and identifying reversible causes such as pericardial tamponade. There is no agreed guideline on how to safely and effectively incorporate PoCUS into the advanced cardiac life support (ACLS) algorithm. We consider that a consensus-based priority checklist using a “4 F’s” approach (Fluid; Form; Function; Filling), would provide a better algorithm during ACLS. Methods: The ultrasound subcommittee of the Australasian College for Emergency Medicine (ACEM) drafted a checklist incorporating PoCUS into the ACLS algorithm. This was further developed using the input of 24 international experts associated with five professional organizations led by the International Federation of Emergency Medicine. A modified Delphi tool was developed to reach an international consensus on how to integrate ultrasound into cardiac arrest algorithms for emergency department patients. Results: Consensus was reached following 3 rounds. The agreed protocol focuses on the timing of PoCUS as well as the specific clinical questions. Core cardiac windows performed during the rhythm check pause in chest compressions are the sub-xiphoid and parasternal cardiac views. Either view should be used to detect pericardial fluid, as well as examining ventricular form (e.g. right heart strain) and function, (e.g. asystole versus organized cardiac activity). Supplementary views include lung views (for absent lung sliding in pneumothorax and for pleural fluid), and IVC views for filling. Additional ultrasound applications are for endotracheal tube confirmation, proximal leg veins for DVT, or for sources of blood loss (AAA, peritoneal/pelvic fluid). Conclusion: The authors hope that this process will lead to a consensus-based SHoC-cardiac arrest guideline on incorporating PoCUS into the ACLS algorithm.

Introduction: Patients with asthma frequently present to the emergency department (ED) with exacerbations; however, a select number of patients require admission to hospital. The objective of this study was to summarize the evidence regarding asthma-related hospital admissions and factors associated with these admissions following ED presentation. Methods: Comprehensive literature searches were conducted in seven electronic databases (database inception to 2015); manual and grey literature searches were also performed. Studies reporting disposition for adults after ED presentation were included. Study quality was assessed using the Newcastle-Ottawa Scale (NOS); standardized data-collection forms were used for data extraction. Admission proportions and factors associated with admission at a statistical significance level (p<0.05) were reported. Results: Out of an initial 5865 identified articles, 37 articles met full inclusion criteria. Admission proportions were reported in 25/37 studies, ranged from 1% to 37%, and collectively demonstrated a decline of ~9% in admissions between 1993 and 2012. Studies including a >50% Caucasian ethnicity were found to have a median admission proportion of 13% (interquartile range [IQR]= 7, 20) versus studies with >50% non-Caucasian ethnicity at 22% (IQR=20, 28). Age, female sex, and previous hospitalizations for asthma exacerbation were the most individually identifiable factors associated with admission. Presenting features and medication profile were the most frequent domains associated with admission. Conclusion: Admission rates have decreased approximately 9% in a nearly 20-year span and seem to be higher in studies involving mostly non-Caucasian ethnic groups. Demographic factors, markers of severity obtained by history or at ED presentation, and medication profile could be assessed by ED clinicians to effectively discern patients at high risk for admission.

Introduction: Most patients with acute renal colic are discharged from the ED after initial diagnosis and symptom control, but 20-30% require repeat ED visits for ongoing pain, and 15-25% require rescue intervention (ureteroscopic intervention or lithotripsy). If patients destined for failure of outpatient management could be identified based on information available during their ED visits, they could be prioritized early for intervention to reduce short term pain and disability. Our objective was to identify predictors of outpatient treatment failure, defined as the need for hospitalization or rescue intervention within 60 days of ED discharge. Methods: We collated prospectively gathered administrative data from all Calgary region patients with an ED diagnosis of renal colic over a one-year period. Demographics, arrival mode, triage category, vital signs, pain scores, analgesic use and ED disposition were recorded. Research assistants reviewed imaging reports and documented stone characteristics. These data were linked with regional hospital databases to identify ED revisits, hospital admissions, and surgical procedures. The primary outcome was hospitalization or rescue intervention within 60 days of ED discharge. Results: Of 3104 patients with first ED visit for acute renal colic, 1296 had CT or US imaging and were discharged without intervention. Median age was 50 years and 69% were male. 325 patients (25.1%) required an ED re-visit and 11.8% required admission or rescue intervention. Patients with small (<5mm), medium (5-7mm) and large (>7mm) stones failed in 9.0%, 14.4% and 9.9% of cases respectively. The only factor predictive of treatment failure in multivariable models was stone position in the proximal or mid-ureter. Age, sex, vital signs, pain score, WBC, creatinine, history of prior stone or intervention, stone side, stone size, presence of stranding and degree of hydronephrosis were not associated with outpatient failure. Conclusion: Outpatient treatment failure could not be predicted based on any of the predictors studied.

Introduction: Ketamine is a popular sedative agent for painful procedures. It is not widely used at sub-dissociative analgesic doses in the emergency department (ED). We sought to determine the performance of low-dose ketamine (LDK) as an analgesic for acute pain management in adult patients in the ED. Methods: We systematically reviewed electronic databases (MEDLINE, EMBASE, AMED, CINAHL, PubMed and Cochrane database of systematic reviews), grey literature, conference proceedings and clinical trials registries. Two independent reviewers identified eligible studies using pre-determined criteria. We included peer-reviewed studies that used LDK (<1 mg/kg IV or <2mg/kg IM) in adult patients (>18 yo) requiring acute pain management for any condition in the ED. Our outcome measures included analgesic effect of LDK compared to any opioids, need for rescue analgesia, and neuropsychological adverse events. We assessed inter-rater agreement using kappa statistics, risk of bias using the Cochrane Collaboration’s Tool, and propose a treatment recommendation using GRADE. Heterogeneity among studies precluded meta-analysis. Results: We reviewed 1,408 studies and selected 44 for full review (kappa = 0.70). Thirty-three were excluded due to wrong patient population and non-analgesic use of ketamine. Eleven studies with 1,249 participants were included - six randomized control trials (RCTs) and five observational studies. All of which had an overall low risk of bias. There was extensive variation in the dose and route of LDK used (0.1 - 0.7 mg/kg SC/IV/IM), administration protocols, and use of adjunct analgesia. There is a lack of high quality data regarding the use of LDK as an analgesic agent in the ED. However, the current moderate quality data demonstrates a significant analgesic effect of LDK with occasional need for rescue analgesia and neuropsychological adverse events. Commonly reported neuropsychological adverse events included dizziness, dysphoria, and confusion, rarely agitation or hallucinations. All adverse events were self-limited or occasionally required benzodiazepines for resolution. Conclusion: Our GRADE evidence table identified moderate quality evidence from six RCTs supporting the analgesic effect of LDK for acute pain management in the ED when compared to using opioids alone.

Introduction: Pediatric fracture pain is under-treated both in the emergency department (ED) and after discharge. Oral opioids and ibuprofen are amongst the top medications used to treat this pain. This study describes the post ED discharge effectiveness and safety of ibuprofen and oxycodone. Methods: A prospective cohort observational study was conducted at the Stollery Children’s Hospital (Edmonton, Alberta) from June 2010 to July 2014. Children aged 4-16 years, with an acute fracture, who were being discharged home with either ibuprofen (Ibu) or oxycodone (Oxy) for pain management were eligible for recruitment. Patients were contacted daily for three days, and at 2 and 6 weeks post-injury. Information regarding medication use, pain levels (with the Faces Pain Scale, Revised), adjuvant therapies, adverse events, and side effects and follow up was collected. Results: A total of 329 children (n=112 Oxy, n= 217 Ibu) were included. Mean age was 10.4 years (Ibu), and 12.3 years (Oxy); 68% (n=223) were male. Fracture types included forearm/wrist (47%,n=154), lower leg/ankle (14%,n=46), shoulder/clavicle (13%,n=42), and upper arm/elbow (12%,n=39). Reductions were performed in 34% of cases (n=113), while 9% (n=29) had buckle fractures. Children receiving Oxy had their eating, sleeping, play, and school attendance affected more than those receiving Ibu. More children receiving Oxy (81%, 91/112) experienced an adverse effect than those receiving Ibu (61%, 129/213) (p=0.0002); abdominal pain, dizziness, drowsiness, nausea, and vomiting were most prominent. The change in pain score (maximum pain - post-treatment pain) for Day 1 was 3.79 for Oxy and 3.61 Ibu; Day 2 was 3.68 Oxy and 3.55 Ibu; Day 3 was 3.34 Oxy and 3.66 Ibu. On Day 1, 59% (66/112) of Oxy cohort patients used other medication(s) for their pain treatment; 19% (41/213) did the same in the Ibu cohort. Conclusion: Ibuprofen and oxycodone provide similar pain relief for children with post-Ed discharge fracture pain. Oxycodone has greater impact on activities of daily living, side effects, and use of other medications to relieve pain. Oxycodone does not appear to confer any benefit over ibuprofen for pain relief, and given its negative side effect profile, this study suggests that ibuprofen is the better option. Further research is needed to determine the best combination treatment for fracture pain for children.

Introduction: Patients with upper gastrointestinal bleeding (UGIB) are at risk for serious adverse events (SAE) after emergency department (ED) discharge. Endoscopy can aid in risk stratification but is not easily available. Therefore, stratifying using pre-endoscopic risk scores can aid ED physicians in disposition decisions. The aim of this study was to conduct a systematic review to assess the predictive value of pre-endoscopic risk scores for risk-stratification of ED UGIB patients. Methods: We searched 4 databases from inception to March 2015 with search terms related to “UGIB” and “ED”. Inclusion criteria were: 1) adult UGIB patients presenting to the ED; 2) risk scores without endoscopic predictors developed and validated in variceal and non-variceal UGIB patients. We excluded case reports, reviews, abstracts, animal studies and commentaries. In 2 phases (screening and full-review), 2 reviewers independently screened articles for inclusion. SAE included 30-day death, recurrent bleeding and need for intervention. Two reviewers independently extracted patient level data and the consensus data was used for analysis. We report kappa for the article selection, and pooled sensitivity, specificity, positive and negative predictive value, positive and negative likelihood ratios and accuracy with 95% CI for the risk scores. Results: We identified 3,173 articles, of which 3,065 were excluded in phase I (kappa 0.88, 95% CI 0.83-0.93). In phase II, we included 16 of the 108 remaining articles (kappa 0.84, 95% CI 0.70-0.97); 3 studied Glasgow Blatchford Score (GBS), 1 clinical Rockall score (cRockall) and 2 AIMS65; 6 compared GBS and cRockall, 3 compared GBS, a modification of the GBS and cRockall and 1 compared the GBS and AIMS65. Overall, the accuracy of the GBS, cRockall and AIMS65 was 0.47 (95% CI 0.46-0.47), 0.47 (95% CI 0.46-0.49) and 0.62 (95% CI 0.61-0.62), respectively. The accuracy for the GBS with a cut-off score of 2 was 0.73 (95% CI 0.71-0.74). Conclusion: None of the risk scores identified by our systematic review were robust and hence, cannot be recommended for use in clinical practice. However, the GBS with a cut-off score of 2 was superior over other risk scores. Future prospective studies are needed to develop robust new scores for use in ED patients with UGIB.

Introduction: Adverse drug events (ADE) are a leading cause of emergency department (ED) visits, yet are missed in up to 50% of presentations. In 2014, Accreditation Canada, a not-for-profit organization that evaluates healthcare institutions based on quality of care, introduced a requirement for EDs to identify patients at high-risk for drug-related morbidity, so that medication management interventions can be targeted to high-risk groups. We derived a clinical decision rule to identify patients at high-risk for ADEs using 4 variables. Our objective was to validate the rule by determining its sensitivity and specificity in a new sample. Methods: We conducted a prospective observational study in two tertiary care and one urban community hospital in British Columbia and Ontario. We used a systematic selection algorithm to generate a representative sample, and enrolled adults who reported taking at least one medication during the prior two weeks. Nurses completed the clinical decision rule and evaluated patients for standardized clinical findings. Each patient was assessed by a research pharmacist and a physician who were blinded to data collected by nurses. Any disagreement was subsequently adjudicated by an independent committee. The primary outcome was an ADE, defined as an unintended and harmful event related to medication use resulting a change in medical management, hospital admission or causing death. We calculated the rule’s sensitivity, specificity, and the proportion of patients screening positive with 95% confidence intervals (CI). Results: Among 1529 enrolled patients, 196 (12.8%, 95% CI 11.2-14.6%) were deemed to have experienced an ADE. The rule, consisting of the variables (i) having a pre-existing medical condition or having taken antibiotics within one week, and (ii) age ≥ 80 or having a medication change within 28 days, had a sensitivity of 92.9% (95%CI 88.3%-96.0%) and a specificity of 35.0% (95%CI 32.5%-37.7%) for ADEs. The proportion of patients screening positive was 41.7%. Conclusion: Among adults presenting to EDs, the rule was sensitive for ADEs while maintaining reasonable specificity. If implemented, the rule may help identify those patients at high-risk for ADEs who may benefit from evaluation by a clinical pharmacist in the ED, and will help institutions meet current Accreditation Canada standards.