A simple application linking mortality data from the Bureau of Vital Statistics with data from the emergency department information system is described. This application has been used to supplement the regular mortality review process, identify deaths of patients who left without being seen, and perform outcome studies looking at specified clinical conditions.

The purpose of this report is to examine Ontario's geographic variation in emergency department (ED) visits for conditions that may be treated in alternative primary care settings. We studied all visits to Ontario EDs in 2002/03 and calculated county-specific age-standardized rates. Overall in Ontario, there were 3174 ED visits per 100 000 population aged 1-74 for conditions that could be treated in alternate primary care settings, but rates varied widely across counties. They were higher in rural counties with rates up to 7-fold higher than the provincial average. Urban counties had lower rates, some were less than one-third of the provincial average. Further research is needed to determine the relationship between ED utilization and primary care capacity.

Hydrogen sulfide is a potent lethal gas. Supportive care, nitrite therapy and hyperbaric oxygen are the treatment modalities reported in the literature in cases of hydrogen sulfide exposure. We describe an industrial exposure in which 6 workers inhaled high concentrations of hydrogen sulfide when they entered a closed spreader tank partially filled with liquid swine manure. Five of the 6 lost consciousness, and 2 were agitated and poorly responsive on arrival to the emergency department despite having already received high-flow oxygen for nearly 1 hour. These 2 patients received nitrite therapy followed by orotracheal intubation and hyperbaric oxygen. All patients were discharged home without sequelae after short stays in hospital. The emergency management of hydrogen sulfide exposure is briefly reviewed.

Wolff–Parkinson–White (WPW) syndrome with atrial fibrillation (AF) is a potentially life-threatening problem requiring rapid conversion to sinus rhythm. The most recent American Heart Association guidelines for the treatment of patients with WPW, published in conjunction with the 2000 Advanced Cardiac Life Support (ACLS) guidelines, suggests that intravenous amiodarone is a first-line therapy for AF–WPW; however the evidence suggests this is a potentially dangerous myth.

Neuroleptic malignant syndrome (NMS) is a potentially life-threatening condition that has been associated with antipsychotic use. Most diagnostic criteria include fever and muscle rigidity, although NMS may present without either. Diagnostic uncertainty in such cases may result in delays in diagnosis and management, leading to adverse consequences for these patients. The differential diagnosis of NMS is broad and includes a number of neurological, medical and psychiatric conditions as well as substance and medication-induced disorders. A case is described that illustrates an atypical presentation of NMS and demonstrates some of the challenges in its diagnosis. Limitations of current NMS criteria are also examined, and suggestions for future criteria are presented.

Thrombotic venous obstruction in patients with a tunnelled central venous catheter is a cause of superior vena cava syndrome that is not routinely encountered by emergency physicians. Diagnosis requires identifying patients at risk (e.g., those under treatment for cancer and those who have a tunnelled central venous catheter), recognizing the signs and symptoms of superior vena cava syndrome, usually dyspnea and dilated neck or thoracic veins, and imaging the venous obstruction using computer tomography or sonography. Management involves anticoagulation and local thrombolytic administration. We report the case of a 28-year-old woman who presented with a 2-day history of face, chest and bilateral arm swelling who had been receiving maintenance chemotherapy for acute lymphoblastic leukemia through a Hickman® catheter. This case demonstrates the need to be vigilant for thrombus formation in patients with long-term, indwelling central venous catheters.

Modern air-nailing tools are known to cause penetrating trauma. We report the unusual case of a pneumatically fired carpenter's nail that penetrated the chest of a 30-year-old man and subsequently embolized from the heart to the left femoral artery without clinical evidence of having entered the heart. The nail was surgically removed, and the patient was discharged from hospital without sequelae after 10 days. This case and the relevant literature are discussed from the perspective of the emergency department investigation and care of such patients.