Use of Topical Anesthetics in the Management of Patients With Simple Corneal Abrasions: Consensus Guidelines From the American College of Emergency Physicians.

The management of corneal abrasions has largely excluded dispensing topical local anesthetics for home use due to concern for corneal toxicity. We have reviewed and critically appraised the available literature evidence regarding the use of topical anesthetics in patients with simple corneal abrasions. Using sequential Delphi review, we have developed these clinical guidelines. Herein are evidentiary summaries and consensus recommendations for 8 specific relevant questions. Our key observation is that for only simple corneal abrasions, as diagnosed and treated in accordance with the full protocol described herein, it appears safe to prescribe or otherwise provide a commercial topical anesthetic (ie, proparacaine, tetracaine, oxybuprocaine) for use up to every 30 minutes as needed during the first 24 hours after presentation, as long as no more than 1.5 to 2 mL total (an expected 24-hour supply) is dispensed and any remainder is discarded after 24 hours. Importantly, although published findings suggest absent harm for short courses, more rigorous studies with a greater cumulative sample size and ophthalmologic follow-up are needed.

SGEM Hot Off the Press: ultrasound during critical care simulation: a randomized crossover study.

As part of the Canadian Journal of Emergency Medicine's (CJEM) developing social media strategy, 1 we are collaborating with the Skeptics' Guide to Emergency Medicine (SGEM) to summarize and critically appraise the current emergency medicine (EM) literature using evidence-based medicine principles. In the "Hot Off the Press" series, we select original research manuscripts published in CJEM to be featured on the SGEM website/podcast 2 and discussed by the study authors and the online EM community. A similar collaboration is underway between the SGEM and Academic Emergency Medicine. What follows is a summary of the selected article the immediate post-publication synthesis from the SGEM podcast, commentary by the first author, and the subsequent discussion from the SGEM blog and other social media. Through this series, we hope to enhance the value, accessibility, and application of important, clinically relevant EM research. In this, the third SGEM HOP hosted collaboratively with CJEM, we discuss Olszynski et al.'s randomized crossover study evaluating the use of ultrasound simulator devices during critical care simulation. 3.

SGEM Hot Off the Press: hypertonic saline in severe traumatic brain injury: a systematic review and meta-analysis of randomized controlled trials.

As part of the Canadian Journal of Emergency Medicine's (CJEM) developing social media strategy, 1 we are collaborating with the Skeptics' Guide to Emergency Medicine (SGEM) to summarize and critically appraise the current emergency medicine (EM) literature using evidence-based medicine principles. In the "Hot Off the Press" series, we select original research manuscripts published in CJEM to be featured on the SGEM website/podcast and discussed by the study authors and the online EM community. A similar collaboration is under way between the SGEM and Academic Emergency Medicine. What follows is a summary of the selected article, the immediate post-publication synthesis from the SGEM podcast, commentary by the first author, and the subsequent discussion from the SGEM blog and other social media. Through this series, we hope to enhance the value, accessibility, and application of important, clinically relevant EM research. In this, the second SGEM HOP hosted collaboratively with CJEM, we discuss a systematic review evaluating the use of hypertonic saline in the treatment of severe traumatic brain injury. 2.

The Safety of Topical Anesthetics in the Treatment of Corneal Abrasions: A Review.

BACKGROUND: Despite the fact that topical anesthetics provide superb analgesia to the painful eye, they are not prescribed routinely to patients when they are discharged from the emergency department because of concerns for delayed healing and corneal erosion. OBJECTIVE: To summarize the evidence for the safety of topical proparacaine and tetracaine for pain relief in patients with corneal abrasions. METHODS: This is a systematic review looking at the use of topical anesthetic agents in the treatment of corneal abrasions in the emergency department. RESULTS: Our literature search produced two emergency department-based, randomized, double blind, placebo-controlled studies on human patients with corneal abrasions. Additionally, we found four studies that investigated the application of topical anesthetics in patients who underwent photorefractive keratectomy. All six studies demonstrated that a short course of dilute topical anesthetic provided efficacious analgesia without adverse effects or delayed epithelial healing. CONCLUSION: Limited available data suggests that the use of dilute topical ophthalmologic proparacaine or tetracaine for a short duration of time is effective, though their safety for outpatient use is inconclusive.

Determination of the psychometric properties of a behavioural marking system for obstetrical team training using high-fidelity simulation.

BACKGROUND: To determine the effectiveness of high-fidelity simulation for team training, a valid and reliable tool is required. This study investigated the internal consistency, inter-rater reliability and test-retest reliability of two newly developed tools to assess obstetrical team performance. METHODS: After research ethics board approval, multidisciplinary obstetrical teams participated in three sessions separated by 5-9 months and managed four high-fidelity simulation scenarios. Two tools, an 18-item Assessment of Obstetric Team Performance (AOTP) and a six-item Global Assessment of Obstetric Team Performance (GAOTP) were used.(5) Eight reviewers rated the DVDs of all teams' performances. RESULTS: Two AOTP items were consistently incomplete and omitted from the analyses. Cronbach's α for the 16-item AOTP was 0.96, and 0.91 for the six-item GAOTP. The eight-rater α for the GAOTP was 0.81 (single-rater intra-class correlation coefficient, 0.34) indicating acceptable inter-rater reliability. The 'four-scenario' α for the 12 teams was 0.79 for session 1, 0.88 for session 2, and 0.86 for session 3, suggesting that performance is not being strongly affected by the context specificity of the cases. Pearson's correlation of team performance scores for the four scenarios were 0.59, 0.35, 0.40 and 0.33, and for the total score across scenarios it was 0.47, indicating moderate test-retest reliability. CONCLUSIONS: The results from this study indicate that the GAOTP would be a sufficient assessment tool for obstetrical team performance using simulation provided that it is used to assess teams with at least eight raters to ensure a sufficiently stable score. This could allow the quantitative evaluation of an educational intervention.

RETIRED: Providing opinion for medico-legal cases.

This document has been archived because it contains outdated information. It should not be consulted for clinical use, but for historical research only. Please visit the journal website for the most recent guidelines.

RETIRED: Fetal health surveillance in labour.

This document has been archived because it contains outdated information. It should not be consulted for clinical use, but for historical research only. Please visit the journal website for the most recent guidelines.

Fetal health surveillance in labour.

OBJECTIVE: This guideline defines the standards pertaining to the application and documentation of fetal surveillance in labour that will decrease the incidence of birth asphyxia while maintaining the lowest possible rate of obstetrical intervention. Both high- and low-risk obstetrical populations are considered. It is intended that this guideline could be used by all persons providing intrapartum care in Canada, including nurses, physicians, and midwives. OPTIONS: Consideration has been given to methods of fetal surveillance currently available in Canada, including intermittent auscultation, electronic fetal monitoring (alone and when paired with vibro-acoustic or scalp stimulation and fetal scalp blood sampling), the "admission strip," computerized heart rate analysis, fetal oxygen saturation monitoring, fetal electrocardiogram analysis, and near-infrared spectroscopy. OUTCOMES: Short- and long-term outcomes were considered that may indicate the presence of birth asphyxia. The associated rates of operative or other labour interventions were also considered. EVIDENCE: A comprehensive review of randomized controlled trials performed from 1995 to date and a search of the literature using Medline and the Cochrane Database of all new studies on fetal surveillance. The level of evidence has been determined using the criteria described by the Canadian Task Force on the Periodic Health Examination. RECOMMENDATIONS: Part I: Standard Fetal Surveillance in Labour 1. Women in active labour should receive continuous close support from an appropriately trained professional. One-to-one nursing is recommended. (I-A) 2. Intermittent auscultation following an established protocol of surveillance and response (Figure 1) is the preferred method of fetal surveillance in healthy pregnancies in the active phase of labour. (I-A) 3. Labour induction requires close monitoring of uterine activity and fetal heart rate. (III-B) 4. In the presence of abnormal fetal heart rate characteristics detected by intermittent auscultation and unresponsive to resuscitative measures, increased surveillance by continuous electronic fetal monitoring or fetal scalp sampling or delivery should be instituted. (I-A) 5. Continuous intrapartum electronic fetal monitoring is recommended: a) for pregnancies where there is an increased risk of perinatal death, cerebral palsy, or neonatal encephalopathy (III-C) b) when oxytocin is being used for augmentation of labour (1-A) c) when oxytocin is being used for induction of labour (III-C). 6. With respect to continuous electronic fetal monitoring, all professionals must be familiar with the paper speed used in each case to avoid misinterpretation. The correct time should be recorded on the electronic fetal monitoring record. (III-C) 7. Electronic fetal monitoring records should be inspected and documented every 15 minutes in the active phase of labour and at least every 5 minutes in the second stage of labour. (III-C) 8. The timing of electronic fetal monitoring patterns should be determined in association with uterine contractions. The contraction frequency, duration, intensity, and resting tone should be assessed and documented. Abdominal palpation, a tocodynamometer, or an intrauterine pressure catheter may be used to facilitate the assessment. (III-C) 9. Practitioners should use standard terminology when describing fetal heart rate characteristics of an electronic fetal monitoring record. (III-C) 10. Fetal scalp blood sampling is recommended in association with electronic fetal monitoring patterns that are uninterpretable or non-reassuring, such as sustained minimal or absent variability, uncorrectable late decelerations, increasing fetal tachycardia, and abnormal FHR characteristics on auscultation. (II-3B) 11. The limited knowledge available on the use of labour admission tests warrants further research to establish the usefulness of this screening approach. (III-C) Part II: New Technologies for Fetal Surveillance in Labour 12. The use of computer-based algorithms alone to interpret fetal heart rate patterns is not recommended as a standard of care at the present time. (III-D) 13. Fetal pulse oximetry as an adjunct to electronic fetal heart monitoring in patients with non-reassuring HR status is not recommended as a standard of care at the present time. (III-D) 14. ST waveform analysis technology is under development but is not recommended as a standard of care at this time. (III-C) 15. Near-infrared spectroscopy as an adjunct to electronic fetal monitoring is currently not recommended as there is insufficient evidence to assess its efficacy in fetal surveillance. (III-D) 16. Further study of fetal pulse oximetry, ST waveform analysis, and near-infrared technology in clinical research settings is encouraged. (III-B) VALIDATION: This guideline was reviewed by the SOGC Clinical Practice Obstetrics Committee, Maternal Fetal Medicine Committee, and ALARM Committee, as well as by the Canadian Medical Protective Association. SPONSOR: The Society of Obstetricians and Gynaecologists of Canada.