Presentations, management and outcomes of postoperative bariatric patients seen in the emergency department.

BACKGROUND: Bariatric surgery is becoming increasingly common and postoperative patients often present to the emergency department (ED) with complications. We sought to describe the presenting complaints, management, and outcomes of postoperative bariatric surgery patients seen in the ED. METHODS: We conducted a health records review of 300 consecutive postoperative Roux-en-Y bypass surgery patients who presented to two tertiary care EDs of a major bariatric surgery center within one year of surgery. Cases were identified using a data analytic tool, and two evaluators abstracted clinical variables, imaging, treatments, and outcomes using the electronic health record. Attending emergency physicians verified the data and an experienced bariatric surgeon interpreted the computed tomography (CT) results and surgical procedures. RESULTS: We included 300 patients with mean age 43.0 years, 89.7% female. Of these, 70.0% presented within 30 days of surgery and 41.7% were admitted to hospital. ED treatments included intravenous fluids (67.0%), antiemetics (53.3%), and analgesia (61.9%). Patients presenting within 30 days of surgery were more likely to undergo a CT (74.3% vs 63.3%; p = 0.06) and to have clinically important CT findings (31.9% vs 6.6%; p ≤0.001). More of the ≤30-day patients were admitted to hospital (46.2% vs 31.1%; p = 0.02). While a higher proportion of patients presenting after 30 days underwent a procedure, a large number of those were not directly related to bariatric surgery, such as appendectomy and cholecystectomy. Of the 34 patients undergoing a procedure, the majority presented with abdominal pain (76.5%). CONCLUSION: This is the first detailed health records review of postoperative bariatric patients seen in the ED in the emergency medicine literature. Those presenting with abdominal pain were more likely to undergo CT abdomen and a surgical procedure. Similarly, those presenting within 30 days of surgery were more likely to have significant CT findings and require hospital admission. Others presenting with primarily nausea and vomiting may improve with ED symptom management and be discharged home with bariatric team follow-up.

Mortality and risk factors associated with misdiagnosis of acute aortic syndrome in Ontario, Canada: a population-based study.

INTRODUCTION: Acute aortic syndrome (AAS) is a life-threatening aortic emergency. It describes three diagnoses: acute aortic dissection, acute intramural haematoma and penetrating atherosclerotic ulcer. Unfortunately, there are no accurate estimates of the miss rate for AAS, risk factors for missed diagnosis or its effect on outcomes. METHODS: A population-based retrospective cohort study of anonymously linked data for residents of Ontario, Canada, was carried out. Incident cases of AAS were identified between 2003 and 2018 using a validated algorithm based on ICD codes and death. Before multivariate modelling, all categorical variables were analysed for an association with missed AAS diagnosis using χ2 tests. These preliminary analyses were unadjusted for clustering or any covariates. Finally, we performed multilevel logistic regression analysis using a generalised linear mixed model approach to model the probability of a missed case occurring. RESULTS: There were 1299 cases of AAS (age mean (SD) 68.03±14.70, woman 500 (38.5%), rural areas (n=111, 8.55%)) over the study period. Missed cases accounted for 163 (12.5%) of the cohort. Mortality (non-missed AAS 59.7% vs missed AAS 54.6%) and surgical intervention (non-missed AAS 31% vs missed AAS 30.7%) were similar in missed and non-missed cases. However, lower acuity (Canadian triage acuity scale >2 (OR 2.45 95% CI 1.71 to 3.52) (the scale is from 1 to 5, with 1 indicating high acuity) had a higher odds of being a missed case and non-ambulatory presentation (OR 0.47 95% CI 0.33 to 0.67) and presenting to a teaching (OR 0.60 95% CI 0.40 to 0.90)) or cardiac centre (OR 0.41 95% CI 0.27 to 0.62) were associated with a lower odds of being a missed case. CONCLUSIONS: The high rate of misdiagnosis has remained stable for over a decade. Non-teaching and non-cardiac hospitals had a higher incidence of missed cases. Mortality and rates of surgery were not associated with a missed diagnosis of AAS. Educational interventions should be prioritised in non-teaching hospitals and non-cardiac centres.

Prospective Validation of Computed Tomography to Identify Patients at High Risk for Stroke After Transient Ischemic Attack or Minor Stroke.

BACKGROUND: Computed tomography (CT) findings of acute and chronic ischemia are associated with subsequent stroke risk in patients with transient ischemic attack. We sought to validate these associations in a large prospective cohort of patients with transient ischemic attack or minor stroke. METHODS: This prospective cohort study enrolled emergency department patients from 13 hospitals with transient ischemic attack who had CT imaging. Primary outcome was stroke within 90 days. Secondary outcomes were stroke within 2 or 7 days. CT findings were abstracted from radiology reports and classified for the presence of acute ischemia, chronic ischemia, or microangiopathy. Multivariable logistic regression was used to test associations with primary and secondary end points. RESULTS: From 8670 prospectively enrolled patients between May 2010 and May 2017, 8382 had a CT within 24 hours. From this total population, 4547 (54%) patients had evidence of acute ischemia, chronic ischemia, or microangiopathy on CT, of whom 175 had a subsequent stroke within 90 days (3.8% subsequent stroke rate; adjusted odds ratio [aOR], 2.33 [95% CI, 1.62-3.36]). This was in comparison to those with CT imaging without ischemia. Findings associated with an increased risk of stroke at 90 days were isolated acute ischemia (6.0%; aOR, 2.42 [95% CI, 1.03-5.66]), acute ischemia with microangiopathy (10.7%; aOR, 3.34 [95% CI, 1.57-7.14]), chronic ischemia with microangiopathy (5.2%; aOR, 1.83 [95% CI, 1.34-2.50]), and acute ischemia with chronic ischemia and microangiopathy (10.9%; aOR, 3.49 [95% CI, 1.54-7.91]). Acute ischemia with chronic ischemia and microangiopathy were most strongly associated with subsequent stroke within 2 days (aOR, 4.36 [95% CI, 1.31-14.54]) and 7 days (aOR, 4.50 [95% CI, 1.73-11.69]). CONCLUSIONS: In patients with transient ischemic attack or minor stroke, CT evidence of acute ischemia with chronic ischemia or microangiopathy significantly increases the risk of subsequent stroke within 90 days of index visit. The combination of all 3 findings results in the greatest early risk.

Misdiagnosis of Uncomplicated Cellulitis: a Systematic Review and Meta-analysis.

BACKGROUND: Cellulitis is a clinical diagnosis with several mimics and no gold standard diagnostic criteria. Misdiagnosis is common. This review aims to quantify the proportion of cellulitis misdiagnosis in primary or unscheduled care settings based on a second clinical assessment and describe the proportion and types of alternative diagnoses. METHODS: Electronic searches of Medline, Embase and Cochrane library (including CENTRAL) using MeSH and other subject terms identified 887 randomised and non-randomised clinical trials, and cohort studies. Included articles assessed the proportion of cellulitis misdiagnosis in primary or unscheduled care settings through a second clinical assessment up to 14 days post initial diagnosis of uncomplicated cellulitis. Studies on infants and patients with (peri-)orbital, purulent and severe or complex cellulitis were excluded. Screening and data extraction was conducted independently in pairs. Risk of bias was assessed using a modified risk of bias tool from Hoy et al. Meta-analyses were undertaken where ≥ 3 studies reported the same outcome. RESULTS: Nine studies conducted in the USA, UK and Canada, including a total of 1600 participants, were eligible for inclusion. Six studies were conducted in the inpatient setting; three were in outpatient clinics. All nine included studies provided estimates of the proportion cellulitis misdiagnosis, with a range from 19 to 83%. The mean proportion misdiagnosed was 41% (95% CI 28 to 56% for random effects model). Heterogeneity between studies was very high both statistically (I2 96%, p-value for heterogeneity < 0.001) and clinically. Of the misdiagnoses, 54% were attributed to three conditions (stasis dermatitis, eczematous dermatitis and edema/lymphedema). DISCUSSION: The proportion of cellulitis misdiagnosis when reviewed within 14 days was substantial though highly variable, with the majority attributable to three diagnoses. This highlights the need for timely clinical reassessment and system initiatives to improve diagnostic accuracy of cellulitis and its most common mimics. TRIAL REGISTRATION: Open Science Framework ( https://osf.io/9zt72 ).

A systematic review of sufentanil for the management of adults with acute pain in the emergency department and pre-hospital setting.

BACKGROUND: Pain is commonly encountered in the Emergency Department (ED) and pre-hospital setting and often requires opioid analgesia. We sought to synthesize the available evidence on the effectiveness of sufentanil for acute pain relief for adult patients in the pre-hospital or ED setting. METHODS: This systematic review was conducted in accordance with PRISMA guidelines. Medline, Embase, Cochrane CENTRAL, and CINAHL were searched from inception to February 1, 2022. The grey literature was also searched. We included randomized controlled trials of adult patients with acute pain who were treated with sufentanil. Two reviewers independently completed screening, full text review, and data extraction. Primary outcome was reduction in pain. Secondary outcomes included adverse events, need for rescue analgesia, and patient and provider satisfaction. Risk of bias was assessed using the Cochrane Risk of Bias 2 tool. A meta-analysis was not performed due to heterogeneity. RESULTS: Of 1120 unique citations, four studies (3 ED and 1 pre-hospital) met full inclusion criteria (n = 467 participants). The overall quality of the included studies was high. Intranasal (IN) sufentanil was superior to placebo for pain relief at 30 min (difference 20.8%, 95% CI 4.0-36.2%, p = 0.01). Both IN (two studies) and IV sufentanil (one study) were comparable to IV morphine. Mild adverse events were common and there was a higher propensity for minor sedation in patients receiving sufentanil. There were no serious adverse events requiring advanced interventions. CONCLUSION: Sufentanil was comparable to IV morphine and was superior to placebo for rapid relief of acute pain in the ED setting. The safety profile of sufentanil is similar to IV morphine in this setting, with minimal concern for serious adverse events. The intranasal formulation may provide an alternative, rapid, non-parenteral route that could benefit our unique emergency department and pre-hospital patient population. Due to the overall small sample size of this review, larger studies are required to confirm safety.

Can you accurately rule out acute aortic syndrome by restricting imaging of the aorta to the area of the patient's pain?

BACKGROUND: Acute aortic syndrome (AAS) is a life-threatening condition necessitating timely and accurate diagnosis for appropriate treatment. Currently, the only way to rule out the diagnosis is advanced imaging. The most accessible is computed tomography of the entire aorta. Most scans are negative, exposing patients to radiation, increased time in the emergency department (ED), and non-significant incidental findings. This study investigated whether restricting imaging to the area of aortic-related pain accurately rules out AAS. METHODS: A health records review was conducted on consecutive cases from three academic EDs between 2015 and 2020. Data were extracted and verified from multiple sources. Participants included adults diagnosed with AAS based on radiological evidence. The diagnostic performance of the restricted imaging strategy was assessed; sensitivity and likelihood ratios with 95% confidence intervals were calculated. RESULTS: Data from 149 cases of AAS were collected, with the majority presenting with chest pain (46%) or abdominal pain (24%). The restricted imaging strategy demonstrated a sensitivity of 96% (95% CI 91.4-98.5%) in ruling out AAS. In a subset of patients with systolic blood pressure > 90 mmHg and without aortic aneurysm/repair (n = 86), the sensitivity was 100% (95% CI 96-100%). CONCLUSION: Restricting imaging to the area of pain in hemodynamically stable patients without known aortic aneurysm provides a highly sensitive approach to ruling out AAS.

Relationship between systolic blood pressure and mortality in older vs younger trauma patients - a retrospective multicentre observational study.

BACKGROUND: The population of older trauma patients is increasing. Those patients have heterogeneous presentations and need senior-friendly triaging tools. Systolic blood pressure (SBP) is commonly used to assess injury severity, and some authors advocated adjusting SBP threshold for older patients. We aimed to describe and compare the relationship between mortality and SBP in older trauma patients and their younger counterparts. METHODS: We included patients admitted to three level-I trauma centres and performed logistic regressions with age and SBP to obtain mortality curves. Multivariable Logistic regressions were performed to measure the association between age and mortality at different SBP ranges. Subgroup analyses were conducted for major trauma and severe traumatic brain injury admissions. RESULTS: A total of 47,661 patients were included, among which 12.9% were aged 65-74 years and 27.3% were ≥ 75 years. Overall mortality rates were 3.9%, 8.1%, and 11.7% in the groups aged 16-64, 65-74, and ≥ 75 years, respectively. The relationship between prehospital SBP and mortality was nonlinear (U-shape), mortality increased with each 10 mmHg SBP decrement from 130 to 50 mmHg and each 10-mmHg increment from 150 to 220 mmHg across all age groups. Older patients were at higher odd for mortality in all ranges of SBP. The highest OR in patients aged 65-74 years was 3.67 [95% CI: 2.08-6.45] in the 90-99 mmHg SBP range and 7.92 [95% CI: 5.13-12.23] for those aged ≥ 75 years in the 100-109 mmHg SBP range. CONCLUSION: The relationship between SBP and mortality is nonlinear, regardless of trauma severity and age. Older age was associated with a higher odd of mortality at all SBP points. Future triage tools should therefore consider SBP as a continuous rather than a dichotomized predictor.

The impact of antibiotics on clinical response over time in uncomplicated cellulitis: a systematic review and meta-analysis.

PURPOSE: Antibiotic treatment of uncomplicated cellulitis is highly variable with respect to agent, dose, and route of administration. As there is uncertainty about optimal/appropriate time to reassess, we aimed to assess time to clinical response. METHODS: We conducted a systematic review of randomized controlled trials reporting clinical response of uncomplicated cellulitis to antibiotic treatment over multiple timepoints. PubMed, Embase, CENTRAL, WHO ICTRP, and clinicaltrials.gov were searched from inception to June 2021 without language restrictions. The primary outcome was time to clinical response. Other outcomes were components of clinical response (pain, severity score, redness, edema measured at ≥ 2 timepoints) and the proportion of patients with treatment failure. We performed a pooled estimate of the average time to clinical response together with 95% confidence intervals using a random effects model. RESULTS: We included 32 randomized controlled trials (n = 13,576 participants). The mean time to clinical response was 1.68 days (95%CI 1.48-1.88; I2 = 76%). The response to treatment for specific components was as follows: ~ 50% reduction of pain and severity score by day 5, a ~ 33% reduction in area of redness by day 2-3, and a 30-50% reduction of proportion of patients with edema by day 2-4. Treatment failure was variably defined with an overall failure rate of 12% (95%CI 9-16%). CONCLUSION: The best available data suggest the optimal time to clinical reassessment is between 2 and 4 days, but this must be interpreted with caution due to considerable heterogeneity and small number of included studies.

Current practice for primary headache disorders and perspectives on peripheral nerve blocks among emergency physicians in Canada: A national survey.

OBJECTIVE: This national postal survey aimed to examine Canadian emergency physicians' practice patterns with respect to drug treatment and perspectives on peripheral nerve blocks. BACKGROUND: The treatment of primary headache disorders in the emergency department is variable. METHODS: We surveyed 500 emergency physicians listed in the Canadian Medical Directory according to a modified Dillman's method: an initial invitation was followed by up to four reminders to nonresponders. Physicians were asked questions regarding their frequency of medication administration and perspectives toward peripheral nerve blocks. RESULTS: Of 500 mailed surveys, 468 were delivered and 179 physicians responded (response rate = 38.2%). The majority of physicians were men (92/144, 63.9%); 80.6% (116/144) had been in practice for greater than or equal to 10 years with 50.7% (75/148) in a community or district general teaching hospital. Commonly used pharmacotherapies for primary headaches were intravenous dopamine receptor antagonists (69%), co-administration of ketorolac and a dopamine receptor antagonist (54.2%), intravenous fluid boluses (54%), nonsteroidal anti-inflammatory drugs (NSAIDs) alone (53.5%), and acetaminophen (51.4%). Only 80 of 144 physicians (55.6%) reported previous experience with peripheral nerve blocks (95% confidence interval [CI] = 48%-65%). The majority (68/80, 85.0%) agreed peripheral nerve blocks are safe and 55.1% (43/78) agreed they are effective. The vast majority (118/140, 84.3%) would consider peripheral nerve blocks as a first-line treatment option given sufficient evidence from a future trial (95% CI = 78%-90%). CONCLUSION: NSAIDs alone, as well as dopamine receptor antagonists with or without ketorolac are commonly used for primary headache in Canadian emergency departments. A large proportion of physicians have never used a peripheral nerve block in their practice; among those who have experience with peripheral nerve blocks, the majority find them safe and effective. The majority of respondents would consider peripheral nerve blocks as a first-line treatment option given sufficient evidence from a future trial.

Effectiveness of Peripheral Nerve Blocks for the Treatment of Primary Headache Disorders: A Systematic Review and Meta-Analysis.

STUDY OBJECTIVE: Primary headache disorders are prevalent and account for 2% of all emergency department visits. Current treatment options are effective; however, time to pain relief is suboptimal. Alternatives such as peripheral nerve blocks have shown promising results. The objective of this systematic review is to examine the effectiveness of peripheral nerve blocks for timely pain relief. METHODS: We searched Ovid MEDLINE, EMBASE, Web of Science Core Collection, and the Cochrane Central Register of Controlled Trials and included randomized controlled trials comparing peripheral nerve blocks to placebo or active therapy. The primary outcome was pain within 120 minutes. Secondary outcomes were pain after 120 minutes, adverse events, need for rescue medications, and relapse of headache. Two reviewers screened and extracted data independently; mean differences (MDs) were calculated, and results were pooled using a random-effects model. RESULTS: Eleven studies met our eligibility criteria (n=860), of which 9 were included in the meta-analysis. Pain scores were significantly lower in patients treated with peripheral nerve blocks than with placebo at 15 minutes (MD: -1.17; 95% confidence interval: -1.82 to -0.51) and 30 minutes (MD: -0.99; 95% confidence interval: -1.66 to -0.32), and no serious adverse events were reported. Pain scores for peripheral nerve blocks versus active therapy and secondary outcomes were not pooled due to clinical heterogeneity. CONCLUSION: Our review shows peripheral nerve blocks are effective as a rapid treatment option when compared to placebo; however, we were unable to assess effectiveness against standard treatment. Emergency physicians should consider peripheral nerve blocks as an adjunct therapy for patients with primary headache disorders.

Barriers and facilitators to nursing delirium screening in older emergency patients: a qualitative study using the theoretical domains framework.

BACKGROUND: delirium is common in older emergency department (ED) patients, but vastly under-recognised, in part due to lack of standardised screening processes. Understanding local context and barriers to delirium screening are integral for successful implementation of a delirium screening protocol. OBJECTIVES: we sought to identify barriers and facilitators to delirium screening by nurses in older ED patients. METHODS: we conducted 15 semi-structured, face-to-face interviews based on the Theoretical Domains Framework with bedside nurses, nurse educators and managers at two academic EDs in 2017. Two research assistants independently coded transcripts. Relevant domains and themes were identified. RESULTS: a total of 717 utterances were coded into 14 domains. Three dominant themes emerged: (i) lack of clinical prioritisation because of competing demands, lack of time and heavy workload; (ii) discordance between perceived capabilities and knowledge and (iii) hospital culture. CONCLUSION: this qualitative study explored nursing barriers and facilitators to delirium screening in older ED patients. We found that delirium was recognised as an important clinical problem; however, it was not clinically prioritised; there was a false self-perception of knowledge and ability to recognise delirium and hospital culture was a strong influencer of behaviour. Successful adoption of a delirium screening protocol will only be realised if these issues are addressed.

Effect of inpatient antibiotic treatment among older adults with delirium found with a positive urinalysis: a health record review.

BACKGROUND: Among older adults with delirium and positive urinalysis, antibiotic treatment for urinary tract infection is common practice, but unsupported by literature or guidelines. We sought to: i) determine the rate of antibiotic treatment and the proportion of asymptomatic patients (other than delirium) in this patient population, and ii) examine the effect of antibiotic treatment on delirium resolution and adverse outcomes. METHODS: A health record review was conducted at a tertiary academic centre from January to December 2020. Inclusion criteria were age ≥ 65, positive delirium screening assessment, positive urinalysis, and admission to general medical units. Outcomes included rates of antibiotic treatment, delirium on day 7 of admission, and 30-day adverse outcomes. We compared delirium and adverse outcome rates in antibiotic-treated vs. non-treated groups. We conducted subgroup analyses among asymptomatic patients. RESULTS: We included 150 patients (57% female, mean age 85.4 years). Antibiotics were given to 86%. The asymptomatic subgroup (delirium without urinary symptoms or fever) comprised 38% and antibiotic treatment rate in this subgroup was 68%. There was no significant difference in delirium rate on day 7 between antibiotic-treated vs. non-treated groups, (entire cohort RR 0.94 [0.41-2.16] and asymptomatic subgroup RR 0.69 [0.22-2.15]) or in 30-day adverse outcomes. CONCLUSIONS: Older adults with delirium and positive urinalysis in general medical inpatient units were frequently treated with antibiotics - often despite the absence of urinary or other infectious symptoms. We failed to find evidence that antibiotic treatment in this population is associated with delirium resolution on day 7 of admission.

Macrocirculatory and Microcirculatory Endpoints in Sepsis Resuscitation.

Sepsis is a common disease process encountered by physicians. Sepsis can lead to septic shock, which carries a hospital mortality rate in excess of 40%. Although the Surviving Sepsis Guidelines recommend targeting a mean arterial pressure (MAP) of 65 mmHg and normalization of lactate, these endpoints do not necessarily result in tissue perfusion in states of shock. While MAP and lactate are commonly used markers in resuscitation, clinicians may be able to improve their resuscitation by broadening their assessment of the microcirculation, which more adequately reflects tissue perfusion. As such, in order to achieve a successful resuscitation, clinicians must optimize both macrocirculatory (MAP, cardiac output) and microcirculatory (proportion of perfused vessels, lactate, mottling, capillary refill time) endpoints. This review will summarize various macrocirculatory and microcirculatory markers of perfusion that can be used to guide the initial resuscitation of patients with sepsis.

A Delphi study to identify prehospital and emergency department trauma care modifiers for older adults.

Background: Older patients (age ≥ 65 yr) with trauma have increased morbidity and mortality compared to younger patients; this is partly explained by undertriage of older patients with trauma, resulting in lack of transfer to a trauma centre or failure to activate the trauma team. The objective of this study was to identify modifiers to the prehospital and emergency department phases of major trauma care for older adults based on expert consensus. Methods: We conducted a modified Delphi study between May and September 2019 to identify major trauma care modifiers for older adults based on national expert consensus. The panel consisted of 24 trauma care professionals from across Canada from the prehospital and emergency department phases of care. The survey consisted of 16 trauma care modifiers. Three online survey rounds were distributed. Consensus was defined a priori as a disagreement index score less than 1. Results: There was a 100% response rate for all survey rounds. Three new trauma care modifiers were suggested by panellists. The panel achieved consensus agreement for 17 of the 19 trauma care modifiers. The prehospital modifier with the strongest agreement to transfer to a trauma centre was a respiratory rate less than 10 or greater than 20 breaths/min or need for ventilatory support. The emergency department modifier with the strongest level of agreement was obtaining 12-lead electrocardiography following the primary and secondary survey. Conclusion: Using a modified Delphi process, an expert panel agreed on 17 trauma care modifiers for older adults in the prehospital and emergency department settings. These modifiers may improve the delivery of trauma care for older adults and should be considered when developing local and national trauma guidelines.

Contexte: Les polytraumatisés âgés (≥ 65 ans) sont exposés à un risque plus grand de morbidité et de mortalité comparativement aux jeunes polytraumatisés; cela s'explique en partie par un triage inadéquat des patients âgés victimes de traumatismes, qui fait en sorte qu'on ne les oriente pas vers un centre de traumatologie ou qu'on ne fait pas intervenir l'équipe de traumatologie. L'objectif de la présente étude était d'identifier les éléments de soins à modifier au stade préhospitalier et en médecine d'urgence lors de la prise en charge des cas de traumatismes graves chez les adultes âgés, sur la base d'un consensus d'experts. Méthodes: Nous avons procédé à une analyse Delphi modifiée entre mai et septembre 2019 pour recenser les éléments de soins à modifier chez les polytraumatisés âgés à partir d'un consensus national d'experts. Le panel d'experts se composait de 24 professionnels en traumatologie du Canada entier chargés des soins au stade préhospitalier et en médecine d'urgence. Le questionnaire portait sur 16 éléments à modifier en traumatologie. Trois questionnaires successifs ont été distribués en ligne. Le consensus était défini a priori par un indice de désaccord inférieur à 1. Résultats: Le taux de réponse a été de 100 % pour les 3 questionnaires. Les membres du comité ont suggéré 3 nouveaux éléments à modifier. Le comité est arrivé à un consensus pour 17 des éléments à modifier sur 19. L'élément préhospitalier ayant fait l'objet du plus solide consensus concernant le transfert vers un centre de traumatologie était une fréquence respiratoire inférieure à 10 ou supérieure à 20 respirations/minute ou la nécessité d'une assistance respiratoire. L'élément à modifier parmi les soins prodigués à l'urgence ayant fait l'objet du plus solide consensus après les 2 premiers questionnaires était l'obtention d'un électrocardiogramme à 12 dérivations. Conclusion: À l'aide d'une analyse Delphi modifiée, un comité d'expert s'est entendu sur 17 éléments de soins à modifier chez les polytraumatisés âgés au stade préhospitalier et en médecine d'urgence. Ces éléments pourraient améliorer les soins aux adultes âgés et méritent d'être pris en compte lors de la création de lignes directrices locales et nationales en traumatologie.

Treatment failure definitions for non-purulent skin and soft tissue infections: a systematic review.

OBJECTIVE: There is currently no uniform definition for antimicrobial treatment failure for adults with non-purulent skin and soft tissue infections (SSTIs). The objective of this systematic review was to identify treatment failure definitions and their common components in the literature. METHODS: Five electronic databases were searched from inception to March 2019. Two independent reviewers identified studies involving adults (age ≥ 18 years) with non-purulent SSTIs in which antimicrobial treatment failure was a defined outcome. There were no language restrictions. Only randomized trials or observational studies were included. RESULTS: After screening 4953 abstracts, 26 studies (N = 6629 patients) met full inclusion criteria. Reported treatment failure ranged from 0 to 29.5%. The most common definition components were hospital admission (78.9%), change in antibiotics (65.4%), and persistent or worsening signs and symptoms of infection (34.6%). Only one study listed specific criteria for persistent or worsening signs and symptoms of infection. CONCLUSIONS: For studies involving non-purulent SSTIs, the outcome of treatment failure is inconsistently defined and reported failure rates are highly variable. This systematic review has highlighted the need for more robust treatment failure definitions for non-purulent SSTIs. Research should focus on the development of a uniform treatment failure definition that should be used in future studies.

Elder Abuse in the Out-of-Hospital and Emergency Department Settings: A Scoping Review.

This scoping review aimed to synthesize the available evidence on the epidemiology, patient- and caregiver-associated factors, clinical characteristics, screening tools, prevention, interventions, and perspectives of health care professionals in regard to elder abuse in the out-of-hospital or emergency department (ED) setting. Literature search was performed with MEDLINE, EMBASE, the Cumulative Index of Nursing and Allied Health, PsycINFO, and the Cochrane Library. Studies were eligible if they were observational or experimental and reported on elder abuse in the out-of-hospital or ED setting. A qualitative approach, performed independently by 2 reviewers, was used to synthesize and report the findings. A total of 413 citations were retrieved, from which 55 studies published between 1988 and 2019 were included. The prevalence of elder abuse reported during the ED visit was lower than reported in the community. The most commonly detected type of elder abuse was neglect, and then physical abuse. The following factors were more common in identified cases of elder abuse: female sex, cognitive impairment, functional disability, frailty, social isolation, and lower socioeconomic status. Psychiatric and substance use disorders were more common among victims and their caregivers. Screening tools have been proposed, but multicenter validation and influence of screening on patient-important outcomes were lacking. Health care professionals reported being poorly trained and acknowledged numerous barriers when caring for potential victims. There is insufficient knowledge, limited training, and a poorly organized system in place for elder abuse in the out-of-hospital and ED settings. Studies on the processes and effects of screening and interventions are required to improve care of this vulnerable population.

Optimizing the Early Resuscitation After Out-of-Hospital Cardiac Arrest.

Resuscitation after out-of-hospital cardiac arrest can be one of the most challenging scenarios in acute-care medicine. The devastating effects of postcardiac arrest syndrome carry a substantial morbidity and mortality that persist long after return of spontaneous circulation. Management of these patients requires the clinician to simultaneously address multiple emergent priorities including the resuscitation of the patient and the efficient diagnosis and management of the underlying etiology. This review provides a concise evidence-based overview of the core concepts involved in the early postcardiac arrest resuscitation. It will highlight the components of an effective management strategy including addressing hemodynamic, oxygenation, and ventilation goals as well as carefully considering cardiac catheterization and targeted temperature management. An organized approach is paramount to providing effective care to patients in this vulnerable time period.

Contemporary Management of the High-Risk Pulmonary Embolism: The Clot Thickens.

Pulmonary embolism (PE) is a common disease process encountered in the acute care setting. It presents on a spectrum of severity with the most severe presentations carrying a substantial risk of morbidity and mortality. In recent years, a wide range of competing treatment strategies have been proposed for the high-risk PE including new catheter-based and extracorporeal techniques, and management has become more challenging. There is currently no consensus as to the optimal approach to treatment. Contemporary management decisions are informed by the balance between the risk of deterioration and the risk of harm from intervention, within the available resources. This review will summarize the current evidence to better inform clinical decision-making in high-risk PE and highlight future directions in management.

Serial Ottawa 3DY assessments to detect delirium in older emergency department community dwellers.

BACKGROUND: delirium is associated with increased morbidity and mortality among older emergency department (ED) patients. When using physician gestalt, delirium is missed in the majority of patients. The Ottawa 3DY (O3DY) has been validated to detect cognitive dysfunction among older ED patients. OBJECTIVES: to determine the sensitivity and specificity of serial O3DY assessments to detect delirium in older ED patients. DESIGN: a prospective observational multicenter cohort study. SETTING: four Quebec EDs. PARTICIPANTS: independent or semi-independent older patients (age ≥ 65 years) with an ED stay of at least 8 hours that required hospitalisation. MEASUREMENTS: eligible patients were evaluated using serial O3DY assessments at least 6 hours apart. The primary outcome was delirium after at least 8 hours in the ED. The reference standard for delirium assessment was the confusion assessment method (CAM). The sensitivity and specificity of the serial O3DY to detect delirium were calculated. RESULTS: we enrolled 301 patients (mean age 77 years, 49.5% male, 3.0% with a history of mild dementia). Thirty patients (10.0%) were CAM positive for delirium. Patients had a median of three O3DY assessments. Serial O3DY evaluations to detect delirium among patients with at least one abnormal O3DY had a sensitivity of 86.7% (95% confidence interval-CI 69.3-96.2%) and a specificity of 44.3% (95%; CI 38.3-50.4%). CONCLUSION: serial O3DY testing demonstrates good sensitivity as a screening tool to detect delirium among older adult patients with prolonged ED lengths of stay. Emergency physicians should consider the use of the serial O3DY over clinician gestalt to improve delirium detection.

Evaluation of an emergency department to outpatient parenteral antibiotic therapy program for cellulitis.

OBJECTIVE: Emergency department (ED) patients with non-purulent skin and soft tissue infections (SSTIs) requiring intravenous antibiotics may be managed via outpatient parenteral antibiotic therapy (OPAT). Prospective studies describing the performance of an ED-to-OPAT clinic program are lacking. The primary objective was to determine the OPAT treatment failure rate for ED patients with non-purulent SSTIs. METHODS: We conducted a prospective observational cohort study of adults with non-purulent SSTIs managed via an ED-to-OPAT clinic program. OPAT treatment failure was defined as hospitalization after a minimum of 48 h of OPAT for: worsening infection; intravenous line complications; or adverse antibiotic effects. Secondary outcomes were to describe OPAT clinic processes, patient satisfaction, and physician rationale for selecting intravenous antibiotics. RESULTS: We enrolled a consecutive sample of 153 patients [mean age 60.5 years, 82 male (53.6%)]; 137 patients (89.5%) attended their clinic appointment. OPAT treatment failure was 4.4%. None of the adverse intravenous line (10.9%) and adverse antibiotic (8.0%) events required hospitalization. Patients reported high satisfaction with timeliness of referral (median score 9 out of 10) and overall care received (median score of 10). The top five reasons given by physicians for selecting intravenous therapy were: clinical impression (52.9%); failed oral therapy (41.8%); diabetes (17.6%); severe pain (7.8%); and peripheral vascular disease (7.8%). CONCLUSIONS: This prospective study demonstrates that an ED-to-OPAT clinic program for non-purulent SSTIs is safe, has a low rate of treatment failures and results in high patient satisfaction. The rationale for selecting intravenous antibiotics showed significant variability among ED physicians.