Hypotension and respiratory events related to electrical cardioversion for atrial fibrillation or atrial flutter in the emergency department.

INTRODUCTION: Electrical cardioversion for atrial fibrillation/atrial flutter (AF/AFL) is common in the ED. Our previous work showed that hypotension and respiratory events were important adverse events that occurred in patients undergoing electrical cardioversion for AF/AFL. The purpose of this study was to examine if (1) beta-blockers or calcium channel blocker use prior to ECV were associated with hypotension and (2) medications used for procedural sedation were associated with respiratory events. METHODS: This was a secondary analysis of pooled study data from four previous multicentred studies on AF/AFL. We conducted a multivariable logistic regression to examine predictors of hypotension and respiratory adverse events. RESULTS: There were 1736 patients who received ECV. A hypotensive event occurred in 62 (3.6%) patients. There was no significant difference in the odds of a hypotensive event in patients who received a beta-blocker or calcium channel blocker in the ED compared to no rate control. Procedural sedation with fentanyl (OR 2.01 95% CI 1.15-3.51) and home beta-blocker use (OR 1.92, 95% CI 1.14-3.21) were significantly associated with hypotensive events. A respiratory event occurred in 179 (10.3%) patients. Older age (OR 2.02, 95% CI 1.30- 3.15) and receiving midazolam for procedural sedation were found to be significantly associated with respiratory events (OR 1.99, 95% CI 1.02-3.88). CONCLUSION: Beta-blocker or calcium channel blocker use prior to ECV for AF/AFL was not associated with hypotension. However, sedation with fentanyl and home beta-blocker use was associated with hypotension. The use of midazolam for procedural sedation was significantly associated with respiratory events.

RéSUMé: INTRODUCTION: La cardioversion électrique pour la fibrillation auriculaire / flutter auriculaire (AF / AFL) est fréquente aux urgences. Nos travaux précédents ont montré que l'hypotension et les événements respiratoires étaient des événements indésirables importants qui se sont produits chez les patients subissant une cardioversion électrique pour AF / AFL. Le but de cette étude était d'examiner si 1) les bêtabloquants ou les inhibiteurs calciques utilisés avant l'ECV étaient associés à l'hypotension et 2) les médicaments utilisés pour la sédation procédurale sont associés à des événements respiratoires. MéTHODES: Il s'agissait d'une analyse secondaire des données d'études regroupées de quatre études multicentriques précédentes sur l'AF/AFL. Nous avons effectué une régression logistique multivariée pour examiner les prédicteurs de l'hypotension et des événements indésirables respiratoires. RéSULTATS: Il y avait 1736 patients qui ont reçu ECV. Un événement hypotenseur s'est produit dans 62 (3,6%) patients. Il n'y avait pas de différence significative dans la probabilité d'un événement hypotenseur chez les patients qui ont reçu un bêtabloquant ou un inhibiteur calcique à l'urgence par rapport à aucun contrôle de taux. La sédation procédurale avec du fentanyl (RC 2,01 à 95 %, IC 1,15 à 3,51) et l'utilisation de bêtabloquants à domicile (RC 1,92, IC à 95 %, 1,14 à 3,21) étaient significativement associées à des événements hypotensifs. Un événement respiratoire est survenu chez 179 (10,3 %) patients. Un âge plus avancé (RC 2,02, IC à 95 % : 1,30 à 3,15) et la réception de midazolam pour sédation procédurale étaient significativement associés à des événements respiratoires (RC 1,99, IC à 95 % 1,02-3,88). CONCLUSIONS: L'utilisation d'un bêtabloquant ou d'un inhibiteur calcique avant l'ECV pour l'AF/AFL n'était pas associée à l'hypotension. Cependant, la sédation avec du fentanyl et l'utilisation de bêtabloquants à domicile étaient associées à l'hypotension. L'utilisation du midazolam pour la sédation procédurale était significativement associée aux événements respiratoires.

Was Virtual Care as Safe as In-Person Care? Analyzing Patient Outcomes at Seven and Thirty Days in Ontario during the COVID-19 Pandemic.

In 2020, almost overnight, the paradigm for healthcare interactions changed in Ontario. To limit person-to-person transmission of COVID-19, the norm of in-person interactions shifted to virtual care. While this shift was part of broader public health measures and an acknowledgment of patient and societal concerns, it also represented a change in care modalities that had the potential to affect the quality of care provided, as well as short- and long-term patient outcomes. While public policy decisions were being made to moderate the use of virtual care at the end of the declared pandemic, a thorough analysis of short-term patient outcomes was needed to quantify the impact of virtual care on the population of Ontario.

Hospital admission from the emergency department for selected emergent diagnoses during the first year of the COVID-19 pandemic in Ontario: a retrospective population-based study.

BACKGROUND: Avoidance of care during the pandemic may have contributed to delays in care, and as a result, worse patient outcomes. We evaluated markers of illness acuity on presentation to the emergency department among patients with non-COVID-19-related emergent diagnoses and associated outcomes. METHODS: We conducted a retrospective study using linked administrative data from Ontario. We selected 4 emergent diagnoses, namely appendicitis, ectopic pregnancy, renal failure and diabetic ketoacidosis. We used the nonemergent diagnosis of cellulitis as a control. Our primary outcome of interest was hospital admission. Secondary outcomes were ambulance arrival, surgical intervention, subsequent hospital admission within 30 days of discharge from the emergency department or hospital and 30-day mortality. We compared outcomes during the first year of the COVID-19 pandemic (Mar. 15-Dec. 31, 2020) with a control period (Mar. 15-Dec. 31, 2018, and Mar. 15-Dec. 31, 2019). RESULTS: Emergency department visits for all conditions initially decreased during the pandemic. During this period, patients across all study diagnoses were more likely to arrive to the emergency department via ambulance. Patients with an ectopic pregnancy had higher odds of surgery in the pandemic period (odds ratio [OR] 1.27, 95% confidence interval [CI] 1.04-1.55) but this was not observed among patients with appendicitis. Patients with renal failure had increased odds of hospital admission (OR 1.14, 95% CI 1.04-1.24) and 30-day mortality (OR 1.17, 95% CI 1.04-1.31) during the pandemic period. INTERPRETATION: The pandemic period was associated with increased arrival to the emergency department via ambulance across all study diagnoses. Although patients with renal failure had increased hospital admission and death, and patients with ectopic pregnancy had an increased risk of surgery, there were no differences in outcomes for other populations, suggesting the health care system was able to care for these patients effectively.

Patient outcomes associated with cancer diagnosis through the emergency department: A systematic review.

OBJECTIVE: Many patients are initially diagnosed with a new suspected cancer through the emergency department (ED). The objective of this systematic review was to compare stage of cancer and survival of patients diagnosed with cancer through the ED to patients diagnosed elsewhere. METHODS: Electronic searches of Medline and EMBASE were conducted and reference lists were hand-searched. Studies comparing adult patients diagnosed with any type of cancer through the ED (ED diagnosis) to patients diagnosed elsewhere (non-ED diagnosis) were included. Two reviewers independently screened titles and abstracts, assessed quality of the studies, and extracted data. The risk of bias of included studies was assessed using the Newcastle-Ottawa Scale. Data pertaining to patient outcomes were summarized and pooled using random-effects models and reported as risk ratios (RRs) with 95% confidence intervals (CIs), where applicable. RESULTS: Fourteen studies were included. There was an increased risk of more advanced/later stage cancer (Stage III/IV or late-stage vs. earlier stage) among patients with an ED diagnosis of cancer compared to a non-ED diagnosis of cancer (RR 1.30, 95% CI 1.39-1.58). Survival was lower for patients with an ED diagnosis of cancer compared to those diagnosed elsewhere (RR 0.61, 95% CI 0.49-0.75). CONCLUSIONS: Patients with an ED diagnosis of cancer had more advanced/late stage of cancer at diagnosis and worse survival compared to patients diagnosed elsewhere. Future research examining patients diagnosed with cancer through the ED is required.

Delayed intracranial hemorrhage after head injury among elderly patients on anticoagulation seen in the emergency department.

INTRODUCTION: Elderly patients on oral anticoagulation are commonly seen in emergency departments (EDs). Oral anticoagulation, particularly warfarin, is associated with an increased risk of intracranial hemorrhage after head trauma. Data on delayed bleeds in anticoagulated patients are limited. The objective of this study was to examine risk of delayed intracranial hemorrhage in patients presenting to the ED with a head injury anticoagulated with warfarin or a direct oral anticoagulant, compared to patients not anticoagulated. METHODS: Cohort study using administrative data from Ontario of patients ≥ 65 years presenting to the ED with a complaint of head injury between 2016 and 2018. The primary outcome was delayed intracranial hemorrhage, defined as a new ICD-10 code for intracranial hemorrhage within 90 days of the initial ED visit for a head injury where no intracranial hemorrhage was diagnosed. The main exposure variable was oral anticoagulation use, which was a three-level variable (warfarin, direct oral anticoagulants, or no oral anticoagulation). We used multivariable logistic regression to determine the odds of delayed intracranial hemorrhage based on anticoagulation status. RESULTS: 69,321 patients were included: 58,233 (84.0%) had not been prescribed oral anticoagulation, 3081 (4.4%) had a warfarin prescription, and 8007 (11.6%) had a direct oral anticoagulant prescription. Overall, 718 (1.0%) patients had a delayed intracranial hemorrhage within 90 days of ED visit for head injury. Among patients not anticoagulated, 586 (1.0%) had a delayed intracranial hemorrhage, 54 (1.8%) patients on warfarin, and 78 (1.0%) patients on a direct oral anticoagulant had a delayed intracranial hemorrhage. There was an increased odds of delayed intracranial hemorrhage with warfarin use compared with no anticoagulation (OR 1.5, 95% CI 1.1-2.1). There was no association between delayed intracranial hemorrhage and direct oral anticoagulant use compared to no anticoagulation (OR 0.9, 95% CI 0.6-1.1). CONCLUSIONS: There was an increased odds of delayed intracranial hemorrhage within 90 days in older ED head injured patients prescribed warfarin compared to patients not on anticoagulation. direct oral anticoagulant use was not associated with increased risk of delayed intracranial hemorrhage.

RéSUMé: INTRODUCTION: Les patients âgés sous anticoagulation orale sont fréquemment accueillis dans les services d'urgence. L'anticoagulation orale, en particulier la warfarine, est associée à un risque accru d'hémorragie intracrânienne après un traumatisme crânien. Les données sur les saignements retardés chez les patients anticoagulés sont limitées. L'objectif de cette étude était d'examiner le risque d'hémorragie intracrânienne tardive chez les patients se présentant aux urgences avec un traumatisme crânien et anticoagulés avec de la warfarine ou un anticoagulant oral direct, par rapport aux patients non anticoagulés. MéTHODES: Étude de cohorte utilisant les données administratives de l'Ontario des patients ≥ 65 ans se présentant aux urgences avec une plainte de traumatisme crânien entre 2016 et 2018. L'issue primaire était l'hémorragie intracrânienne tardive, définie comme un nouveau code CIM-10 pour une hémorragie intracrânienne dans les 90 jours suivant la visite initiale aux urgences où aucune hémorragie intracrânienne n'a été diagnostiquée. La principale variable d'exposition était le recours à l'anticoagulation orale, qui était une variable à trois niveaux (warfarine, anticoagulants oraux directs ou pas d'anticoagulation orale). Nous avons utilisé une régression logistique multivariable pour déterminer les chances d'hémorragie intracrânienne tardive en fonction du statut d'anticoagulation. RéSULTATS: 69 321 patients ont été inclus : 58 233 (84,0 %) n'avaient pas reçu de prescription d'anticoagulant oral, 3 081 (4,4 %) avaient une prescription de warfarine et 8 007 (11,6 %) avaient une prescription directe d'anticoagulant oral. Dans l'ensemble, 718 (1,0 %) patients ont présenté une hémorragie intracrânienne tardive dans les 90 jours suivant leur visite aux urgences pour un traumatisme crânien. Parmi les patients non anticoagulés, 586 (1,0 %) ont eu une hémorragie intracrânienne retardée, 54 (1,8 %) patients sous warfarine et 78 (1,0 %) patients sous anticoagulant oral direct ont eu une hémorragie intracrânienne retardée. Le risque d'hémorragie intracrânienne tardive était plus élevé avec l'utilisation de la warfarine qu'en l'absence d'anticoagulation (OR : 1,5, IC 95 % : 1,1-2,1). Il n'y avait pas d'association entre l'hémorragie intracrânienne tardive et l'utilisation d'anticoagulants oraux directs par rapport à l'absence d'anticoagulation (OR : 0,9, IC 95 % : 0,6-1,1). CONCLUSIONS: Il y avait une probabilité accrue d'hémorragie intracrânienne retardée dans les 90 jours chez les patients plus âgés victimes d'un traumatisme crânien aux urgences à qui l'on avait prescrit de la warfarine que chez les patients qui n'étaient pas sous anticoagulation. L'utilisation d'anticoagulants oraux directs n'était pas associée à un risque accru d'hémorragie intracrânienne tardive.

Intra-articular lidocaine versus intravenous sedation for closed reduction of acute anterior shoulder dislocation in the emergency department: a systematic review and meta-analysis.

OBJECTIVE: Anterior shoulder dislocations are commonly treated in the emergency department (ED). Analgesia for reduction is provided by intra-articular lidocaine (IAL) injection or intravenous sedation (IV sedation). The objective of this systematic review and meta-analysis was to compare IAL versus IV sedation for closed reduction of acute anterior shoulder dislocation in the ED. METHODS: Electronic searches of MEDLINE and EMBASE (1946-September 2021) were completed and reference lists were hand-searched. Randomized controlled trials (RCTs) comparing IAL and IV sedation for reduction of acute anterior shoulder dislocations among patients ≥ 15 years old in the ED were included. Outcomes of interest included a successful reduction, adverse events, ED length of stay, pain scores, procedure time, ease of reduction, patient satisfaction, and cost. Two reviewers independently screened abstracts, assessed study quality and extracted data. Data were pooled using random-effects models and reported as mean differences and risk ratios (RR) with 95% confidence intervals (CIs). RESULTS: 12 RCTs were included with a total of 630 patients (IAL = 327; IV sedation = 303). There was no difference in reduction success between IAL and IV sedation (RR 0.93; 95% CI 0.86-1.01, I2 = 69%), significantly lower adverse events with IAL (RR 0.16; 95% CI 0.07-0.33, I2 = 0%), shorter ED length of stay with IAL (mean difference - 1.48; 95% CI - 2.48 to - 0.47, I2 = 93%), no difference in pain scores post-analgesia and no difference in ease of reduction. CONCLUSIONS: Intra-articular lidocaine may have similar effectiveness as IV sedation in the successful reduction of anterior shoulder dislocations in the ED with fewer adverse events, shorter ED length of stay, and no difference in pain scores or ease of reduction. Intra-articular lidocaine may be an effective alternative to IV sedation for reducing anterior shoulder dislocations, particularly when IV sedation is contraindicated or not feasible.

RéSUMé: OBJECTIF: Les luxations antérieures de l'épaule sont couramment traitées au service des urgences (SU). L'analgésie pour la réduction est fournie par une injection intra-articulaire de lidocaïne (IAL) ou par une sédation intraveineuse (sédation IV). L'objectif de cette revue systématique et méta-analyse était de comparer la sédation IAL par rapport à la sédation IV pour la réduction fermée de la luxation antérieure aiguë de l'épaule aux urgences. MéTHODES: Des recherches électroniques ont été effectuées sur MEDLINE et EMBASE (1946-septembre 2021) et les listes de références ont été consultées manuellement. Les essais contrôlés randomisés (ECR) comparant la sédation IAL et IV pour la réduction des luxations antérieures aiguës de l'épaule chez les patients ≥ 15 ans aux urgences ont été inclus. Les résultats d'intérêt comprenaient une réduction réussie, les effets indésirables, la durée de séjour aux urgences, les scores de douleur, la durée de la procédure, la facilité de réduction, la satisfaction du patient et le coût. Deux examinateurs ont indépendamment passé en revue les résumés, évalué la qualité des études et extrait les données. Les données ont été regroupées à l'aide de modèles à effets aléatoires et présentées sous forme de différences moyennes et de rapports de risque (RR) avec des intervalles de confiance (IC) à 95 %. RéSULTATS: 12 ECR ont été inclus avec un total de 630 patients (IAL = 327 ; sédation IV = 303). Il n'y avait pas de différence dans le succès de réduction entre la sédation IAL et la sédation IV (RR = 0,93; IC à 95 % : 0,86 à 1,01, I2 = 69 %), événements indésirables significativement plus faibles avec IAL (RR = 0,16; IC à 95 % : 0,07 à 0,33, I2 = 0 %), durée de séjour plus courte avec IAL (différence moyenne = -1,48; IC à 95 % : -2,48 à -0,47, I2 = 93 %), aucune différence dans les scores de douleur après l'analgésie et aucune différence dans la facilité de réduction. CONCLUSIONS: La lidocaïne intra-articulaire peut avoir une efficacité similaire à celle de la sédation IV dans la réduction réussie des luxations antérieures de l'épaule aux urgences avec moins d'effets indésirables, une durée de séjour aux urgences plus courte et aucune différence dans les scores de douleur ou la facilité de réduction. La lidocaïne intra-articulaire peut être une alternative efficace à la sédation IV pour réduire les luxations antérieures de l'épaule, en particulier lorsque la sédation IV est contre-indiquée ou impossible.

Risk of intracranial hemorrhage between different direct oral anticoagulants in older patients seen in the emergency department with a head injury: A population-based cohort study.

INTRODUCTION: Patients taking direct oral anticoagulants (DOACs) are increasingly managed in emergency departments (ED). It is unknown whether the risk of traumatic intracranial hemorrhage (ICH) after a head injury differs between DOACs. The objective of this study was to compare risk of ICH at the index ED visit among older adults presenting to the ED with a head injury prescribed different DOACs. METHODS: Retrospective cohort study using population-based administrative databases from Ontario, Canada between 2016 and 2018 of patients age 65 years and older prescribed DOACs who were seen in the ED with a head injury. Patients were matched on the propensity score to create three pairwise-matched cohorts based on the DOAC prescribed (dabigatran vs rivaroxaban; dabigatran vs apixaban; rivaroxaban vs apixaban). For each cohort, relative risk (RR) and 95% confidence intervals (CI) of ICH diagnosed at the index ED visit were calculated. RESULTS: We identified 9230 older adults presenting with a head injury prescribed a DOAC. There were 1274 (13.8%) patients with a prescription for dabigatran, 3136 (34.0%) patients with a prescription for rivaroxaban, and 4820 (52.2%) patients with a prescription for apixaban. Overall, 5.9% of patients had an ICH at the index ED visit. After matching, there were no significant differences in the risk of ICH between any matched DOAC cohorts. CONCLUSION: In patients aged 65 years and older with a prescription for a DOAC seen in the ED for a head injury, there were no differences in the risk of ICH between DOACs.

Venous Thromboembolism in Patients Discharged From the Emergency Department With Ankle Fractures: A Population-Based Cohort Study.

STUDY OBJECTIVE: Temporary lower limb immobilization may be a risk for venous thromboembolism. The purpose of this study was to examine the 90-day incidence of venous thromboembolism among patients discharged from an emergency department (ED) with ankle fractures requiring temporary immobilization. Secondary objectives were to examine individual factors associated with venous thromboembolism in this population and to compare the risk of venous thromboembolism in patients with ankle fractures against a priori-selected control groups. METHODS: This was a retrospective cohort study using province-wide health datasets from Ontario, Canada. We included patients aged 16 years and older discharged from an ED between 2013 and 2018 with closed ankle fractures requiring temporary immobilization. We estimated 90-day incidence of venous thromboembolism after ankle fracture. A Cox proportional hazards model was used to evaluate risk factors associated with venous thromboembolism, censoring at 90 days or death. Patients with ankle fractures were then propensity score matched to 2 control groups: patients discharged with injuries not requiring lower limb immobilization (ie, finger wounds and wrist fractures) to compare relative hazard of venous thromboembolism. RESULTS: There were 86,081 eligible patients with ankle fractures. Incidence of venous thromboembolism within 90 days was 1.3%. Factors associated with venous thromboembolism were older age (hazard ratio [HR]: 1.18; 95% confidence interval [CI]: 1.00 to 1.39), venous thromboembolism or superficial venous thrombosis history (HR: 5.18; 95% CI: 4.33 to 6.20), recent hospital admission (HR: 1.33; 95% CI: 1.05 to 1.68), recent nonankle fracture surgery (HR: 1.58; 95% CI: 1.30 to 1.93), and subsequent surgery for ankle fracture (HR: 1.80; 95% CI: 1.48 to 2.20). In the matched cohort, patients with ankle fractures had an increased hazard of venous thromboembolism compared to matched controls with finger wounds (HR: 6.31; 95% CI: 5.30 to 7.52) and wrist fractures (HR: 5.68; 95% CI: 4.71 to 6.85). CONCLUSION: The 90-day incidence of venous thromboembolism among patients discharged from the ED with ankle fractures requiring immobilization was 1.3%. These patients had a 5.7- to 6.3-fold increased hazard compared to matched controls. Certain patients immobilized for ankle fractures are at higher risk of venous thromboembolism, and this should be recognized by emergency physicians.

Antibiotic prescribing and use of corticosteroids for the emergency department management of acute uncomplicated pharyngitis.

BACKGROUND: Acute pharyngitis is common in the ambulatory setting. The Modified Centor score uses five criteria to predict Group A Streptococcus (GAS) infection and can be used to guide management. OBJECTIVE: The objective of this study was to describe the emergency department (ED) management (throat cultures, antibiotics and corticosteroids) of acute, uncomplicated pharyngitis by Centor score. METHODS: This was a retrospective chart review of adult (>17 years) patients with an ED discharge diagnosis of acute pharyngitis from January 2016 to December 2018. RESULTS: Of 638 patients included, 286 (44.8%) had a Centor score of 0-1, 328 (51.4%) had a score of 2-3 and 24 (3.8%) had a score of ≥4. Of those with a Centor score of 0-1, 83 (29.0%) had a throat culture, 88 (30.8%) were prescribed antibiotics, 15 (5.2%) were positive for GAS and 74 (25.9%) received corticosteroids. Of those with a Centor score of 2-3, 156 (47.6%) had a throat culture, 220 (67.1%) were prescribed antibiotics, 44 (13.4%) were positive for GAS and 145 (44.2%) received corticosteroids. Of those with a Centor score ≥4, 14 (58.3%) had a throat culture, 18 (75.0%) were prescribed antibiotics, 7 (29.2%) were positive for GAS and 12 (50.0%) received corticosteroids. CONCLUSIONS: A higher Centor score was associated with a higher risk of GAS infection, increased antibiotic prescribing and use of corticosteroids. Many patients with low Centor scores were prescribed antibiotics and had throat cultures. Further work is required to understand clinical decision-making for the management of acute pharyngitis.

Influence of electronic triage decision-support on hospital admission, left without being seen and time to physician initial assessment in the emergency department.

OBJECTIVE: To explore the impact of the implementation of eCTAS, a real-time electronic decision-support tool, on hospital admission, rate of left without being seen, and time from triage to physician initial assessment. METHODS: We conducted a cohort study using population-based administrative data from all Ontario emergency departments (EDs) that had implemented eCTAS for 9 months. We compared 6 months post-eCTAS data to the same 6 months the previous year (pre-eCTAS). We included triage encounters of adult (≥ 18 years) patients if they had one of 16 pre-specified, high-volume presenting complaints. Multivariable logistic regression and quantile regression models informed the effect of eCTAS on outcomes. RESULTS: We included data from 354,176 triage encounters from 31 EDs. There was a change in the distribution of triage scores post-eCTAS, with fewer patients classified as CTAS 2 and CTAS 3, and more patients classified as CTAS 1 and CTAS 4. Overall, hospital admission decreased post-eCTAS (adjusted OR: 0.98; 95% CI: 0.97 to 1.00), with fewer CTAS 2 and more CTAS 3 and CTAS 4 patients admitted post-eCTAS. The rate of left without being seen increased (2.8% vs. 3.0%; adjusted OR: 1.07; 95% CI: 1.03 to 1.11) post-eCTAS, while time to physician initial assessment proved similar pre and post-eCTAS. CONCLUSIONS: eCTAS implementation had little impact on admission, rate of left without being seen and time to physician initial assessment. eCTAS appears to reclassify patients from higher to lower acuity scores, resulting in higher admission rates for CTAS 3 and CTAS 4 patients. It remains unknown if this reclassification is appropriate.

RéSUMé: OBJECTIF: Étudier l'impact de la mise en œuvre de l'eCTAS, un outil électronique d'aide à la décision en temps réel, sur l'admission à l'hôpital, le taux de personnes qui ne sont pas vues et le délai entre le triage et l'évaluation initiale du médecin. LES MéTHODES: Nous avons mené une étude de cohorte en utilisant les données administratives basées sur la population de tous les services d'urgence (SU) de l'Ontario qui avaient mis en place l'eCTAS depuis 9 mois. Nous avons comparé les données de six mois après l'eCTAS aux mêmes données de six mois de l'année précédente (avant l'eCTAS). Nous avons inclus les rencontres de triage des patients adultes (≥ 18 ans) s'ils présentaient l'une des 16 plaintes pré-spécifiées à haut volume. Des modèles de régression logistique multivariable et de régression quantile ont permis d'évaluer l'effet de l'eCTAS sur les résultats. RéSULTATS: Nous avons inclus les données de 354 176 rencontres de triage provenant de 31 services d'urgence. Il y a eu un changement dans la distribution des scores de triage après l'eCTAS, avec moins de patients classés comme CTAS 2 et CTAS 3, et plus de patients classés comme CTAS 1 et CTAS 4. Dans l'ensemble, les admissions à l'hôpital ont diminué après l'eCTAS (RC ajusté: 0,98 ; 95 % IC 0,97 à 1,00), avec moins de patients CTAS 2 et plus de patients CTAS 3 et CTAS 4 admis après eCTAS. Le taux de personnes laissées sans surveillance a augmenté (2,8 % contre 3,0 % ; RC ajusté : 1,07 ; 95 % IC 1,03 à 1,11) après l'eCTAS, tandis que le délai avant l'évaluation initiale par le médecin s'est avéré similaire avant et après l'eCTAS. CONCLUSIONS: La mise en œuvre de l'eCTAS a eu peu d'impact sur l'admission, le taux de patients laissés sans consultation et le temps nécessaire à l'évaluation initiale par le médecin. L'eCTAS semble reclasser les patients des scores d'acuité supérieurs aux scores d'acuité inférieurs, ce qui entraîne des taux d'admission plus élevés pour les patients CTAS 3 et CTAS 4. On ignore encore si ce reclassement est approprié.

Barbeque Brush Bristle Ingestion.

BACKGROUND: Patients presenting to the emergency department with a possible barbeque brush bristle ingestion pose many challenges. A detailed history and oral examination is needed and the typical first line investigation involves flexible laryngoscopy for direct visualization of the bristle. Given the high rate of false negatives with laryngoscopy, further imaging may be required in patients with a high suspicion of bristle ingestion Case Reports: We report on two cases presenting to the emergency department with pain following ingestion of grilled food. In both cases imaging was required to identify and assist with the removal of the bristle. Why Should an Emergency Physician Be Aware of This? Emergency physicians should have a high index of suspicion for bristle ingestion in patients with acute onset of pain or a foreign body sensation after ingesting grilled meats. Patients may require imaging to identify bristles if physical examination and laryngoscopy is negative.

Intracranial hemorrhage after head injury among older patients on anticoagulation seen in the emergency department: a population-based cohort study.

BACKGROUND: Intracranial hemorrhage (ICH) after head injury is a concern among older adult patients on anticoagulation. We evaluated the risk of ICH after an emergency department visit for head injury among patients 65 years and older taking warfarin or a direct oral anticoagulant (DOAC) compared with patients not taking anticoagulants. We also evaluated risk of 30-day mortality and neurosurgical intervention among patients with ICH. METHODS: In this retrospective cohort study, we used population-based data of patients 65 years and older seen in an Ontario emergency department with a head injury. We matched patients on the propensity score to create 3 pairwise-matched cohorts based on anticoagulation status (warfarin v. DOAC, warfarin v. no anticoagulant, DOAC v. no anticoagulant). For each cohort, we calculated the relative risk of ICH at the index emergency department visit and 30-day mortality. We also calculated the hazard of neurosurgical intervention among patients with ICH. RESULTS: We identified 77 834 patients with head injury, including 64 917 (83.4%) who were not on anticoagulation, 9214 (11.8%) who were on DOACs and 3703 (4.8%) who were on warfarin. Of these, 5.9% of patients had ICH at the index emergency department visit. Patients on warfarin had an increased risk of ICH compared with matched patients on DOACs (relative risk [RR] 1.43, 95% confidence interval [CI] 1.20-1.69) and patients not on anticoagulation (RR 1.36, 95% CI 1.15-1.61). We did not observe a difference in ICH between patients on DOACs compared with matched patients not on anticoagulation. In patients with ICH, 30-day mortality did not differ by anticoagulation status or type. Patients on warfarin had an increased hazard of neurosurgery compared with patients not on anticoagulation. INTERPRETATION: Patients on warfarin seen in the emergency department with a head injury had higher relative risks of ICH than matched patients on a DOAC and patients not on anticoagulation, respectively. The risk of ICH for patients on a DOAC was not significantly different compared with no anticoagulation. Further research should confirm that older adults using warfarin are the only group at higher risk of ICH after head injury.

Low-dose Ketamine For Acute Pain Control in the Emergency Department: A Systematic Review and Meta-analysis.

OBJECTIVE: There has been increased interest in the use of low-dose ketamine (LDK) as an alternative analgesic for the management of acute pain in the emergency department (ED). The objective of this systematic review was to compare the analgesic effectiveness and safety profile of LDK and morphine for acute pain management in the ED. METHODS: Electronic searches of Medline and EMBASE were conducted and reference lists were hand-searched. Randomized controlled trials (RCTs) comparing LDK to morphine for acute pain control in the ED were included. Two reviewers independently screened abstracts, assessed quality of the studies, and extracted data. Data were pooled using random-effects models and reported as mean differences and risk ratios (RRs) with 95% confidence intervals (CIs). We used the Grading of Recommendations Assessment, Development and Evaluation approach to assess the certainty of the evidence. RESULTS: Eight RCTs were included with a total of 1,191 patients (LDK = 598, morphine = 593). There was no significant difference in reported mean pain scores between LDK and morphine within the first 60 minutes after analgesia administration and a slight difference in pain scores favoring morphine at 60 to 120 minutes. The need for rescue medication was also similar between groups (RR = 1.26, 95% CI = 0.50 to 3.16), as was the proportion of patients who experienced nausea (RR = 0.97, 95% CI = 0.63 to 1.49) and hypoxia (RR = 0.38, 95% CI = 0.10 to 1.41). All outcomes were judged to have low certainty in the evidence. CONCLUSION: Low-dose ketamine and morphine had similar analgesic effectiveness within 60 minutes of administration with comparable safety profiles, suggesting that LDK is an effective alternative analgesic for acute pain control in the ED.

Consistency of triage scores by presenting complaint pre- and post-implementation of a real-time electronic triage decision support tool.

OBJECTIVE: eCTAS is a real-time electronic decision-support tool designed to standardize the application of the Canadian Triage and Acuity Scale (CTAS). This study addresses the variability of CTAS score distributions across institutions pre- and post-eCTAS implementation. METHODS: We used population-based administrative data from 2016-2018 from all emergency departments (EDs) that had implemented eCTAS for 9 months. Following a 3-month stabilization period, we compared 6 months post-eCTAS data to the same 6 months the previous year (pre-eCTAS). We included triage encounters of adult (≥17 years) patients who presented with 1 of 16 pre-specified, high-volume complaints. For each ED, consistency was calculated as the absolute difference in CTAS distribution compared to the average of all included EDs for each presenting complaint. Pre-eCTAS and post-eCTAS change scores were compared using a paired-samples t-test. We also assessed if eCTAS modifiers were associated with triage consistency. RESULTS: There were 363,214 (183,231 pre-eCTAS, 179,983 post-eCTAS) triage encounters included from 35 EDs. Triage scores were more consistent (P < 0.05) post-eCTAS for 6 (37.5%) presenting complaints: chest pain (cardiac features), extremity weakness/symptoms of cerebrovascular accident, fever, shortness of breath, syncope, and hyperglycemia. Triage consistency was similar pre- and post-eCTAS for altered level of consciousness, anxiety/situational crisis, confusion, depression/suicidal/deliberate self-harm, general weakness, head injury, palpitations, seizure, substance misuse/intoxication, and vertigo. Use of eCTAS modifiers was associated with increased triage consistency. CONCLUSIONS: eCTAS increased triage consistency across many, but not all, high-volume presenting complaints. Modifier use was associated with increased triage consistency, particularly for non-specific complaints such as fever and general weakness.

Outcomes after emergency department use in patients with cancer receiving chemotherapy in Ontario, Canada: a population-based cohort study.

BACKGROUND: Patients with cancer frequently require emergency medical care during treatment. The objective of this study was to characterize emergency department visits made by patients with cancer receiving chemotherapy and to describe associated outcomes. METHODS: This retrospective cohort study used population-based administrative data from Ontario, Canada. Patients aged 18 years and older, with a cancer diagnosis, and who received chemotherapy in the 30 days before being seen in an emergency department between 2013 and 2017 were included. Emergency department discharge diagnosis codes were categorized to identify the most frequent emergency department diagnoses. We examined the proportion of patients admitted to hospital and 30-day mortality. We used logistic regression to identify predictors of hospital admission. RESULTS: We identified 218 459 emergency department visits made by 87 555 patients. The median number of emergency department visits per patient was 2 (interquartile range 1-3). Hematological, gastrointestinal, breast and lung cancer were the most common malignancies represented. The most common emergency department diagnoses were infection or fever (57 036 [26.1%]) and gastrointestinal diagnoses (26 456 [12.2%]). Of all visits, 77 978 (35.7%) resulted in admission to hospital. Thirty-day mortality after an emergency department visit was 9.8%. There was an increased odds of admission among patients who previously received palliative consultation, patients with bone or soft tissue or hematological malignancies, and patients with infection, gastrointestinal, pulmonary, cardiac, weakness or genitourinary and nephrology diagnoses. INTERPRETATION: Patients with cancer frequently used the emergency department during chemotherapy, and 1 in 4 emergency department visits were for infection or fever. These results highlight opportunities to optimize care for certain patients being actively treated for cancer, particularly around infectious complaints.

Just the Facts: Adverse events associated with immune checkpoint inhibitor treatment for cancer.

A 64-year-old male with lung cancer presents to the emergency department with one week of cough and increasing shortness of breath. At triage, his temperature is 37.3° Celsius, heart rate 106 beats per minute, blood pressure 136/80, and oxygen saturation 87% on room air, which improves to 94% with 3 L of oxygen via nasal prongs. He has a chest X-ray that demonstrates bilateral patchy infiltrates. He is treated for pneumonia with antibiotics. His respiratory status worsens, with an increasing oxygen requirement. Additional history reveals that the patient recently finished treatment for lung cancer with an immune checkpoint inhibitor.