Off-road vehicle crashes: dangers of alcohol and drug impairment.

BACKGROUND: Impaired driving is a public health issue, yet little is known concerning the prevalence of substance use in drivers involved in off-road vehicle crashes. The goal of the present study was to describe the demographics and prevalence of alcohol and drug use in drivers of off-road vehicle crashes. METHODS: In this observational substudy, we collected clinical and toxicological data on all moderately or severely injured off-road vehicle drivers who had blood samples obtained within 6 h of the crash. Clinical data were extracted from patients' medical charts and toxicology analyses were performed for blood alcohol, cannabinoids, recreational drugs, and impairing medications. RESULTS: Thirty-three injured drivers met the inclusion criteria. The mean age was 37.6 ± 13.4 years and 79% were male. Blood alcohol was detected in 58% of drivers and 42% of these were above the legal limit. Tetrahydrocannabinol was positive in 12% of drivers, and 18% were positive for recreational drugs. Opiates were detected in 21% of drivers. Overall, 85% were positive for at least one substance and 39% tested positive for multiple substances. CONCLUSION: This study presents the first evidence of alcohol and drug use in off-road vehicle drivers after cannabis legalization in Canada. Our results show that over half of drivers in off-road vehicle crashes test positive for alcohol and 30% tested positive for THC, cocaine, or amphetamines. Opiates are also commonly detected in off-road vehicle drivers. Emergency department (ED) visits resulting from drug driving of off-road vehicles serve as an opportunity for screening, initiating treatment, and connecting patients to interventions for substance use disorders.

ABSTRAIT: CONTEXTE: La conduite avec facultés affaiblies est un problème de santé publique, mais on sait peu de choses sur la prévalence de la toxicomanie chez les conducteurs impliqués dans des accidents de la route. L'objectif de la présente étude était de décrire la démographie et la prévalence de la consommation d'alcool et de drogues chez les conducteurs de véhicules hors route. MéTHODES: Dans le cadre de cette sous-étude observationnelle, nous avons recueilli des données cliniques et toxicologiques sur tous les conducteurs de véhicules hors route ayant subi des blessures modérées ou graves qui avaient reçu des échantillons de sang dans les 6 heures suivant l'accident. Les données cliniques ont été extraites des dossiers médicaux des patients et des analyses toxicologiques ont été effectuées pour l'alcool dans le sang, les cannabinoïdes, les drogues récréatives et les médicaments pour les facultés affaiblies. RéSULTATS: Trente-trois conducteurs blessés répondaient aux critères d'inclusion. L'âge moyen était de 37,6 13,4 ans et 79 % étaient des hommes. L'alcool dans le sang a été détecté chez 58 % des conducteurs et 42 % d'entre eux dépassaient la limite légale. Le tétrahydrocannabinol était positif chez 12 % des conducteurs et 18 % étaient positifs aux drogues récréatives. Des opiacés ont été détectés chez 21 % des conducteurs. Dans l'ensemble, 85 % étaient positifs pour au moins une substance et 39 % étaient positifs pour plusieurs substances. CONCLUSION: Cette étude présente les premières preuves de la consommation d'alcool et de drogues chez les conducteurs de véhicules hors route après la légalisation du cannabis au Canada. Nos résultats montrent que plus de la moitié des conducteurs de véhicules hors route ont un résultat positif au test de dépistage de l'alcool et 30 % ont un résultat positif au test de dépistage du THC, de la cocaïne ou des amphétamines. Les opiacés sont également couramment détectés chez les conducteurs de véhicules hors route. Les visites aux services d'urgence (SU) découlant de la conduite de véhicules hors route avec facultés affaiblies par la drogue constituent une occasion de dépistage, d'amorcer un traitement et de mettre les patients en contact avec des interventions pour les troubles liés à la consommation de substances.

Ready for practice? National recommendations for emergency medicine transition to practice curriculum.

BACKGROUND: Transition from residency to unsupervised practice represents a critical stage in learning and professional identity formation, yet there is a paucity of literature to inform residency curricula and emergency department transition programming for new faculty. OBJECTIVE: The objective of this study was to develop consensus-based recommendations to optimize the transition to practice phase of emergency medicine training. METHODS: A literature review and results of a survey of emergency medicine (EM) residency program directors informed focus groups of recent (within 5 years) EM graduates. Focus group transcripts were analyzed following conventional content analysis. Preliminary recommendations, based on identified themes, were drafted and presented at the 2022 Canadian Association of Emergency Physicians (CAEP) Academic Symposium on Education. Through a live presentation, symposium attendees representing the Canadian national EM community participated in a facilitated discussion of the recommendations. The authors incorporated this feedback to construct a final set of 14 recommendations, 8 targeted toward residency training programs and 6 specific to department leadership. CONCLUSION: The Canadian EM community used a structured process to develop 14 best practice recommendations to enhance the transition to practice phase of residency training as well as the transition period in the career of junior attending physicians.

ABSTRAIT: ARRIèRE-PLAN: La transition de la résidence à la pratique non supervisée représente une étape cruciale de l'apprentissage et de la formation de l'identité professionnelle, mais il y a peu de documentation pour éclairer les programmes de résidence et les programmes de transition des services d'urgence pour les nouveaux professeurs. OBJECTIF: L'objectif de cette étude était d'élaborer des recommandations consensuelles pour optimiser la transition vers la pratique de la formation en médecine d'urgence. MéTHODES: Une recension des écrits et les résultats d'un sondage auprès des directeurs des programmes de résidence en médecine d'urgence (GU) ont informé les groupes de discussion des diplômés récents (moins de cinq ans) en GU. Les transcriptions des groupes de discussion ont été analysées à la suite d'une analyse du contenu classique. Des recommandations préliminaires, fondées sur des thèmes déterminés, ont été rédigées et présentées au Symposium universitaire sur l'éducation de 2022 de l'Association canadienne des médecins d'urgence (ACMU). Au moyen d'une présentation en direct, les participants au symposium représentant la communauté nationale canadienne de la GU ont participé à une discussion dirigée sur les recommandations. Les auteurs ont intégré ces commentaires pour élaborer un ensemble final de 14 recommandations, 8 ciblant les programmes de formation en résidence et 6 ciblant le leadership ministériel. CONCLUSIONS: La communauté canadienne de la GU a utilisé un processus structuré pour élaborer 14 recommandations de pratiques exemplaires afin d'améliorer la transition à la phase de pratique de la formation en résidence ainsi que la période de transition dans la carrière des médecins traitants débutants.

Low Back Pain in a Nova Scotian Emergency Department: Prevalence and Patient Characteristics in the Older Adult Patient Population.

Low back pain is a major cause of disability in older adults, and results in many emergency department visits each year. Characteristics of the older back pain population are largely unknown. We conducted a retrospective study to examine the prevalence and patient characteristics for older (≥ 65 years of age) and younger (16-64 years of age) adults presenting with back pain. Study objectives were to describe the characteristics of older adults with back pain presenting to an emergency department and to identify age-group-based differences in management. Older adults were most commonly diagnosed with non-specific low back pain (49%). For older adults with this diagnosis, the length of stay was 2.1 times longer (p < 0.001), and odds of being admitted to the hospital were 5.1 times higher (p < 0.001) than for younger adults. Patterns of management are different for younger and older adults with low back pain; this information can be used to direct future resource planning.

Are Emergency Medicine Provider Characteristics Associated With Diagnostic Imaging for Low Back Pain?

Background Low back pain (LBP) is one of the most common reasons for presentation to the emergency department (ED). LBP is most commonly non-specific or mechanical in nature yet can be debilitating. Diagnostic imaging (DI) is commonly ordered contrary to guideline recommendations for patients with LBP. This study seeks to determine if physician characteristics are associated with ordering of DI for patients with non-specific or mechanical LBP in the ED. These characteristics include physician sex, age, experience level, location of residency training, and full-time status. Methodology We included all patients presenting to the ED of a Canadian tertiary care center with a diagnosis of non-specific or mechanical LBP between January 2015 and June 2018. We tracked the use of DI for physicians caring for patients presenting to the ED over this period. Simple and multivariable logistic regression analyses were performed, controlling for patient characteristics, to identify provider characteristics that were independently associated with DI use. Results Internationally trained physicians were less likely to order diagnostic radiographs than Canadian trained physicians (odds ratio [OR], 0.625; 95% confidence interval [CI], 0.48-0.95), while middle-aged physicians ordered more computed tomography scans (OR, 6.34; 95% CI, 1.52-26.52) compared to younger physicians; there was no significant difference between younger and older physicians. Conclusions Few physician characteristics were associated with any DI ordering for non-specific or mechanical LBP. The likelihood of receiving DI for non-specific or mechanical LBP may be more strongly related to unmeasured patient characteristics, settings, or logistical factors.

When Cannabis Use Goes Wrong: Mental Health Side Effects of Cannabis Use That Present to Emergency Services.

Cannabis use is a modifiable risk factor for the development and exacerbation of mental illness. The strongest evidence of risk is for the development of a psychotic disorder, associated with early and consistent use in youth and young adults. Cannabis-related mental health adverse events precipitating Emergency Department (ED) or Emergency Medical Services presentations can include anxiety, suicidal thoughts, psychotic or attenuated psychotic symptoms, and can account for 25-30% of cannabis-related ED visits. Up to 50% of patients with cannabis-related psychotic symptoms presenting to the ED requiring hospitalization will go on to develop schizophrenia. With the legalization of cannabis in various jurisdiction and the subsequent emerging focus of research in this area, our understanding of who (e.g., age groups and risk factors) are presenting with cannabis-related adverse mental health events in an emergency situation is starting to become clearer. However, for years we have heard in popular culture that cannabis use is less harmful or no more harmful than alcohol use; however, this does not appear to be the case for everyone. It is evident that these ED presentations should be considered another aspect of potentially harmful outcomes that need to be included in knowledge mobilization. In the absence of a clear understanding of the risk factors for mental health adverse events with cannabis use it can be instructive to examine what characteristics are seen with new presentations of mental illness both in emergency departments (ED) and early intervention services for mental illness. In this narrative review, we will discuss what is currently known about cannabis-related mental illness presentations to the ED, discussing risk variables and outcomes both prior to and after legalization, including our experiences following cannabis legalization in Canada. We will also discuss what is known about cannabis-related ED adverse events based on gender or biological sex. We also touch on the differences in magnitude between the impact of alcohol and cannabis on emergency mental health services to fairly present the differences in service demand with the understanding that these two recreational substances may impact different populations of individuals at risk for adverse events.

Canada-wide mixed methods analysis evaluating the reasons for inappropriate emergency department presentation in patients with a history of atrial fibrillation: the multicentre AF-ED trial.

OBJECTIVES: The primary objective of this study was to ascertain the reasons for emergency department (ED) attendance among patients with a history of atrial fibrillation (AF). DESIGN: Appropriate ED attendance was defined by the requirement for an electrical or chemical cardioversion and/or an attendance resulting in hospitalisation or administration of intravenous medications for ventricular rate control. Quantitative and qualitative responses were recorded and analysed using descriptive statistics and content analysis, respectively. Random effects logistic regression was performed to estimate the OR of inappropriate ED attendance based on clinically relevant patient characteristics. PARTICIPANTS: Participants ≥18 years with a documented history of AF were approached in one of eight centres partaking in the study across Canada (Ontario, Nova Scotia, Alberta and British Columbia). RESULTS: Of the 356 patients enrolled (67±13, 45% female), the majority (271/356, 76%) had inappropriate reasons for presentation and did not require urgent ED treatment. Approximately 50% of patients(172/356, 48%) were driven to the ED due to symptoms, while the remainder presented on the basis of general fear or anxiety (67/356, 19%) or prior medical advice (117/356, 33%). Random effects logistic regression analysis showed that patients with a history of congestive heart failure were significantly more likely to seek urgent care for appropriate reasons (p=0.03). Likewise, symptom-related concerns for ED presentation were significantly less likely to result in inappropriate visitation (p=0.02). When patients were surveyed on alternatives to ED care, the highest proportion of responses among both groups was in favour of specialised rapid assessment outpatient clinics (186/356, 52%). Qualitative content analysis confirmed these results. CONCLUSIONS: Improved education focused on symptom management and alleviating disease-related anxiety as well as the institution of rapid access arrhythmias clinics may reduce the need for unnecessary healthcare utilisation in the ED and subsequent hospitalisation. TRIAL REGISTRATION NUMBER: NCT03127085.

The competency-based medical education evolution of Canadian emergency medicine specialist training.

Canadian specialist emergency medicine (EM) residency training is undergoing the most significant transformation in its history. This article describes the rationale, process, and redesign of EM competency-based medical education. The rationale for this evolution in residency education includes 1) improved public trust by increasing transparency of the quality and rigour of residency education, 2) improved fiscal accountability to government and institutions regarding specialist EM training, 3) improved assessment systems to replace poor functioning end-of-rotation assessment reports and overemphasis on high-stakes, end-of-training examinations, and 4) and tailored learning for residents to address individualized needs. A working group with geographic and stakeholder representation convened over a 2-year period. A consensus process for decision-making was used. Four key design features of the new residency education design include 1) specialty EM-specific outcomes to be achieved in residency; 2) designation of four progressive stages of training, linked to required learning experiences and entrustable professional activities to be achieved at each stage; 3) tailored learning that provides residency programs and learner flexibility to adapt to local resources and learner needs; and 4) programmatic assessment that emphasizes systematic, longitudinal assessments from multiple sources, and sampling sentinel abilities. Required future study includes a program evaluation of this complex education intervention to ensure that intended outcomes are achieved and unintended outcomes are identified.

Choosing Wisely Canada's emergency medicine recommendations: Time for a revision.

Choosing Wisely Canada (CWC) is a national initiative designed to encourage patient-clinician discussions about the appropriate, evidence-based use of medical tests, procedures and treatments. The Canadian Association of Emergency Physicians' (CAEP) Choosing Wisely Canada (CWC) working group developed and released ten recommendations relevant to Emergency Medicine in June 2015 (items 1-5) and October 2016 (items 6-10). In November 2016, the CAEP CWC working group developed a process for updating the recommendations. This process involves: 1) Using GRADE to evaluate the quality of evidence, 2) reviewing relevant recommendations on an ad hoc basis as new evidence emerges, and 3) reviewing all recommendations every five years. While the full review of the CWC recommendations will be performed in 2020, a number of high-impact studies were published after our initial launch that prompted an ad hoc review of the relevant three of our ten recommendations prior to the full review in 2020. This paper describes the results of the CAEP CWC working group's ad hoc review of three of our ten recommendations in light of recent publications.

L'initiative nationale Choisir avec soin a été conçue pour favoriser les discussions entre patients et cliniciens sur l'utilisation appropriée et fondée sur des données probantes des examens médicaux, des interventions et des traitements. Le groupe de travail sur l'initiative, de l'Association canadienne des médecins d'urgence, a élaboré et diffusé dix recommandations relatives à la pratique de la médecine d'urgence, d'abord en juin 2015 (points 1-5), puis en octobre 2016 (points 6-10). En novembre 2016, le groupe de travail sur l'initiative s'est penché sur un processus de mise à jour des recommandations. Ce dernier comprend trois éléments : 1) l'application de l'instrument GRADE pour évaluer la qualité des données probantes; 2) une révision ponctuelle des recommandations pertinentes suivant la diffusion de nouvelles données; 3) un réexamen quinquennal de toutes les recommandations. La révision complète des recommandations présentées dans l'initiative est prévue en 2020; toutefois, un certain nombre d'études ayant une incidence importante ont déjà été publiées après le premier lancement des recommandations, ce qui a incité le groupe de travail à procéder à une révision ponctuelle de trois recommandations pertinentes sur les dix existantes, avant l'examen complet prévu en 2020. Il sera donc question, dans l'article, des résultats de la révision ponctuelle de ces trois recommandations, réalisée à la lumière des récentes publications, par le groupe de travail sur l'initiative.

Development of a clinical decision support tool for diagnostic imaging use in patients with low back pain: a study protocol.

BACKGROUND: Low back pain is one of the most common and disabling health problems in Canada and internationally. In most cases, low back pain is a benign, self-limiting condition that can be managed with little diagnostic investigation or treatment. Yet contrary to clinical practice guideline recommendations, diagnostic imaging (here meaning X-ray, MRI, CT) is commonly used in the assessment of low back pain. Diagnostic imaging is of limited value in most cases, exposing patients to unnecessary radiation and leading to increased health services use and worse patient health outcomes. The Choosing Wisely campaign has highlighted the need to reduce diagnostic imaging for low back pain; however, no clinical decision rules are available. METHODS: This project will develop a clinical decision support tool for appropriate use of diagnostic imaging for patients with low back pain in the emergency department. We will conduct a prospective cohort study at five Canadian emergency departments. The study will follow recommendations for prediction model development and testing. The study population will be 4000 patients presenting to the emergency department with low back pain. We will assess potential clinical indications of emergent-cause (i.e., "red flag" items), including clinical characteristics and past history. Our outcome, emergent-cause for low back pain such as fracture, cancer, infection, or cauda equina syndrome, will be assessed at discharge and at 1-, 3-, and 12-month follow-up periods using information from self-report and health administrative data. We will construct and assess the performance of a multivariable prediction model that has strong measurement properties, presented as a clinical decision support tool acceptable to knowledge users. DISCUSSION: Practice guidelines describe "red flags" for which diagnostic imaging is likely appropriate. However, recommendations across guidelines are discordant, and few studies have evaluated these criteria to determine which characteristics best predict emergent etiology that warrant diagnostic imaging. A clinical decision support tool, that recommends diagnostic imaging where appropriate, has the potential to improve clinical care and patient outcomes and reduce costs associated with managing low back pain patients.

The Canadian Community Utilization of Stroke Prevention Study in Atrial Fibrillation in the Emergency Department (C-CUSP ED).

STUDY OBJECTIVE: Lack of oral anticoagulation prescription in the emergency department (ED) has been identified as a care gap in atrial fibrillation patients. This study seeks to determine whether the use of a tool kit for emergency physicians with a follow-up community-based atrial fibrillation clinic resulted in greater oral anticoagulation prescription at ED discharge than usual care. METHODS: This was a before-after study in 5 Canadian EDs in 3 cities. Patients who presented to the ED with atrial fibrillation were eligible for inclusion. The before phase (1) was retrospective; 2 after phases (2 and 3) were prospective: phase 2 used an oral anticoagulation prescription tool for emergency physicians and patient education materials, whereas phase 3 used the same prescription tool, patient materials, atrial fibrillation educational session, and follow-up in an atrial fibrillation clinic. Each phase was 1 year long. The primary outcome was the rate of new oral anticoagulation prescription at ED discharge for patients who were oral anticoagulation eligible and not receiving oral anticoagulation at presentation. RESULTS: A total of 631 patients were included. Mean age was 69 years (SD 14 years), 47.4% were women, and 69.6% of patients had a CHADS2 score greater than or equal to 1. The rate of new oral anticoagulation prescription in phase 1 was 15.8% compared with 54.1% and 47.2%, in phases 2 and 3, respectively. After multivariable adjustment, the odds ratio for new oral anticoagulation prescription was 8.03 (95% confidence interval 3.52 to 18.29) for phase 3 versus 1. The 6-month rate of oral anticoagulation use was numerically but not significantly higher in phase 3 compared with phase 2 (71.6% versus 79.4%; adjusted odds ratio 2.30; 95% confidence interval 0.89 to 5.96). The rate of major bleeding at 6 months was 0%, 0.8%, and 1% in phases 1, 2, and 3, respectively. CONCLUSION: An oral anticoagulation prescription tool was associated with an increase in new oral anticoagulation prescription in the ED, irrespective of whether an atrial fibrillation clinic follow-up was scheduled. The use of an atrial fibrillation clinic was associated with a trend to a higher rate of oral anticoagulation at 6-month follow-up.

The prevalence of low back pain in the emergency department: a descriptive study set in the Charles V. Keating Emergency and Trauma Centre, Halifax, Nova Scotia, Canada.

BACKGROUND: While low back pain is a common presenting complaint in the emergency department, current estimates from Canada are limited. Furthermore, existing estimates do not clearly define low back pain. As such, our main objective was to estimate prevalence rates of low back pain in a large Nova Scotian emergency department using various definitions, and to describe characteristics of individuals included in these groups. An additional objective was to explore trends in low back pain prevalence in our emergency department over time. METHODS: We conducted a cross sectional analysis using six years of administrative data from our local emergency setting. We first calculated the prevalence and patient characteristics for individuals presenting with any complaint of back pain, and for groups diagnosed with different types of low back pain. We explored prevalence over time by analyzing presentation trends by month, day of the week and hour of the day. RESULTS: The prevalence of patients presenting to the emergency department with a complaint of back pain was 3.17%. Individuals diagnosed with non-specific/mechanical low back pain with no potential nerve root involvement made up 60.8% of all back pain presentations. Persons diagnosed with non-specific/mechanical low back pain with potential nerve root involvement made up 6.7% of presentation and the low back pain attributed to secondary factors accounted for 9.9% of back pain presentations. We found a linear increase in presentations for low back pain over the study period. CONCLUSION: This is the first multi-year analysis assessing the prevalence of low back pain in a Canadian emergency department. Back pain is a common presenting complaint in our local emergency department, with most of these persons receiving a diagnosis of non-specific/mechanical low back pain with no potential nerve root involvement. Future research should concentrate on understanding the management of low back pain in this setting, to ensure this is the proper setting to manage this common condition.

Between- and within-site variation in medication choices and adverse events during procedural sedation for electrical cardioversion of atrial fibrillation and flutter.

OBJECTIVES: Although procedural sedation for cardioversion is a common event in emergency departments (EDs), there is limited evidence surrounding medication choices. We sought to evaluate geographic and temporal variation in sedative choice at multiple Canadian sites, and to estimate the risk of adverse events due to sedative choice. METHODS: This is a secondary analysis of one health records review, the Recent Onset Atrial Fibrillation or Flutter-0 (RAFF-0 [n=420, 2008]) and one prospective cohort study, the Recent Onset Atrial Fibrillation or Flutter-1 (RAFF-1 [n=565, 2010 - 2012]) at eight and six Canadian EDs, respectively. Sedative choices within and among EDs were quantified, and the risk of adverse events was examined with adjusted and unadjusted comparisons of sedative regimes. RESULTS: In RAFF-0 and RAFF-1, the combination of propofol and fentanyl was most popular (63.8% and 52.7%) followed by propofol alone (27.9% and 37.3%). There were substantially more adverse events in the RAFF-0 data set (13.5%) versus RAFF-1 (3.3%). In both data sets, the combination of propofol/fentanyl was not associated with increased adverse event risk compared to propofol alone. CONCLUSION: There is marked variability in procedural sedation medication choice for a direct current cardioversion in Canadian EDs, with increased use of propofol alone as a sedation agent over time. The risk of adverse events from procedural sedation during cardioversion is low but not insignificant. We did not identify an increased risk of adverse events with the addition of fentanyl as an adjunctive analgesic to propofol.

Emergency department procedural sedation for primary electrical cardioversion - a comparison with procedural sedations for other reasons.

BACKGROUND: Atrial fibrillation (AF) is the most common arrhythmia treated in the emergency department (ED), with primary electrical cardioversion (PEC) the preferred method of rhythm control. Anecdotally, patients undergoing ED procedural sedation (EDPS) for PEC differ from those requiring EDPS for other procedures: they are at higher risk of adverse events, and require fewer drugs and lower doses. We attempt to verify this using an EDPS registry at a Canadian, tertiary care teaching hospital. METHODS: This is a retrospective review of patients that underwent EDPS for the period of June 2006 to September 2014. We compared demographics, medication use and intra-procedural adverse events between those receiving EDPS for PEC for AF compared to that for other indications. We report the asssociation between AEs and predictors using logistic regression. RESULTS: A total of 4 867 patients were included, 714 for PEC for AF and 4 153 for other indications. PEC patients were more likely male (58.5% vs. 47.1%), older (59.5 years vs. 48.1 years), and less likely to be ASA I (46.6% vs. 69.0%). PEC patients received smaller doses of propofol and less likely to receive adjuvant analgesic therapy (11.5% vs. 78.2%). PEC patients were more likely to experience hypotension (27.6% vs. 16.5%) but respiratory AEs (apnea, hypoxia and airway intervention) were not different. CONCLUSION: EDPS for PEC differs from that conducted for other purposes: patients tend to be less healthy, receive smaller doses of medication and more likely to suffer hypotension without an increase in respiratory AEs. These factors should be considered when performing EDPS.

Prevalence of low back pain in emergency settings: a systematic review and meta-analysis.

BACKGROUND: Low back pain may be having a significant impact on emergency departments around the world. Research suggests low back pain is one of the leading causes of emergency department visits. However, in the peer-reviewed literature, there has been limited focus on the prevalence and management of back pain in the emergency department setting. The aim of the systematic review was to synthesize evidence about the prevalence of low back pain in emergency settings and explore the impact of study characteristics including type of emergency setting and how the study defined low back pain. METHODS: Studies were identified from PubMed and EMBASE, grey literature search, and other sources. We selected studies that presented prevalence data for adults presenting to an emergency setting with low back pain. Critical appraisal was conducted using a modified tool developed to assess prevalence studies. Meta-analyses and a meta-regression explored the influence of study-level characteristics on prevalence. RESULTS: We screened 1187 citations and included 21 studies, reported between 2000 and 2016 presenting prevalence data from 12 countries. The pooled prevalence estimate from studies of standard emergency settings was 4.39% (95% CI: 3.67-5.18). Prevalence estimates of the included studies ranged from 0.9% to 17.1% and varied with study definition of low back pain and the type of emergency setting. The overall quality of the evidence was judged to be moderate as there was limited generalizability and high heterogeneity in the results. CONCLUSION: This is the first systematic review to examine the prevalence of low back pain in emergency settings. Our results indicate that low back pain is consistently a top presenting complaint and that the prevalence of low back pain varies with definition of low back pain and emergency setting. Clinicians and policy decisions makers should be aware of the potential impact of low back pain in their emergency settings.

Choosing Wisely Canada®: Five tests, procedures and treatments to question in Emergency Medicine.

OBJECTIVES: Choosing Wisely Canada (CWC) is an initiative to encourage patient-physician discussions about the appropriate, evidence based use of medical tests, procedures and treatments. We present the Canadian Association of Emergency Physicians' (CAEP) top five list of recommendations, and the process undertaken to generate them. METHODS: The CAEP Expert Working Group (EWG) generated a candidate list of 52 tests, procedures, and treatments in emergency medicine whose value to care was questioned. This list was distributed to CAEP committee chairs, revised, and then divided and randomly allocated to 107 Canadian emergency physicians (EWG nominated) who voted on each item based on: action-ability, effectiveness, safety, economic burden, and frequency of use. The EWG discussed the items with the highest votes, and generated the recommendations by consensus. RESULTS: The top five CAEP CWC recommendations are: 1) Don't order CT head scans in adults and children who have suffered minor head injuries (unless positive for a validated head injury clinical decision rule); 2) Don't prescribe antibiotics in adults with bronchitis/asthma and children with bronchiolitis; 3) Don't order lumbosacral spinal imaging in patients with non-traumatic low back pain who have no red flags/pathologic indicators; 4) Don't order neck radiographs in patients who have a negative examination using the Canadian C-spine rules; and 5) Don't prescribe antibiotics after incision and drainage of uncomplicated skin abscesses unless extensive cellulitis exists. CONCLUSIONS: The CWC recommendations for emergency medicine were selected using a mixed methods approach. This top 5 list was released at the CAEP Conference in June 2015 and should form the basis for future implementation efforts.

Capnography versus standard monitoring for emergency department procedural sedation and analgesia.

BACKGROUND: Procedural sedation and analgesia (PSA) is used frequently in the emergency department (ED) to facilitate painful procedures and interventions. Capnography, a monitoring modality widely used in operating room and endoscopy suite settings, is being used more frequently in the ED setting with the goal of reducing cardiopulmonary adverse events. As opposed to settings outside the ED, there is currently no consensus on whether the addition of capnography to standard monitoring modalities reduces adverse events in the ED setting. OBJECTIVES: To assess whether capnography in addition to standard monitoring (pulse oximetry, blood pressure and cardiac monitoring) is more effective than standard monitoring alone to prevent cardiorespiratory adverse events (e.g. oxygen desaturation, hypotension, emesis, and pulmonary aspiration) in ED patients undergoing PSA. SEARCH METHODS: We searched the Cochrane Central Register of Controlled Trials (2016, Issue 8), and MEDLINE, Embase, and CINAHL to 9 August 2016 for randomized controlled trials (RCTs) and quasi-randomized trials of ED patients requiring PSA with no language restrictions. We searched meta-registries (www.controlled-trials.com, www.clinicalstudyresults.org, and clinicaltrials.gov) for ongoing trials (February 2016). We contacted the primary authors of included studies as well as scientific advisors of capnography device manufacturers to identify unpublished studies (February 2016). We handsearched conference abstracts of four organizations from 2010 to 2015. SELECTION CRITERIA: We included any RCT or quasi-randomized trial comparing capnography and standard monitoring to standard monitoring alone for ED patients requiring PSA. DATA COLLECTION AND ANALYSIS: Two authors independently performed study selection, data extraction, and assessment of methodological quality for the 'Risk of bias' tables. An independent researcher extracted data for any included studies that our authors were involved in. We contacted authors of included studies for incomplete data when applicable. We used Review Manager 5 to combine data and calculate risk ratios (RR) and 95% confidence intervals (CI) using both random-effects and fixed-effect models. MAIN RESULTS: We identified three trials (κ = 1.00) involving 1272 participants. Comparing the capnography group to the standard monitoring group, there were no differences in the rates of oxygen desaturation (RR 0.89, 95% CI 0.48 to 1.63; n = 1272, 3 trials; moderate quality evidence) and hypotension (RR 2.36, 95% CI 0.98 to 5.69; n = 986, 1 trial; moderate quality evidence). There was only one episode of emesis recorded without significant difference between the groups (RR 3.10, 95% CI 0.13 to 75.88, n = 986, 1 trial; moderate quality evidence). The quality of evidence for the primary outcomes was moderate with downgrades primarily due to heterogeneity and reporting bias.There were no differences in the rate of airway interventions performed (RR 1.26, 95% CI 0.94 to 1.69; n = 1272, 3 trials; moderate quality evidence). In the subgroup analysis, we found a higher rate of airway interventions for adults in the capnography group (RR 1.44, 95% CI 1.16 to 1.79; n = 1118, 2 trials; moderate quality evidence) with a number needed to treat for an additional harmful outcome of 12. Although statistical heterogeneity was reduced, there was moderate quality of evidence due to outcome definition heterogeneity and limited reporting bias. None of the studies reported recovery time. AUTHORS' CONCLUSIONS: There is a lack of convincing evidence that the addition of capnography to standard monitoring in ED PSA reduces the rate of clinically significant adverse events. Evidence was deemed to be of moderate quality due to population and outcome definition heterogeneity and limited reporting bias. Our review was limited by the small number of clinical trials in this setting.

Current management practices for patients presenting with low back pain to a large emergency department in Canada.

BACKGROUND: Low back pain (LBP) is one of the leading causes of disability. Presentations to the emergency department (ED) are common and consume significant healthcare resources. However, treatment of patients with LBP is variable and highly physician dependent. Our study objective was to describe the demographic and clinical characteristics of patients presenting to the ED with LBP, the diagnostic strategies employed by ED physicians, and the subsequent management. METHODS: We conducted a retrospective study using clinical and electronic health data at the Queen Elizabeth II Health Science Center's Charles V. Keating Emergency and Trauma Centre. We selected a simple random sample of 325 adult participants who presented to the ED with non-urgent LBP over a six-year period. Data for all participants, including demographic characteristics, diagnostic testing, and interventions received, was retrieved from the Emergency Department Information System database and from patient charts. RESULTS: Participants had a median age of 43 years and 55% were female. The majority (92.9%) were acute presentations of LBP (less than 4 weeks of duration), with an assigned Canadian Triage Acuity Scale score of 3-4 (92.4%). A range of pain intensity scores were reported, mostly without associated neurological symptoms (81%) or sciatica (68%). At triage, pain score was most commonly reported as moderate intensity (57.6%), followed by severe (32.6%) and mild (9.9%). Documentation of pain rating during assessment was similar (moderate 68.6%; severe 25.9%; mild 5.6%). Laboratory investigations were conducted on 22.5% of participants and 30% received an imaging study. Medications were delivered to 59.4% of participants during their stay in the ED. Of the medications administered, ibuprofen (28.3%), hydromorphone (24.9%), and acetaminophen (21.5%) were the most frequent. Almost all (94%) had a record of having a primary care provider in EDIS and referrals back to the participant's family physician were recorded for 41.2% of non-urgent LBP encounters. CONCLUSIONS: We presented a complete description of patient characteristics, LBP descriptors, and health service use for a random sample of non-urgent LBP patients presenting to the ED. This has allowed for a better understanding of patients who seek care in the ED for their non-urgent LBP.