Associations between SARS-CoV-2 infection and incidence of new chronic condition diagnoses: a systematic review.

Because of the large number of infected individuals, an estimate of the future burdens of the long-term consequences of SARS-CoV-2 infection is needed. This systematic review examined associations between SARS-CoV-2 infection and incidence of categories of and selected chronic conditions, by age and severity of infection (inpatient vs. outpatient/mixed care). MEDLINE and EMBASE were searched (1 January 2020 to 4 October 2022) and reference lists scanned. We included observational studies from high-income OECD countries with a control group adjusting for sex and comorbidities. Identified records underwent a two-stage screening process. Two reviewers screened 50% of titles/abstracts, after which DistillerAI acted as second reviewer. Two reviewers then screened the full texts of stage one selections. One reviewer extracted data and assessed risk of bias; results were verified by another. Random-effects meta-analysis estimated pooled hazard ratios (HR). GRADE assessed certainty of the evidence. Twenty-five studies were included. Among the outpatient/mixed SARS-CoV-2 care group, there is high certainty of a small-to-moderate increase (i.e. HR 1.26-1.99) among adults ≥65 years of any cardiovascular condition, and of little-to-no difference (i.e. HR 0.75-1.25) in anxiety disorders for individuals <18, 18-64, and ≥65 years old. Among 18-64 and ≥65 year-olds receiving outpatient/mixed care there are probably (moderate certainty) large increases (i.e. HR ≥2.0) in encephalopathy, interstitial lung disease, and respiratory failure. After SARS-CoV-2 infection, there is probably an increased risk of diagnoses for some chronic conditions; whether the magnitude of risk will remain stable into the future is uncertain.

Sports-Related Concussions in Adults Presenting to Canadian Emergency Departments.

OBJECTIVE: To document the occurrence and recovery outcomes of sports-related concussions (SRCs) presenting to the Emergency Department (ED) in a community-based sample. DESIGN: A prospective observational cohort study was conducted in 3 Canadian hospitals. SETTING: Emergency Department. PATIENTS: Adults (≥17 years) presenting with a concussion to participating EDs with a Glasgow Coma Scale score ≥13 were recruited. INTERVENTIONS: Patient demographics (eg, age and sex), clinical characteristics (eg, history of depression or anxiety), injury characteristics (eg, injury mechanisms and loss of consciousness and duration), and ED management and outcomes (eg, imaging, consultations, and ED length of stay) were collected. MAIN OUTCOME MEASURES: Patients' self-reported persistent concussion symptoms, return to physical activity status, and health-related quality of life at 30 and 90 days after ED discharge. RESULTS: Overall, 248 patients were enrolled, and 25% had a SRC. Patients with SRCs were younger and reported more physical activity before the event. Although most of the patients with SRCs returned to their normal physical activities at 30 days, postconcussive symptoms persisted in 40% at 90 days of follow-up. After adjustment, there was no significant association between SRCs and persistent symptoms; however, patients with concussion from motor vehicle collisions were more likely to have persistent symptoms. CONCLUSION: Although physically active individuals may recover faster after a concussion, patients returning to their physical activities before full resolution of symptoms are at higher risk of persistent symptoms and further injury. Patient-clinician communications and tailored recommendations should be encouraged to guide appropriate acute management of concussions.

Incidence, risk factors, natural history, and hypothesised mechanisms of myocarditis and pericarditis following covid-19 vaccination: living evidence syntheses and review.

OBJECTIVES: To synthesise evidence on incidence rates and risk factors for myocarditis and pericarditis after use of mRNA vaccination against covid-19, clinical presentation, short term and longer term outcomes of cases, and proposed mechanisms. DESIGN: Living evidence syntheses and review. DATA SOURCES: Medline, Embase, and the Cochrane Library were searched from 6 October 2020 to 10 January 2022; reference lists and grey literature (to 13 January 2021). One reviewer completed screening and another verified 50% of exclusions, using a machine learning program to prioritise records. A second reviewer verified all exclusions at full text, extracted data, and (for incidence and risk factors) risk of bias assessments using modified Joanna Briggs Institute tools. Team consensus determined certainty of evidence ratings for incidence and risk factors using GRADE (Grading of Recommendations, Assessment, Development and Evaluation). ELIGIBILITY CRITERIA FOR SELECTING STUDIES: Large (>10 000 participants) or population based or multisite observational studies and surveillance data (incidence and risk factors) reporting on confirmed myocarditis or pericarditis after covid-19 mRNA vaccination; case series (n≥5, presentation, short term clinical course and longer term outcomes); opinions, letters, reviews, and primary studies focused on describing or supporting hypothesised mechanisms. RESULTS: 46 studies were included (14 on incidence, seven on risk factors, 11 on characteristics and short term course, three on longer term outcomes, and 21 on mechanisms). Incidence of myocarditis after mRNA vaccines was highest in male adolescents and male young adults (age 12-17 years, range 50-139 cases per million (low certainty); 18-29 years, 28-147 per million (moderate certainty)). For girls and boys aged 5-11 years and women aged 18-29 years, incidence of myocarditis after vaccination with BNT162b2 (Pfizer/BioNTech) could be fewer than 20 cases per million (low certainty). Incidence after a third dose of an mRNA vaccine had very low certainty evidence. For individuals of 18-29 years, incidence of myocarditis is probably higher after vaccination with mRNA-1273 (Moderna) compared with Pfizer (moderate certainty). Among individuals aged 12-17, 18-29, or 18-39 years, incidence of myocarditis or pericarditis after dose two of an mRNA vaccine for covid-19 might be lower when administered ≥31 days compared with ≤30 days after dose one (low certainty). Data specific to men aged 18-29 years indicated that the dosing interval might need to increase to ≥56 days to substantially drop myocarditis or pericarditis incidence. For clinical course and short term outcomes, only one small case series (n=8) was found for 5-11 year olds. In adolescents and adults, most (>90%) myocarditis cases involved men of a median 20-30 years of age and with symptom onset two to four days after a second dose (71-100%). Most people were admitted to hospital (≥84%) for a short duration (two to four days). For pericarditis, data were limited but more variation than myocarditis has been reported in patient age, sex, onset timing, and rate of admission to hospital. Three case series with longer term (3 months; n=38) follow-up suggested persistent echocardiogram abnormalities, as well as ongoing symptoms or a need for drug treatments or restriction from activities in >50% of patients. Sixteen hypothesised mechanisms were described, with little direct supporting or refuting evidence. CONCLUSIONS: These findings indicate that adolescent and young adult men are at the highest risk of myocarditis after mRNA vaccination. Use of a Pfizer vaccine over a Moderna vaccine and waiting for more than 30 days between doses might be preferred for this population. Incidence of myocarditis in children aged 5-11 years is very rare but certainty was low. Data for clinical risk factors were very limited. A clinical course of mRNA related myocarditis appeared to be benign, although longer term follow-up data were limited. Prospective studies with appropriate testing (eg, biopsy and tissue morphology) will enhance understanding of mechanism.

Acute pediatric cannabis intoxication: A scoping review.

Little is understood about the unintended consequences of cannabis liberalization on children. Subsequently, this scoping review aimed to map and identify evidence related to acute cannabis intoxication in children. We searched three medical literature databases from inception until October 2019. We identified 4644 information sources and included 158 which were mapped by topic area relating to 1) public health implications and considerations; 2) clinical management; and 3) experiences and information needs of HCPs and families. Public health implications were addressed by 129 (82%) and often reported an increased incidence of acute pediatric cannabis intoxications. Clinical information was reported in 116 (73%) and included information on signs and symptoms (n = 106, 92%), clinical management processes (n = 60, 52%), and treatment recommendations (n = 42, 36%). Few sources addressed the experiences or information needs of either HCPs (n = 5, <1%) treating children for acute cannabis intoxication or families (n = 1, <1%) seeking care. Increasing incidence of acute cannabis intoxications concurrent with liberalization of cannabis legislation is clear, however, evidence around clinical management is limited. Additionally, further research exploring HCPs and families experiences and information needs around cannabis intoxication is warranted.

Interventions to improve consultations in the emergency department: A systematic review.

OBJECTIVES: Emergency department (ED) consultations with specialists are necessary for safe and effective patient care. Delays in the ED consultation process, however, have been shown to increase ED length of stay (LOS) and contribute to ED crowding. This review aims to describe and evaluate the effectiveness of interventions to improve the ED consultation process. METHODS: Eight primary literature databases and the gray literature were searched to identify comparative studies assessing ED-based interventions to improve the specialist consultation process. Two independent reviewers identified eligible studies, assessed study quality, and extracted data. Individual or pooled meta-analysis for continuous outcomes were calculated as mean differences (MDs) with 95% confidence intervals (CIs) using a random-effects model was conducted. RESULTS: Thirty-five unique comparative intervention studies were included. While the interventions varied, four common components/themes were identified including interventions to improve consultant responsiveness (n = 11), improve access to consultants in the ED (n = 9), expedite ED consultations (n = 8), and bypass ED consultations (n = 7). Studies on interventions to improve consult responsiveness consistently reported a decrease in consult response times in the intervention group with percent changes between 10% and 71%. Studies implementing interventions to improve consult responsiveness (MD -2.55, 95% CI -4.88 to -0.22) and interventions to bypass ED consultations (MD -0.99, 95% CI -1.43 to -0.56) consistently reported a decrease in ED LOS; however, heterogeneity was high (I2  = 99%). Evidence on whether any of the interventions were effective at reducing the proportion of patients consulted or subsequently admitted varied. CONCLUSIONS: The various interventions impacting the consultation process were predominately successful in reducing ED LOS, with evidence suggesting that interventions improving consult responsiveness and improving access to consultants in the ED also improve consult response times. Health care providers looking to implement interventions to improve the ED consultation process should identify key areas in their setting that could be targeted.

Sex-based differences in outcomes for adult patients presenting to the emergency department with a concussion.

OBJECTIVE: Patients with concussion frequently present to the emergency department (ED). Studies of athletes and children indicate that concussion symptoms are often more severe and prolonged in females compared with males. Given infrequent study of concussion symptoms in the general adult population, the authors conducted a sex-based comparison of patients with concussion. METHODS: Adults (≥ 17 years of age) presenting with concussion to one of three urban Canadian EDs were recruited. Discharged patients were contacted by telephone 30 and 90 days later to capture the extent of persistent postconcussion symptoms using the Rivermead Post Concussion Symptoms Questionnaire (RPQ). A multivariate logistic regression model for persistent symptoms that included biological sex was developed. RESULTS: Overall, 250 patients were included; 131 (52%) were women, and the median age of women was significantly higher than that of men (40 vs 32 years). Women had higher RPQ scores at baseline (p < 0.001) and the 30-day follow-up (p = 0.001); this difference resolved by 90 days. The multivariate logistic regression identified that women, patients having a history of sleep disorder, and those presenting to the ED with concussions after a motor vehicle collision were more likely to experience persistent symptoms. CONCLUSIONS: In a community concussion sample, inconsequential demographic differences existed between adult women and men on ED presentation. Based on self-reported and objective outcomes, work and daily activities may be more affected by concussion and persistent postconcussion symptoms for women than men. Further analysis of these differences is required to identify different treatment options and ensure adequate care and management of injury.

Pet therapy in the emergency department and ambulatory care: A systematic review and meta-analysis.

BACKGROUND: Pet therapy, or animal-assisted interventions (AAIs), has demonstrated positive effects for patients, families, and health care providers (HCPs) in inpatient settings. However, the evidence supporting AAIs in emergency or ambulatory care settings is unclear. We conducted a systematic review to evaluate the effectiveness of AAIs on patient, family, and HCP experience in these settings. METHODS: We searched (from inception to May 2020) Medline, Embase, Cochrane CENTRAL, PsycINFO, and CINAHL, plus gray literature, for studies assessing AAIs in emergency and ambulatory care settings on: (1) patient and family anxiety/distress or pain and (2) HCP stress. Screening, data extraction, and quality assessment were done in duplicate with conflicts adjudicated by a third party. Random-effects meta-analyses are reported as mean differences (MDs) or standardized mean differences (SMDs) and 95% confidence intervals (CIs), as appropriate. RESULTS: We included nine randomized controlled trials (RCTs; 341 patients, 146 HCPs, 122 child caregivers), four before-after (83 patients), and one mixed-method study (124 patients). There was no effect across three RCTs measuring patient-reported anxiety/distress (n = 380; SMD = -0.36, 95% CI = -0.95 to 0.23, I2  = 81%), while two before-after studies suggested a benefit (n = 80; SMD = -1.95, 95% CI = -2.99 to -0.91, I2  = 72%). Four RCTs found no difference in measures of observed anxiety/distress (n = 166; SMD = -0.44, 95% CI = -1.01 to 0.13, I2  = 73%) while one before-after study reported a significant benefit (n = 60; SMD = -1.64, 95% CI = -2.23 to -1.05). Three RCTs found no difference in patient-reported pain (n = 202; MD = -0.90, 95% CI = -2.01 to 0.22, I2  = 68%). Two RCTs reported positive but nonsignificant effects on HCP stress. CONCLUSIONS: Limited evidence is available on the effectiveness of AAIs in emergency and ambulatory care settings. Rigorous studies using global experience-oriented (or patient-identified) outcome measures are required.

Comparative Efficacy of Bronchiolitis Interventions in Acute Care: A Network Meta-analysis.

CONTEXT: Uncertainty exists as to which treatments are most effective for bronchiolitis, with considerable practice variation within and across health care sites. OBJECTIVE: A network meta-analysis to compare the effectiveness of common treatments for bronchiolitis in children aged ≤2 years. DATA SOURCES: Medline, Embase, Cochrane Central Register of Controlled Trials, Cumulative Index to Nursing and Allied Health Literature, ClinicalTrials.gov, and the World Health Organization International Clinical Trials Registry Platform were searched from inception to September 1, 2019. STUDY SELECTION: A total 150 randomized controlled trials comparing a placebo or active comparator with any bronchodilator, glucocorticoid steroid, hypertonic saline solution, antibiotic, helium-oxygen therapy, or high-flow oxygen therapy were included. DATA EXTRACTION: Data were extracted by 1 reviewer and independently verified. Primary outcomes were admission rate on day 1 and by day 7 and hospital length of stay. Strength of evidence was assessed by using Confidence in Network Meta-Analysis . RESULTS: Nebulized epinephrine (odds ratio: 0.64, 95% confidence interval [CI]: 0.44 to 0.93, low confidence) and nebulized hypertonic saline plus salbutamol (odds ratio: 0.44, 95% CI: 0.23 to 0.84, low confidence) reduced the admission rate on day 1. No treatment significantly reduced the admission rate on day 7. Nebulized hypertonic saline (mean difference: -0.64 days, 95% CI: -1.01 to -0.26, low confidence) and nebulized hypertonic saline plus epinephrine (mean difference: -0.91 days, 95% CI: -1.14 to -0.40, low confidence) reduced hospital length of stay. LIMITATIONS: Because we did not report adverse events in this analysis, we cannot make inferences about the safety of these treatments. CONCLUSIONS: Although hypertonic saline alone, or combined with epinephrine, may reduce an infant's stay in the hospital, poor strength of evidence necessitates additional rigorous trials.

Concussion diagnoses among adults presenting to three Canadian emergency departments: Missed opportunities.

OBJECTIVES: Patients with concussion commonly present to the emergency department (ED) for assessment. Misdiagnosis of concussion has been documented in children and likely impacts treatment and discharge instructions. This study aimed to examine diagnosis of concussion in a general adult population. METHODS: Patients >17years old presenting meeting the World Health Organization's definition of concussion were recruited in one academic (Hospital 1) and two community (Hospitals 2 and 3) EDs in a Canadian city. A physician questionnaire and patient interviews documented recommendations given by emergency physicians. Bi-variable comparisons are reported using chi-square tests, t-tests or Mann-Whitney tests, as appropriate. Multivariate analyses were performed using logistic regression methods. RESULTS: Overall, the study enrolled 250 patients. The median age was 35 (IQR: 23 to 49) and 52% were female. A variety of concussion causes were documented. Forty-one (16%) patients were not diagnosed with a concussion despite meeting criteria. Concussion diagnosis was less likely with a longer ED length of stay (OR=0.71; 95% CI: 0.60 to 0.83), presenting to the non-academic centers (Hospital 2: OR=0.21, 95% CI: 0.08 to 0.58; Hospital 3: OR=0.07, 95% CI: 0.02 to 0.24), or involvement in a motor vehicle collision (OR=0.11; 95% CI: 0.03 to 0.46). CONCLUSION: One in six patients with concussion signs and symptoms were misdiagnosed in the ED. Misdiagnosis was related to injury mechanism, length of stay, and enrolment site. Closer examination of institutional factors is needed to identify effective strategies to promote accurate diagnosis of concussion.

A Prospective Evaluation of the Influence of an Electronic Clinical Practice Guidelines on Concussion Patients' Future Activities and Outcomes.

BACKGROUND: Patients with mild traumatic brain injury or concussion commonly present to the emergency department for assessment; providing patients with information on usual symptoms and their progression may encourage faster recovery. OBJECTIVES: This study aimed to document the role of an electronic clinical practice guideline (eCPG) patient handout on concussion recovery in adult patients discharged from the hospital. METHODS: A prospective cohort study was carried out in 3 Canadian urban emergency departments. Adults (≥17 years of age) with a Glasgow Coma Scale score of 13 to 15 who sustained a concussion were recruited by on-site research assistants. Physician use of a concussion-specific eCPG was documented from physician and patient reports. Patient follow-up calls at 30 and 90 days documented return to work/school activities and patient symptoms. Multivariate analyses were performed using logistic regression methods. RESULTS: Overall, 250 patients were enrolled; the median age was 35 (interquartile range 23-49) and 52% were female. Approximately half (n = 119, 48%) of patients received the eCPG handout, and return to work/school recommendations varied. Symptoms persisted in 60% of patients at 30 days; patients in the eCPG group had fewer symptoms (odds ratio 0.57, 95% confidence interval 0.33-0.99). At 90 days, 40% of patients reported persistent symptoms, with no significant difference between groups. CONCLUSION: An eCPG handout improved patients' short-term outcomes; however, physician use and adherence to guideline recommendations was low. To further facilitate physician compliance and therefore patient recovery, barriers to use of the eCPG handout need to be identified and addressed.

Emergency Physician Training on Mild Traumatic Brain Injury: A Systematic Review.

OBJECTIVES: Mild traumatic brain injury (mTBI) is the most common emergency department (ED) brain injury presentation worldwide. Despite its frequency, practice variation and care gaps exist among emergency physicians (EPs) in diagnosing and appropriately managing mTBI in the ED. The objective of this review was to identify mTBI-specific training undertaken to improve the detection and management of mTBIs by EPs and its impact on practice. METHODS: A comprehensive search strategy utilized four bibliographic databases, the gray literature and the keywords concussion, mild traumatic brain injury, medical education, and continuing medical education (CME). To be included, studies were required to report on mTBI training received by practicing EPs at any point during their medical education or career. Studies examining clinical practice guidelines or use of diagnostic tools without active implementation or formal training were not included. Two reviewers screened unique citations for relevance and reviewed the full texts of relevant articles. Two independent researchers extracted data and assessed methodologic quality. At all stages, a third independent reviewer adjudicated discrepancies. RESULTS: Overall, five studies were included from 409 unique results. None of the included studies were of high quality. Identified training on mTBI consisted of three training toolkits, conference presentations and academic journal articles, and pediatric fellowship training. Training primarily occurred as CME and focused on awareness of and management of mTBI; three studies reported physician practice changes, including increases in the use of evidence-based return-to-school and return-to-activity recommendations. CONCLUSIONS: The few studies identified addressing mTBI training targeting EPs demonstrate the limited attention given to this issue. The current evidence-to-practice gap in mTBI management places patients at risk for suboptimal care in the ED, and existing mTBI knowledge translation, including education, requires optimization to effectively address the current gap in evidence-based practice for mTBI diagnosis and management in the ED.

The epidemiology of fatal cyclist crashes over a 14-year period in Alberta, Canada.

BACKGROUND: Cycling is a popular recreational activity and a common transportation option; however, cycling-related injuries can be fatal. There are few studies of cycling fatalities in Canada and none in a region as sparsely populated as Alberta. METHODS: A chart review was conducted of cyclists involved in fatal crashes. Charts for deaths that occurred between 1998 and 2011 (inclusive) were identified and abstracted onto standardized forms. Personal characteristics and crash circumstances, including motor vehicle involvement, were collected; mechanisms of fatally injured cyclists across age groups were compared. Census data were used to calculate region-specific and provincial age-specific cycling fatality rates. RESULTS: Charts from 101 deaths over 14 years were reviewed. Events mainly occurred during the summer. There were more fatalities in urban (64 [63 %]) than in rural settings. Collisions with motor vehicles and cyclist-only crashes accounted for 68 and 15 % of cycling fatalities, respectively. Most (87 %) deceased cyclists were male, and the median age was 47 years (inter-quartile range: 25, 58). The population-based fatality rate over the study period was highest among deceased cyclists older than 65. Helmet use was reported in 26 (26 %) cases and increased with age. Alcohol use was detected in 25 (25 %) cases. CONCLUSIONS: Fatal cycling crashes in Alberta typically involve adults riding on urban roads and collisions with motor vehicles. While helmet legislation has reduced non-fatal cycling head injuries, deaths may be further prevented by physical separation of cyclists and motor vehicles and avoidance of substance use while operating bicycles.

Management of acute exacerbation of COPD in rural Alberta emergency departments.

INTRODUCTION: Acute exacerbation of chronic obstructive pulmonary disease (COPD) is a common presentation to emergency departments (EDs); however, limited information exists about the management of this condition in nonurban locations. We sought to examine the diagnostic and treatment approaches for acute exacerbation of COPD in 3 rural EDs, and to determine levels of adherence to recommendations from the Canadian Thoracic Society (CTS) clinical practice guideline. METHODS: We conducted retrospective chart reviews to explore the management of patients who presented to 3 rural EDs for acute exacerbation of COPD in 2011. Data are reported as medians and interquartile ranges (IQRs) and proportions. RESULTS: Over a 1-year period, 192 patients presented a total of 266 times with acute exacerbation of COPD. The median age was 68 (IQR 58-77) years, and 54.9% of the patients were women. Diagnostic testing included chest radiography in 65.0%, blood tests in 45.1%, electrocardiography in 33.5%, and arterial blood gas tests in 6.4%; only a few patients received pulmonary function testing. In the ED, 58.7% of patients were given a short-acting ß-agonist, 48.9% a short-acting anticholinergic, 27.4% corticosteroids and 19.9% antibiotics. Overall, short-acting ß-agonists (63.5%), anticholinergic agents (53.4%), corticosteroids (54.5%) and antibiotics (71.1%) were prescribed more commonly to discharged patients (p < 0.05 for all). CONCLUSION: We found a low to moderate level of adherence to the CTS clinical practice guideline for the management of acute exacerbation of COPD in these rural EDs. Moreover, we identified gaps in both diagnostic and therapeutic care.

INTRODUCTION: Les cas d'exacerbation aiguë de la maladie pulmonaire obstructive chronique (MPOC) sont fréquents à l'urgence. Pourtant, il existe peu d'information sur la prise en charge de cette maladie en dehors des centres urbains. Nous voulions examiner les méthodes de diagnostic et de traitement de la MPOC utilisées dans 3 services d'urgence en milieu rural et savoir dans quelle mesure les lignes directrices de la Société canadienne de thoracologie (SCT) sont respectées. MÉTHODES: Nous avons effectué une analyse rétrospective des dossiers pour examiner la prise en charge des patients s'étant présentés dans 3 services d'urgence en milieu rural en raison d'une exacerbation aiguë de la MPOC en 2011. Les données sont présentées en valeurs médianes et en intervalles interquartiles (II) et proportions. RÉSULTATS: Sur une période d'un an, 192 patients se sont présentés au total 266 fois pour exacerbation aiguë de la MPOC. L'âge médian était de 68 ans (II 58­77); 54,9 % des patients étaient des femmes. Les tests diagnostiques comprenaient des radiographies pulmonaires dans 65 % des cas, des analyses sanguines dans 45,1 % des cas, un électrocardiogramme dans 33,5 % des cas et une analyse des gaz artériels dans 6,4 % des cas; seuls quelques patients ont subi un test de la fonction pulmonaire. À l'urgence, 58,7 % des patients ont reçu un ß-2 agoniste à action rapide, 48,9 %, un anticholinergique à action rapide, 27,4 %, un corticostéroïde et 19,9 %, un antibiotique. Dans l'ensemble, les ß-2 agonistes à action rapide (63,5 %), les anticholinergiques (53,4 %), les corticostéroïdes (54,5 %) et les antibiotiques (71,1 %) étaient les agents prescrits le plus souvent aux patients recevant leur congé de l'hôpital (p < 0,05 pour tous). CONCLUSION: Nous avons observé que le degré d'observance des lignes directrices de la SCT variait de faible à moyen dans les services d'urgence en milieu rural. De plus, nous avons observé des lacunes autant en ce qui concerne les tests diagnostiques que les soins thérapeutiques.

Pre-hospital management of anaphylaxis in one Canadian Urban Centre.

STUDY AIM: Anaphylaxis requires prompt recognition and management to improve patient outcomes. This study examined the diagnosis and treatment of anaphylactic reactions by the Emergency Medical Services (EMS) in a Canadian urban centre. METHODS: Electronic patient care records (ePCRs), identifying allergy-related calls in the Edmonton-Zone for the year 2011, were retrospectively reviewed to confirm anaphylaxis diagnosis and record treatments. Data were abstracted and entered into the REDCap electronic platform. Descriptive and multivariable analyses were performed. Pre-hospital management included any care provided by paramedic personnel and/or first-aid treatment received prior to EMS arrival. RESULTS: From 481 identified allergy-related case records, 136 (28%) met guideline criteria for anaphylaxis. Seventy-six (56%) of these confirmed cases were deemed high acuity by medical dispatchers. Self-medication and bystander first-aid was recorded in 60 (44%) anaphylactic events; 34 (25%) received epinephrine. Paramedics administered epinephrine in an additional 49 cases (36%); only 7% received all three primary pre-hospital anaphylaxis treatments: epinephrine, corticosteroids, and antihistamines. Factors associated with pre-hospital epinephrine administration included: previous episode of anaphylaxis (adjusted odds ratio [aOR]=4.9, 95% confidence interval [CI]: 1.30, 19.21); administration of corticosteroids by bystanders or EMS personnel (aOR=3.8, 95% CI: 1.36, 10.65); and transport severity (aOR=3.2, 95% CI: 1.21, 8.36). CONCLUSION: Paramedics in this region demonstrated higher use of epinephrine than reported elsewhere; however, almost half of all patients meeting anaphylaxis criteria did not receive pre-hospital epinephrine. Instead, more patients received antihistamines. Efforts to improve adherence to anaphylaxis protocols and guidelines appear warranted.