Remember that patient you saw last week: characteristics and frequency of patients experiencing anticipated and unanticipated death following ED discharge.

BACKGROUND: The emergency department (ED) is an at-risk area for medical error. We determined the characteristics of patients with unanticipated and anticipated death within 7 days of ED discharge and whether medical error contributed. METHODS: We performed a single-centre health records review of 200 consecutive cases during a 3-year period from 2014 to 2017 in two urban, academic, tertiary care EDs. We included patients evaluated by an emergency physician who were discharged and died within 7 days. Three trained and blinded reviewers determined if deaths were related to the index visit, anticipated or unanticipated, and/or due to potential medical error. Reviewers performed content analysis to identify themes. RESULTS: Of 200 cases, 129 had sufficient information for analysis, translating to 44 deaths per 100,000 ED discharges (200/458,634). 13 cases per 100,000 ED discharges (58/458,634) were related and unanticipated deaths. 4 cases per 100,000 were due to potential medical errors (18/458,634). Over half (52.7%) of 129 patients displayed abnormal vital signs at discharge. Pneumonia (27.1%) was the most common cause of death. Patient themes were: difficult historian, multiple complaints, multiple comorbidities, acute progression of chronic disease, and recurrent falls. Provider themes were: failure to consider infectious etiology, failure to admit high-risk elderly patient, and missed diagnosis. System themes were: multiple ED visits or recent admission, and no repeat vital signs recorded. CONCLUSION: Though the frequency of related and unanticipated deaths and those due to medical error was low, clinicians should carefully consider the highlighted common patient, provider, and system themes to facilitate safe discharge from the ED.

RéSUMé: CONTEXTE: Le service des urgences (SU) est un secteur à risque pour les erreurs médicales. Nous avons déterminé les caractéristiques des patients dont le décès a été anticipé ou non dans les 7 jours suivant la sortie des urgences et si une erreur médicale y a contribué. MéTHODES: Nous avons réalisé une étude monocentrique des dossiers médicaux de 200 cas consécutifs sur une période de trois ans, de 2014 à 2017, dans deux urgences urbaines, universitaires et de soins tertiaires. Nous avons inclus les patients évalués par un médecin urgentiste qui sont sortis de l'hôpital et sont décédés dans les 7 jours. Trois examinateurs formés et en aveugle ont déterminé si les décès étaient liés à la visite de référence, anticipés ou non, et/ou dus à une erreur médicale potentielle. Les examinateurs ont effectué une analyse de contenu pour identifier les thèmes. RéSULTATS: Sur 200 cas, 129 disposaient d'informations suffisantes pour l'analyse, ce qui correspond à 44 décès pour 100 000 sorties des urgences (200/458 634). 13 cas pour 100 000 sorties des urgences (58/458 634) étaient des décès liés et imprévus. 4 cas pour 100 000 étaient dus à des erreurs médicales potentielles (18/458 634). Plus de la moitié (52,7%) des 129 patients présentaient des signes vitaux anormaux à la sortie de l'hôpital. La pneumonie (27,1%) était la cause de décès la plus fréquente. Les thèmes des patients étaient les suivants: patient difficile, plaintes multiples, comorbidités multiples, progression aiguë d'une maladie chronique et chutes récurrentes. Les thèmes abordés par les prestataires étaient les suivants: omission de tenir compte de l'étiologie infectieuse, omission d'admettre un patient âgé à haut risque et omission de diagnostic. Les thèmes du système étaient les suivants: visites multiples à l'urgence ou admission récente, et aucun signe vital répété n'a été enregistré. CONCLUSION: Bien que la fréquence des décès liés et imprévus et ceux dus à une erreur médicale soit faible, les cliniciens doivent examiner attentivement les thèmes communs mis en évidence pour les patients, les prestataires et les systèmes afin de faciliter une sortie en toute sécurité des urgences.

Freeze-dried plasma for major trauma - Systematic review and meta-analysis.

BACKGROUND: Treatment of acute trauma coagulopathy has shifted toward rapid replacement of coagulation factors with frozen plasma (FP). There are logistic difficulties in providing FP. Freeze-dried plasma (FDP) may have logistical advantages including easier storage and rapid preparation time. This review assesses the feasibility, efficacy, and safety of FDP in trauma. STUDY DESIGN AND METHODS: Studies were searched from Medline, Embase, Cochrane Controlled Trials Register, ClinicalTrials.gov, and Google Scholar. Observational and randomized controlled trials (RCTs) assessing FDP use in trauma were included. Trauma animal models addressing FDP use were also included. Bias was assessed using validated tools. Primary outcome was efficacy, and secondary outcomes were feasibility and safety. Meta-analyses were conducted using random-effect models. Evidence was graded using Grading of Recommendations Assessment, Development, and Evaluation profile. RESULTS: Twelve human studies (RCT, 1; observational, 11) and 15 animal studies were included. Overall, studies demonstrated moderate risk of bias. Data from two studies (n = 119) were combined for meta-analyses for mortality and transfusion of allogeneic blood products (ABPs). For both outcomes, no difference was identified. For mortality, pooled odds ratio was 0.66 (95% confidence interval, 0.29-1.49), with I2 = 0%. Use of FDP is feasible, and no adverse events were reported. Animal data suggest similar results for coagulation and anti-inflammatory profiles for FP and FDP. CONCLUSION: Human data assessing FDP use in trauma report no difference in mortality and transfusion of ABPs in patients receiving FDP compared with FP. Data from animal trauma studies report no difference in coagulation factor and anti-inflammatory profiles between FP and FDP. Results should be interpreted with caution because most studies were observational and have heterogeneous population (military and civilian trauma) and a moderate risk of bias. Well-designed prospective observational studies or, preferentially, RCTs are warranted to answer FDP's effect on laboratory (coagulation factor levels), transfusion (number of ABPs), and clinical outcomes (organ dysfunction, length of stay, and mortality). LEVEL OF EVIDENCE: Systematic review and meta-analysis, level IV.

Fatal Cerebral Fat Embolism After Pelvic and Multiple Long Bone Fractures without Associated Lung Injury: A Case Report.

CASE: A 29-year-old motor vehicle collision passenger presented with fractures of the pelvic ring, bilateral femurs, and right tibia/fibula. All fractures were stabilized with external fixation and fixed definitively 48 hours later. Postoperatively, the patient suffered rapid clinical decline. Emergent head computed tomography (CT) demonstrated tonsillar herniation with loss of gray-white matter differentiation. Although respiratory status remained uncompromised throughout presentation, pathology revealed extensive cerebral fat embolism. CONCLUSION: Fat embolism can traverse the lungs without eliciting an inflammatory response, radiographic infiltrate, or impairing gas exchange. This may lead to a clinically silent, fatal cerebral fat embolism in an intubated, sedated patient.