Analgesic Use Among Adults with a Trauma-Related Emergency Department Visit: A Retrospective Cohort Study from Alberta, Canada.

INTRODUCTION: A better understanding of current acute pain-driven analgesic practices within the emergency department (ED) and upon discharge will provide foundational information in this area, as few studies have been conducted in Canada. METHODS: Administrative data were used to identify adults with a trauma-related ED visit in the Edmonton area in 2017/2018. Characteristics of the ED visit included time from initial contact to analgesic administration, type of analgesics dispensed during and upon being discharged home directly from the ED (≤ 7 days after), and patient characteristics. RESULTS: A total of 50,950 ED visits by 40,505 adults with trauma were included. Analgesics were administered in 24.2% of visits, of which non-opioids were dispensed in 77.0% and opioids were dispensed in 49.0%. Time to analgesic initiation occurred more than 2 h after first contact. Upon discharge, 11.5% received a non-opioid and 15.2% received an opioid analgesic, among whom 18.5% received a daily dose ≥ 50 morphine milligram equivalents (MME) and 30.2% received > 7 days of supply. Three hundred and seventeen adults newly met criteria for chronic opioid use after the ED visit, among whom 43.5% received an opioid dispensation upon discharge; of these individuals, 26.8% had a daily dose ≥ 50 MME and 65.9% received > 7 days of supply. CONCLUSIONS: Findings can be used to inform optimization of analgesic pharmacotherapy practices for the treatment of acute pain, which may include reducing the time to initiation of analgesics in the ED, as well as close consideration of recommendations for acute pain management upon discharge to provide ideal patient-centered, evidence-informed care.

Columbia Icefield Bus Rollover: A Case Study of Wilderness Mass Casualty Triage, Treatment, and Transport.

Mass casualty incidents (MCIs) are rare in wilderness and mountain settings. Few case studies have reported the response of such events within jurisdictions with well-developed trauma and emergency medical services systems (EMS). Here we explore a MCI in a wilderness setting on the Columbia Icefield inside the Jasper National Park within the Canadian Rocky Mountains. An all-terrain bus was involved that had rolled over while transporting tourists to explore the glacier. The bus rolled multiple times down the slope adjacent to the road, leading to 3 deceased and 21 patients requiring transport. A massive pre-hospital response ensued.Due to the location, extreme environment, and unusual complexities, the response involved significant use of aeromedical resources, physician field deployment, and centralized coordination centers. Readers are reminded of the importance of aeromedical surge capacity in allowing for effective distribution of patients to multiple receiving facilities. Our experience aligns with and reinforces many of the recommendations for wilderness MCI management; however, future research should focus on determining optimal triage strategies for mountain MCIs. Furthermore, future research should explore optimal strategies for developing a rescue chain given the availability of mixed transport resources, as well as the role of physicians in MCI response and where they are best placed in the incident command system.

Just the facts: Pediatric Dental and Oral Injuries.

A 16-month-old presents to the emergency department (ED) after a fall while running at home. Her mother noted some blood in the child's mouth and believed there was a tear in the skin above the front teeth.

Prehospital dexamethasone administration in children with croup: a medical record review.

OBJECTIVES: Croup is one of the most common childhood respiratory illnesses. Early dexamethasone administration in croup can improve patient outcomes. The objective of this study was to assess the clinical impact of prehospital administration of dexamethasone to children with croup. METHODS: A medical record review that included children between 6 months and 6 years, who were brought via emergency medical services (EMS) to the emergency department (ED) with a final diagnosis of croup, between January 2010 and December 2012, was conducted. Data were collected regarding prehospital management and ED management, length of stay (LOS), final disposition, and patient demographics. RESULTS: A total of 188 patients with an ED diagnosis of croup were enrolled, 35.1% (66/188) of whom received a prehospital diagnosis of croup. The mean age of the participants was 32.96±17.18 months and 10.6% (20/188) were given dexamethasone in the prehospital setting by EMS, while 30.3% (57/188) were given epinephrine nebulizations. Out of the 66 patients with a prehospital diagnosis of croup, 10.6% (7/66) were given dexamethasone by EMS. In ED, dexamethasone was administered to 88.3% (166/188) while 29.8% of participants (56/188) received epinephrine nebulizations. There was no significant difference in ED LOS between those who received prehospital dexamethasone (2.6±1.6 hours, n=18) and those who did not (3.3±2.7 hours, n=159) (P=0.514). The number of in-hospital epinephrine doses per patient was significantly influenced by the administration of prehospital dexamethasone (P=0.010). CONCLUSIONS: Prehospital administration of dexamethasone results in less ED epinephrine use and may reflect dexamethasone's positive influence on the severity and short-term persistence of croup symptoms.

Canadian Association of Emergency Physicians position statement on acute ischemic stroke.

The CAEP Stroke Practice Committee was convened in the spring of 2013 to revisit the 2001 policy statement on the use of thrombolytic therapy in acute ischemic stroke. The terms of reference of the panel were developed to include national representation from urban academic centres as well as community and rural centres from all regions of the country. Membership was determined by attracting recognized stroke leaders from across the country who agreed to volunteer their time towards the development of revised guidance on the topic. The guideline panel elected to adopt the GRADE language to communicate guidance after review of existing systematic reviews and international clinical practice guidelines. Stroke neurologists from across Canada were engaged to work alongside panel members to develop guidance as a dyad-based consensus when possible. There was no unique systematic review performed to support this guidance, rather existing efficacy data was relied upon. After a series of teleconferences and face to face meetings, a draft guideline was developed and presented to the CAEP board in June of 2014. The panel noted the development of significant new evidence to inform a number of clinical questions related to acute stroke management. In general terms the recommendations issued by the CAEP Stroke Practice Committee are supportive of the use of thrombolytic therapy when treatment can be administered within 3 hours of symptom onset. The committee is also supportive of system-level changes including pre-hospital interventions, the transport of patients to dedicated stroke centers when possible and tele-health measures to support thrombolytic therapy in a timely window. Of note, after careful deliberation, the panel elected to issue a conditional recommendation against the use of thrombolytic therapy in the 3­4.5 hour window. The view of the committee was that as a result of a narrow risk benefit balance, one that is considerably narrower than the same considerations under 3 hours, a significant number of informed patients and families would opt against the risk of early intracranial hemorrhage and the possibility of increased 90-day mortality that is not seen for more timely treatment. Furthermore, the frequently impaired nature of patients suffering an acute stroke and the difficulties in asking families to make life and death decisions in a highly time-sensitive context led the panel to restrict a strong endorsement of thrombolytic to the 3 hour outermost limit. The committee noted as well that Health Canada has not approved a thrombolytic agent beyond a three hour window in acute ischemic stroke.

Traumatic coronary artery dissection: a case report and literature review.

BACKGROUND: Coronary artery dissection after blunt chest trauma is a rare, life-threatening condition. OBJECTIVES: To present a case of coronary artery dissection after blunt chest trauma and to outline the appropriate management of this condition based on a literature review. CASE REPORT: We report the case of a 50-year-old woman with traumatic coronary artery dissection after a high-speed motor vehicle collision. She presented to the Emergency Department via ambulance within a few hours of the collision, and her clinical condition deteriorated rapidly. A 12-lead electrocardiogram on arrival demonstrated anterolateral ST-segment elevation. The patient was intubated due to hypoxemic respiratory failure and she required inotropes for blood pressure support. Computed tomography imaging revealed pulmonary edema and right third and fourth rib fractures. Emergent angiography demonstrated dissection of her left main coronary artery, requiring placement of a stent. CONCLUSION: Early recognition of this clinical entity with a screening electrocardiogram, and aggressive management, may result in a favorable outcome. A literature review reveals that coronary artery bypass grafting, angiography with stent placement, and conservative management may all be considered viable treatment options for this condition.