Left ventricular ejection fraction using a simplified wall motion score based on mid-parasternal short axis and apical four-chamber views for non-cardiologists.

BACKGROUND: There is a need for a convenient, yet reliable method to assess left ventricular ejection fraction (LVEF) with point-of-care ultrasound study (POCUS). We aim to validate a novel and simplified wall motion score LVEF based on the analysis of a simplified combination of echocardiographic views. METHODS: In this retrospective study, transthoracic echocardiograms of randomly selected patients were analysed by the standard 16-segments wall motion score index (WMSI) to derive the reference semi-quantitative LVEF. To develop our semi-quantitative simplified-views method, a limited combination of imaging views and only 4 segments per view were tested: (1) A combination of the three parasternal short-axis views (PSAX BASE, MID-, APEX); (2) A combination of the three apical views (apical 2-chamber, 3-chamber and 4-chamber) and (3) A more limited combination of PSAX-MID and apical 4-chamber is called the MID-4CH. Global LVEF is obtained by averaging segmental EF based on contractility (normal = 60%, hypokinesia = 40%, and akinesia = 10%). Accuracy of the novel semi-quantitative simplified-views WMS method compared to the reference WMSI was evaluated using Bland-Altman analysis and correlation was assessed in both emergency physicians and cardiologists. RESULTS: In the 46 patients using the 16 segments WMSI method, the mean LVEF was 34 ± 10%. Among the three combinations of the two or three imaging views analysed, the MID-4CH had the best correlation with the reference method (r2 = 0.90) with very good agreement (mean LVEF bias = - 0.2%) and precision (± 3.3%). CONCLUSIONS: Cardiac POCUS by emergency physicians and other non-cardiologists is a decisive therapeutic and prognostic tool. A simplified semi-quantitative WMS method to assess LVEF using the easiest technically achievable combination of mid-parasternal and apical four-chamber views provides a good approximative estimate for both non-cardiologist emergency physicians and cardiologists.

The "Mirror Effect Plus Protocol" for acute Bell's palsy: A randomized controlled trial with 1-year follow-up.

OBJECTIVE: To study the effects of the "Mirror Effect Plus Protocol" (MEPP) on global facial function in acute and severe Bell's Palsy. DESIGN: Single blind and randomized controlled trial to compare the effects of basic counseling (control group) versus MEPP (experimental group) over one year. SETTING: Outpatient clinic following referrals from Emergency or Otorhinolaryngology Departments. SUBJECTS: 40 patients (n = 20 per group) with moderately severe to total palsy who received standard medication were recruited within 14 days of onset. Baseline characteristics were comparable between the groups. INTERVENTIONS: The experimental group received the MEPP program (motor imagery + manipulations + facial mirror therapy) while the control group received basic counseling. Both groups met the clinician monthly until 6 months and at one-year post-onset for assessments. OUTCOME MEASURES: Facial symmetry, synkinesis, and quality of life were measured using standardized scales. Perceived speech intelligibility was rated before and after therapy by naïve judges. RESULTS: Descriptive statistics demonstrated improvements in favor of the MEPP for each measured variable. Significant differences were found for one facial symmetry score (House-Brackmann 2.0 mean (SD) = 7.40 (3.15) for controls versus 5.1 (1.44) for MEPP), for synkinesis measures (p = 0.008) and for quality-of-life ratings (mean (SD) score = 83.17% (17.383) for controls versus 98.36% (3.608) for MEPP (p = 0.002)). No group difference was found for perceived speech intelligibility. CONCLUSION: The MEPP demonstrates promising long-term results when started during the acute phase of moderately severe to total Bell's Palsy.

Opioid and non-opioid pain relief after an emergency department acute pain visit.

OBJECTIVES: Treatment of acute pain after emergency department (ED) discharge remains a challenge in the opioid crisis context. Our objective was to determine the proportion of patients using opioid vs non-opioid pain medication following discharge from the ED with acute pain, and the association of type of pain medication with average pain intensity before pain medication intake and report of pain relief. METHODS: This was a prospective cohort study of ED patients aged ≥ 18 years with an acute pain (≤ 2 weeks) who were discharged with an opioid prescription. Patients completed a 14-day diary assessing daily pain intensity level before each pain medication intake (0-10 numeric rating scale), type of pain medication use (opioid vs non-opioid), and if pain was relieved by the medication used that day. Multilevel analyses were used to compare the effect of type of analgesic used on pain intensity and relief. RESULTS: A total of 381 participants completed the 14-day diary; 50% were women and median age was 54 years (IQR = 43-66). Average daily pain intensity before pain medication intake was significantly higher for patients who used opioids (5.9; 95% CI 5.7-6.2) as compared to non-opioid analgesics (4.2; 95% CI 4.0-4.5) or no pain medication (2.2; 95% CI 1.9-2.5). Controlling for pain intensity, patients using opioids were more likely to report a pain relief (OR = 1.3; 95% CI 1.1-1.8) as compared to those who used non-opioid analgesics. CONCLUSION: Overall, opioids appear to be effective and used as intended by the prescribing physician.

RéSUMé: OBJECTIFS: Le traitement de la douleur aiguë après la sortie des départements d'urgence (DU) reste un défi dans le contexte de la crise des opioïdes. Notre objectif était de déterminer la proportion de patients utilisant des analgésiques opioïdes par rapport aux analgésiques non opioïdes après leur sortie des urgences avec une douleur aiguë, et l'association du type d'analgésique avec l'intensité moyenne de la douleur avant la prise d'analgésiques et le soulagement de la douleur rapporté. LES MéTHODES: Il s'agissait d'une étude de cohorte prospective de patients (DU) âgés de ≥18 ans souffrant de douleurs aiguës (≤ 2 semaines) et ayant reçu une ordonnance d'opioïdes à leur sortie de l'hôpital. Les patients ont rempli un journal de 14 jours évaluant le niveau d'intensité de la douleur quotidienne avant chaque prise de médicaments anti-douleur (échelle d'évaluation numérique de 0 à 10), le type d'utilisation des médicaments anti-douleur (opioïdes contre non opioïdes), et si la douleur était soulagée par les médicaments utilisés ce jour-là. Des analyses multiniveaux ont été utilisées pour comparer l'effet du type d'analgésique utilisé sur l'intensité et le soulagement de la douleur. RéSULTATS: Au total, 381 participants ont rempli le journal de 14 jours; 50% étaient des femmes et l'âge médian était de 54 ans (EI = 43­66). L'intensité moyenne de la douleur quotidienne avant la prise d'analgésiques était significativement plus élevée chez les patients qui prenaient des opioïdes (5.9; 95% IC: 5.7­6.2) par rapport aux analgésiques non opioïdes (4.2; 95% IC: 4.0­4.5) ou à l'absence d'analgésiques (2.2; 95% IC: 1.9­2.5). En contrôlant l'intensité de la douleur, les patients utilisant des opioïdes étaient plus susceptibles de déclarer un soulagement de la douleur (OR = 1.3; 95% CI: 1.1−1.8) par rapport à ceux qui utilisaient des analgésiques non opioïdes. CONCLUSION: Dans l'ensemble, les opioïdes semblent être efficaces et utilisés comme prévu par le médecin prescripteur.

The Mirror Effect Plus Protocol for acute Bell's palsy: a randomised and longitudinal study on facial rehabilitation.

BACKGROUND: Small but interesting evidences suggest that facial rehabilitation for acute Bell Palsy (BP) could improve facial outcomes in patients who benefited from optimal medication, but whose symptoms are still severe two weeks after BP's onset. AIMS: This study aimed to provide preliminary evidence of the long-term effects of a new facial retraining based on motor imagery and mirror therapy, the Mirror Effect Plus Protocol (MEPP). MATERIAL AND METHODS: Twenty BP patients received the standard medication for acute BP and were then randomly allocated to the treatment (MEPP) or control group, if their palsy was still at least moderate-to-severe at 14 days post onset. Three blind independent assessors graded the patients' evolution until 6 months after onset. RESULTS: Significant differences between the groups were not found for any measured variable; however, a trend toward better recovery was found in the treatment group for every measured variable. This trend grew bigger for patients with severe or total BP. CONCLUSIONS: This study suggests a promising effect of the MEPP on acute severe to total BP but requires further investigation with a larger number of participants. SIGNIFICANCE: Facial rehabilitation should be considered as an adjunct to medication for acute and most severe degrees of BP.

Oxygen Therapy and Risk of Infection for Health Care Workers Caring for Patients With Viral Severe Acute Respiratory Infection: A Systematic Review and Meta-analysis.

STUDY OBJECTIVE: To synthesize the evidence regarding the infection risk associated with different modalities of oxygen therapy used in treating patients with severe acute respiratory infection. Health care workers face significant risk of infection when treating patients with a viral severe acute respiratory infection. To ensure health care worker safety and limit nosocomial transmission of such infection, it is crucial to synthesize the evidence regarding the infection risk associated with different modalities of oxygen therapy used in treating patients with severe acute respiratory infection. METHODS: MEDLINE, EMBASE, and the Cochrane Central Register of Controlled Trials were searched from January 1, 2000, to April 1, 2020, for studies describing the risk of infection associated with the modalities of oxygen therapy used for patients with severe acute respiratory infection. The study selection, data extraction, and quality assessment were performed by independent reviewers. The primary outcome measure was the infection of health care workers with a severe acute respiratory infection. Random-effect models were used to synthesize the extracted data. RESULTS: Of 22,123 citations, 50 studies were eligible for qualitative synthesis and 16 for meta-analysis. Globally, the quality of the included studies provided a very low certainty of evidence. Being exposed or performing an intubation (odds ratio 6.48; 95% confidence interval 2.90 to 14.44), bag-valve-mask ventilation (odds ratio 2.70; 95% confidence interval 1.31 to 5.36), and noninvasive ventilation (odds ratio 3.96; 95% confidence interval 2.12 to 7.40) were associated with an increased risk of infection. All modalities of oxygen therapy generate air dispersion. CONCLUSION: Most modalities of oxygen therapy are associated with an increased risk of infection and none have been demonstrated as safe. The lowest flow of oxygen should be used to maintain an adequate oxygen saturation for patients with severe acute respiratory infection, and manipulation of oxygen delivery equipment should be minimized.

Relationship between acute pain trajectories after an emergency department visit and chronic pain: a Canadian prospective cohort study.

OBJECTIVES: Inadequate acute pain management can reduce the quality of life, cause unnecessary suffering and can often lead to the development of chronic pain. Using group-based trajectory modelling, we previously identified six distinct pain intensity trajectories for the first 14-day postemergency department (ED) discharge; two linear ones with moderate or severe pain during follow-up (~40% of the patients) and four cubic polynomial order trajectories with mild or no pain at the end of the 14 days (low final pain trajectories). We assessed if previously described acute pain intensity trajectories over 14 days after ED discharge are predictive of chronic pain 3 months later. DESIGN: Prospective cohort study. SETTING: Tertiary care trauma centre academic hospital. PARTICIPANTS: This study included 18 years and older ED patients who consulted for acute (≤2 weeks) pain conditions that were discharged with an opioid prescription. Patients completed a 14-day diary in which they listed their daily pain intensity (0-10 numeric rating scale). OUTCOMES: Three months after ED visit, participants were questioned by phone about their current pain intensity (0-10 numeric rating scale). Chronic pain was defined as patients with current pain intensity ≥4 at 3 months. RESULTS: A total of 305 participants remained in the study at 3 months, 49% were women and a mean age of 55±15 years. Twelve per cent (11.9; 95% CI 8.2 to 15.4) of patients had chronic pain at the 3-month follow-up. Controlling for age, sex and pain condition, patients with moderate or severe pain trajectories and those with only a severe pain trajectory were respectively 5.1 (95% CI 2.2 to 11.8) and 8.2 (95% CI 3.4 to 20.0) times more likely to develop chronic pain 3 months later compared with patients in the low final pain trajectories. CONCLUSION: Specific acute pain trajectories following an ED visit are closely related to the development of chronic pain 3 months later. TRIAL REGISTRATION NUMBER: NCT02799004; Results.

Side effects from opioids used for acute pain after emergency department discharge.

OBJECTIVE: Opioid side effects are common when treating chronic pain. However, the frequency of opioid side effects has rarely been examined in acute pain conditions, particularly in a post emergency department (ED) setting. The objective of this study was to evaluate the short-term incidence of opioid-induced side effects (constipation, nausea/vomiting, dizziness, drowsiness, sweating, and weakness) in patients discharged from the ED with an opioid prescription. METHODS: This is a prospective cohort study of patients aged ≥18 years who visited the ED for an acute pain condition (≤2 weeks) and were discharged with an opioid prescription. Patients completed a 14-day diary assessing daily pain medication use and side effects. RESULTS: We recruited 386 patients with a median age of 54 years (IQR:43-66); 50% were women. During the 2-week follow-up, 80% of patients consumed opioids. Among the patients who used opioids, 79% (95%CI:75-83) reported side effects compared to 38% (95%CI:27-49) for non-users. Adjusting for age, sex, and pain condition, patients who used opioids were more likely to report constipation (OR:7.5; 95%CI:3.1-17.9), nausea/vomiting (OR:4.1; 95%CI:1.8-9.5), dizziness (OR:5.4; 95%CI: 2.2-13.2), drowsiness (OR:4.6; 95%CI:2.5-8.7), and weakness (OR:4.2; 95%CI:1.6-11.0) compared to non-users. A dose-response trend was observed for constipation but not for the other side effects. Nausea/vomiting (OR:2.0; 95%CI:1.1-3.6) and dizziness (OR:1.9; 95%CI:1.1-3.4) were more often associated with oxycodone than with morphine. CONCLUSION: As observed for chronic pain treatment, side effects are highly prevalent during short-term opioid treatment for acute pain. Physicians should inform patients about those side effects and should consider prescribing laxatives.

Can the "important brain injury criteria" predict neurosurgical intervention in mild traumatic brain injury? A validation study.

BACKGROUND: There is variability in the management of patients presenting to the emergency department (ED) with mild traumatic brain injury (MTBI) and abnormal findings on their initial head computed tomography (CT). The main objective of this study was to validate the value of the Important Brain Injury (IBI) criteria, introduced by the Canadian CT-Head Rule, in predicting the need for surgical intervention. The secondary objective was to identify independent predictors for neurosurgical intervention. METHODS: This is a post hoc analysis of a prospective cohort of adult patients presenting to the ED of one tertiary care, academic center, between 2008 and 2012, with MTBI and an abnormal initial head CT. Neurosurgical intervention was at the discretion of the treating physician. The sensitivity and specificity of the IBI criteria were calculated with 95% confidence intervals (CI95%). A multivariate logistic regression model was used to identify independent predictors for neurosurgical intervention with the direct entry method. RESULTS: A total of 678 patients (male = 65.9%, mean age = 62.5 years) were included, of whom 114 (16.8%) required neurosurgical intervention. All patients requiring neurosurgical intervention met IBI criteria on their initial head CT (sensitivity of 100% [CI95% 96.8-100]). However, 368 (65.2%) patients with findings of IBI did not require neurosurgical intervention (specificity of 34.8% [CI95% 30.8-38.8]). Age over 65 was independently associated with neurosurgical intervention in the IBI population. CONCLUSION: The IBI criteria for MTBI identified all patients who required neurosurgical intervention; however its specificity is low.

Opioid Use and Misuse Three Months After Emergency Department Visit for Acute Pain.

BACKGROUND: Studies evaluating long-term prescription opioid use are retrospective and based on filled opioid prescriptions from governmental databases. These studies cannot evaluate if opioids were really consumed and are unable to differentiate if they were used for a new pain or chronic pain or were misused. The aim of this study was to assess opioid use rate and reasons for consuming 3 months after being discharged from the emergency department (ED) with an opioid prescription. METHODS: This is a prospective cohort study conducted in the ED of a tertiary care urban center with a convenience sample of discharged patients ≥ 18 years who consulted for an acute pain condition (≤2 weeks). Three months post-ED visit, participants were interviewed by phone on their past 2-week opioid consumption and their reasons for consuming: a) for pain related to the initial ED visit, b) for a new unrelated pain, or c) for another reason. RESULTS: Of the 524 participants questioned at 3 months (mean ± SD age = 51 ± 16 years, 47% women), 47 patients (9%, 95% confidence interval [CI] = 7%-12%) reported consuming opioids in the previous 2 weeks. Among those, 34 (72%) reported using opioids for their initial pain, nine (19%) for a new unrelated pain and four (9%) for another reason (0.8%, 95% CI = 0.3%-2.0%, of the whole cohort). Patients who used opioids during the 2 weeks after the ED visit were 3.8 (95% CI = 1.2-12.7) times more likely to consume opioids at 3 months. CONCLUSION: Opioid use at the 3-month follow-up in ED patients discharged with an opioid prescription for an acute pain condition is not necessarily associated with opioid misuse; 91% of those patients consumed opioids to treat pain. Of the whole cohort, less than 1% reported using opioids for reasons other than pain. The rate of long-term opioid use reported by prescription-filling database studies should not be viewed as a proxy for incidence of opioid misuse.

Acute Pain Resolution After an Emergency Department Visit: A 14-Day Trajectory Analysis.

STUDY OBJECTIVE: The objective of the study is to evaluate the acute pain intensity evolution in emergency department (ED) discharged patients, using group-based trajectory modeling. This method identifies patient groups with similar profiles of change over time without assuming the existence of a particular pattern or number of groups. METHODS: This was a prospective cohort study of ED patients aged 18 years or older, with an acute pain condition (≤2 weeks), and discharged with an opioid prescription. Patients completed a 14-day diary assessing daily pain intensity level (numeric rating scale of 0 to 10) and pain medication use. RESULTS: Among the 372 included patients, 6 distinct post-ED pain intensity trajectories were identified. Two started with severe levels of pain; one remained with severe pain intensity (12.6% of the sample) and the other ended with a moderate pain intensity level (26.3%). Two other trajectories had severe initial pain; one decreased to mild pain (21.7%) and the other to no pain (13.8%). Another trajectory had moderate initial pain that decreased to a mild level (15.9%) and the last one started with mild pain intensity and had no pain at the end of the 14-day period (9.7%). The pain trajectory patterns were significantly associated with age, type of painful conditions, pain intensity at ED discharge, and opioid consumption. CONCLUSION: Acute pain resolution after an ED visit seems to progress through 6 different trajectory patterns that are more informative than simple linear models and could be useful to adapt acute pain management in future research.

Quantity of opioids consumed following an emergency department visit for acute pain: a Canadian prospective cohort study.

OBJECTIVES: Prescription opioid diversion is a significant contributor to the opioid misuse epidemic. We examined the quantity of opioids consumed by emergency department (ED) discharged patients after treatment for an acute pain condition (musculoskeletal, fracture, renal colic, abdominal pain and other), and the percentage of unused opioids available for potential misuse. DESIGN: Prospective cohort study. SETTING: Tertiary care trauma centre academic hospital. PARTICIPANTS: A convenience sample of patients ≥18 years who visited the ED for an acute pain condition (≤2 weeks) and were discharged with an opioid prescription. Patients completed a 14-day paper diary of daily pain medication use. To reduce lost to follow-up, participants also responded to standardised phone interview questions about their previous 14-day pain medication use. OUTCOMES: Quantity of morphine 5 mg tablets (or equivalent) prescribed, consumed and unused during a 14-day follow-up. Quantity of opioids to adequately supply 80% of patients for 2 weeks and 95% of patients for the first 3 days was also calculated. RESULTS: Results for 627 patients were analysed (mean age ±SD: 51±16 years, 48% women). Patients consumed a median of seven tablets of morphine 5 mg (32% of the total prescribed opioids). The quantity of opioids to adequately supply 80% of patients for 2 weeks was 20 tablets of morphine 5 mg for musculoskeletal pain, 30 for fracture, 15 for renal colic or abdominal pain and 20 for other pain conditions. The quantity to adequately supply 95% of patients for the first 3 days was 15 tablets of morphine 5 mg. CONCLUSIONS: Patients discharged from the ED with an acute pain condition consumed a median of fewer than 10 tablets of morphine 5 mg (or equivalent). ED physicians should consider prescribing a smaller quantity of opioids and asking the pharmacist to dispense them in portions to minimise unused opioids. TRIAL REGISTRATION NUMBER: NCT02799004; Results.

Impact of the direct transfer to percutaneous coronary intervention-capable hospitals on survival to hospital discharge for patients with out-of-hospital cardiac arrest.

AIMS: Patients suffering from out-of-hospital cardiac arrest (OHCA) are frequently transported to the closest hospital. Percutaneous coronary intervention (PCI) is often indicated following OHCA. This study's primary objective was to determine the association between being transported to a PCI-capable hospital and survival to discharge for patients with OHCA. The additional delay to hospital arrival which could offset a potential increase in survival associated with being transported to a PCI-capable center was also evaluated. METHODS: This study used a registry of OHCA in Montreal, Canada. Adult patients transported to a hospital following a non-traumatic OHCA were included. Hospitals were dichotomized based on whether PCI was available on-site or not. The effect of hospital type on survival to discharge was assessed using a multivariable logistic regression. The added prehospital delay which could offset the increase in survival associated with being transported to a PCI-capable center was calculated using that regression. RESULTS: A total of 4922 patients were included, of whom 2389 (48%) were transported to a PCI-capable hospital and 2533 (52%) to a non-PCI-capable hospital. There was an association between being transported to a PCI-capable center and survival to discharge (adjusted odds ratio = 1.60 [95% confidence interval 1.25-2.05], p < .001). Increasing the delay from call to hospital arrival by 14.0 min would offset the potential benefit of being transported to a PCI-capable center. CONCLUSIONS: It could be advantageous to redirect patients suffering from OHCA patients to PCI-capable centers if the resulting expected delay is of less than 14 min.

Potential impact of a prehospital redirection system for refractory cardiac arrest.

AIM: A change in prehospital redirection practice could potentially increase the proportion of E-CPR eligible patients with out-of-hospital cardiac arrest (OHCA) transported to extracorporeal cardiopulmonary resuscitation (E-CPR) capable centers. The objective of this study was to quantify this potential increase of E-CPR candidates transported to E-CPR capable centers. METHODS: Adults with non-traumatic OHCA refractory to 15min of resuscitation were selected from a registry of adult OHCA collected between 2010 and 2015 in Montreal, Canada. Using this cohort, three simulation scenarios allowing prehospital redirection to E-CPR centers were created. Stringent eligibility criteria for E-CPR and redirection for E-CPR (e.g. age <60years old, initial shockable rhythm) were used in the first scenario, intermediate eligibility criteria (e.g. age <65years old, at least one shock given) in the second scenario and inclusive eligibility criteria (e.g. age <70years old, initial rhythm ≠ asystole) in the third scenario. All three scenarios were contrasted with equivalent scenarios in which patients were transported to the closest hospital. Proportions were compared using McNemar's test. RESULTS: The proportion of E-CPR eligible patients transported to E-CPR capable centers increased in each scenario (stringent criteria: 48 [24.5%] vs 155 patients [79.1%], p<0.001; intermediate criteria: 81 [29.6%] vs 262 patients [95.6%], p<0.001; inclusive criteria: 238 [23.9%] vs 981 patients [98.5%], p<0.001). CONCLUSIONS: A prehospital redirection system could significantly increase the number of patients with refractory OHCA transported to E-CPR capable centers, thus increasing their access to this potentially life-saving procedure, provided allocated resources are planned accordingly.

Prehospital Advanced Cardiac Life Support for Out-of-hospital Cardiac Arrest: A Cohort Study.

OBJECTIVES: Out-of-hospital advanced cardiac life support (ACLS) has not consistently shown a positive impact on survival. Extracorporeal cardiopulmonary resuscitation (E-CPR) could render prolonged on-site resuscitation (ACLS or basic cardiac life support [BCLS]) undesirable in selected cases. The objectives of this study were to evaluate, in patients suffering from out-of-hospital cardiac arrest (OHCA) and in a subgroup of potential E-CPR candidates, the association between the addition of prehospital ACLS to BCLS and survival to hospital discharge, prehospital return of spontaneous circulation (ROSC), and delay from call to hospital arrival. METHODS: This cohort study targets adult patients treated for OHCA between April 2010 and December 2015 in the city of Montreal, Canada. We defined potential E-CPR candidates using clinical criteria previously described in the literature (65 years of age or younger, initial shockable rhythm, absence of ROSC after 15 minutes of prehospital resuscitation, and emergency medical services-witnessed collapse or witnessed collapse with bystander cardiopulmonary resuscitation). Associations were evaluated using multivariate regression models. RESULTS: A total of 7,134 patients with OHCA were included, 761 (10.7%) of whom survived to discharge. No independent association between survival to hospital discharge and the addition of prehospital ACLS to BCLS was found in either the entire cohort (adjusted odds ratio [AOR] = 1.05 [95% confidence interval {CI} = 0.84-1.32], p = 0.68) or among the 246 potential E-CPR candidates (AOR = 0.82 [95% CI = 0.36-1.84], p = 0.63). The addition of prehospital ACLS to BCLS was associated with a significant increase in the rate of prehospital ROSC in all patients experiencing OHCA (AOR = 3.92 [95% CI = 3.38-4.55], p < 0.001) and in potential E-CPR candidates (AOR = 3.48 [95% CI = 1. 76-6.88], p < 0.001) compared to isolated prehospital BCLS. Delay from call to hospital arrival was longer in the ACLS group than in the BCLS group (difference = 16 minutes [95% CI = 15-16 minutes], p < 0.001). CONCLUSIONS: In a tiered-response urban emergency medical service setting, prehospital ACLS is not associated with an improvement in survival to hospital discharge in patients suffering from OHCA and in potential E-CPR candidates, but with an improvement in prehospital ROSC and with longer delay to hospital arrival.

Lung Sliding Identification Is Less Accurate in the Left Hemithorax.

OBJECTIVES: The aim of our study was to compare the accuracy of lung sliding identification for the left and right hemithoraxes, using prerecorded short US sequences, in a group of physicians with mixed clinical and US training. METHODS: A total of 140 US sequences of a complete respiratory cycle were recorded in the operating room. Each sequence was divided in two, yielding 140 sequences of present lung sliding and 140 sequences of absent lung sliding. Of these 280 sequences, 40 were randomly repeated to assess intraobserver variability, for a total of 320 sequences. Descriptive data, the mean accuracy of each participant, as well as the rate of correct answers for each of the original 280 sequences were tabulated and compared for different subgroups of clinical and US training. A video with examples of present and absent lung sliding and a lung pulse was shown before testing. RESULTS: Two sessions were planned to facilitate the participation of 75 clinicians. In the first group, the rate of accurate lung sliding identification was lower in the left hemithorax than in the right (67.0% [interquartile range (IQR), 43.0-83.0] versus 80.0% [IQR, 57.0-95.0]; P < .001). In the second group, the rate of accurate lung sliding identification was also lower in the left hemithorax than in the right (76.3% [IQR, 42.9-90.9] versus 88.7% [IQR, 63.1-96.9]; P = .001). Mean accuracy rates were 67.5% (95% confidence interval, 65.7-69.4) in the first group and 73.1% (95% confidence interval, 70.7-75.5) in the second (P < .001). CONCLUSIONS: Lung sliding identification seems less accurate in the left hemithorax when using a short US examination. This study was done on recorded US sequences and should be repeated in a live clinical situation to confirm our results.

Impact of Age on Pain Perception for Typical Painful Diagnoses in the Emergency Department.

BACKGROUND: Age-related differences in pain perception have been demonstrated in experimental settings but have been investigated scarcely and without valid scale in the clinical framework. OBJECTIVES: To examine the effect of age on pain perception for recognized painful diagnoses encountered in the emergency department (ED). METHODS: A post-hoc analysis of real-time archived data was performed in a tertiary urban and a secondary regional ED. We included all consecutive adult patients (≥18 years) with the following diagnosis at discharge: renal colic, pancreatitis, appendicitis, headache/migraine, dislocation and extremities fractures, and a pain evaluation of ≥1 (0-10, verbal numerical scale) at triage. The primary outcome was to compare for each of these diagnoses the level of pain intensity between four age groups (18-44; 45-64; 65-74; 75+ years). RESULTS: A total of 15,670 patients (48% women) were triaged with a mean pain intensity of 7.7 (SD=2.0). Women exhibited greater pain scores than men for pancreatitis, headache/migraine, and extremity fracture. Renal colic, pancreatitis, appendicitis, and headache/migraine showed a linear decrease in pain scores with age whereas dislocation and extremity fractures did not present age differences. Mean differences in pain intensity scores between young adults (18-44 years) and patients aged ≥75 years were 0.79 (95% confidence interval [95% CI] 0.5-1.1) for renal colic, 1.1 (95% CI 0.7-1.4) for pancreatitis, 0.70 (95% CI 0.2-1.2) for appendicitis, and 0.86 (95% CI 0.6-1.1) for headache/migraine. CONCLUSION: Older patients perceive similar pain for dislocation and extremity fractures and less for visceral and headache/migraine pain; however, these age differences may not be clinically important.

Vital Signs Are Not Associated with Self-Reported Acute Pain Intensity in the Emergency Department.

OBJECTIVES: This study aimed to ascertain the association between self-reported pain intensity and vital signs in both emergency department (ED) patients and a subgroup of patients with diagnosed conditions known to produce significant pain. METHODS: We performed a retrospective analysis of real-time, archived data from an electronic medical record system at an urban teaching hospital and regional community hospital. We included consecutive ED patients ≥16 years old who had a self-reported pain intensity ≥1 as measured during triage, from March 2005 to December 2012. The primary outcome was vital signs for self-reported pain intensity levels (mild, moderate, severe) on an 11-point verbal numerical scale. Changes in pain intensity levels were also compared to variations in vital signs. Both analyses were repeated on a subgroup of patients with diagnosed conditions recognized to produce significant pain: fracture, dislocation, or renal colic. RESULTS: We included 153,567 patients (mean age of 48.4±19.3 years; 55.5% women) triaged with pain (median intensity of 7/10±3). Of these, 8.9% of patients had diagnosed conditions recognized to produce significant pain. From the total sample, the difference between mild and severe pain categories was 2.7 beats/minutes (95% CI: 2.4-3.0) for heart rate and 0.13 mm Hg (95% CI: -0.26-0.52) for systolic blood pressure. These differences generated small effect sizes and were not clinically significant. Results were similar for patients who experienced changes in pain categories and for those conditions recognized to produce significant pain. CONCLUSION: Health care professionals cannot use vital signs to estimate or substantiate self-reported pain intensity levels or changes over time.

A majority of rural emergency departments in the province of Quebec use point-of-care ultrasound: a cross-sectional survey.

BACKGROUND: Point-of-care ultrasound (POCUS) can be used to provide rapid answers to specific and potentially life-threatening clinical questions, and to improve the safety of procedures. The rate of POCUS access and use in Canada is unclear. The objective of this study was to examine access to POCUS and potential barriers/facilitators to its use among rural physicians in Quebec. METHODS: This descriptive cross-sectional study used an online survey. The 30-item questionnaire is an adapted and translated version of a questionnaire used in a prior survey conducted in rural Ontario, Canada. The questionnaire was pre-tested for clarity and relevance. The survey was sent to non-locum physicians working either full- or part-time in rural emergency departments (EDs) (n = 206). All EDs were located in rural and small towns and provided 24/7 medical coverage with acute care hospitalization beds. RESULTS: In total, 108 surveys were completed (participation rate = 52.4%). Of the individuals who completed surveys, ninety-three percent were family physicians, and seven percent had Canadian College of Family Physicians - Emergency Medicine (CCFP-EM) certification. The median number of years of practice was seven. A bedside ultrasound device was available in 95% of rural EDs; 75.9% of physicians reported using POCUS on a regular basis. The most common indications for POCUS use were to rule out abdominal aortic aneurysm (70.4%) and to evaluate presence of free fluid in trauma and intrauterine pregnancy (60%). The most common reason (73%) for not using POCUS was limited access to POCUS training programs. Over 40% of POCUS users received training in POCUS during medical school or residency. Sixty-four percent received training from the Canadian Emergency Ultrasound Society, 13% received training from the Canadian Association of Emergency Physicians, and 23% were trained in another course. Finally, 95% of respondents reported that POCUS skills are essential for rural ED practice. CONCLUSIONS: POCUS use in rural EDs in the province of Quebec appears to be relatively widespread. Access to training programs is a barrier to greater use.

Impact of age, sex and route of administration on adverse events after opioid treatment in the emergency department: a retrospective study.

BACKGROUND: The efficacy of opioids for acute pain relief in the emergency department (ED) is well recognized, but treatment with opioids is associated with adverse events ranging from minor discomforts to life-threatening events. OBJECTIVE: To assess the impact of age, sex and route of administration on the incidence of adverse events due to opioid administration in the ED. METHODS: Real-time archived data were analyzed retrospectively in a tertiary care urban hospital. All consecutive patients (≥16 years of age) who were assigned to an ED bed and received an opioid between March 2008 and December 2012 were included. Adverse events were defined as: nausea/vomiting (minor); systolic blood pressure (SBP) <90 mmHg, oxygen saturation (Sat) <92% and respiration rate <10 breaths/min (major) within 2 h of the first opioid doses. RESULTS: In the study period, 31,742 patients were treated with opioids. The mean (± SD) age was 55.8±20.5 years, and 53% were female. The overall incidence of adverse events was 12.0% (95% CI 11.6% to 12.4%): 5.9% (95% CI 5.6% to 6.2%) experienced nausea/vomiting, 2.4% (95% CI 2.2% to 2.6%) SBP <90 mmHg, 4.7% (95% CI 4.5% to 4.9%) Sat that dropped to <92% and 0.09% respiration rate <10 breaths/min. After controlling for confounding factors, these adverse events were associated with: female sex (more nausea/vomiting, more SBP <90 mmHg, less Sat <92%); age ≥65 years (less nausea/vomiting, more SBP <90 mmHg, more Sat <92%); and route of administration (intravenous > subcutaneous > oral). CONCLUSIONS: The incidence of adverse events associated with opioid administration in the ED is generally low and is associated with age, sex and route of administration.