Corticosteroids for preventing relapse following acute exacerbations of asthma.

BACKGROUND: Acute asthma is responsible for many emergency department (ED) visits annually. Between 12 to 16% will relapse to require additional interventions within two weeks of ED discharge. Treatment of acute asthma is based on rapid reversal of bronchospasm and reducing airway inflammation. OBJECTIVES: To determine the benefit of corticosteroids (oral, intramuscular, or intravenous) for the treatment of asthmatic patients discharged from an acute care setting (i.e. usually the emergency department) after assessment and treatment of an acute asthmatic exacerbation. SEARCH STRATEGY: We searched the Cochrane Airways Group Specialised Register and reference lists of articles. In addition, authors of all included studies were contacted to locate unpublished studies. The most recent search was run in October 2006. SELECTION CRITERIA: Randomized controlled trials comparing two types of corticosteroids (oral, intra-muscular, or inhaled) with placebo for outpatient treatment of asthmatic exacerbations in adults or children. DATA COLLECTION AND ANALYSIS: Two review authors independently assessed trial quality and extracted data. Study authors were contacted for additional information. MAIN RESULTS: Six trials involving 374 people were included. One study used intramuscular corticosteroids, five studies used oral corticosteroids. The review was split into two reviews and although the latest search yielded no additional placebo controlled trials an additional IM study was included. Significantly fewer patients in the corticosteroid group relapsed to receive additional care in the first week (Relative risk (RR) 0.38; 95% confidence interval (CI) 0.2 to 0.74). This favourable effect was maintained over the first 21 days (RR 0.47; 95% CI 0.25 to 0.89) and there were fewer subsequent hospitalizations (RR 0.35; 95% CI 0.13 to 0.95). Patients receiving corticosteroids had less need for beta(2)-agonists (mean difference (MD) -3.3 activations/day; 95% CI -5.6 to -1.0). Changes in pulmonary function tests (SMD 0.045; 95% CI -0.47 to 0.56) and side effects (SMD 0.03; 95% CI -0.38 to 0.44) in the first 7 to 10 days, while rarely reported, showed no significant differences between the treatment groups. Statistically significant heterogeneity was identified for the side effect results; all other outcomes were homogeneous. From these results, as few as ten patients need to be treated to prevent relapse to additional care after an exacerbation of asthma. AUTHORS' CONCLUSIONS: A short course of corticosteroids following assessment for an asthma exacerbation significantly reduces the number of relapses to additional care, hospitalizations and use of short-acting beta(2)-agonist without an apparent increase in side effects. Intramuscular and oral corticosteroids are both effective.

Corticosteroids for preventing relapse following acute exacerbations of asthma.

BACKGROUND: Acute asthma is responsible for many emergency department visits annually. Between 12-16% will relapse to require additional interventions within two weeks of ED discharge. Treatment of acute asthma is based on rapid reversal of bronchospasm and reducing airway inflammation and this review examines the evidence for using systemic corticosteroids to improve outcomes after discharge from the ED. OBJECTIVES: To determine the benefit of corticosteroids (oral, intramuscular, or intravenous) for the treatment of asthmatic patients discharged from an acute care setting (i.e. usually the emergency department) after assessment and treatment of an acute asthmatic exacerbation. SEARCH STRATEGY: The Cochrane Airways Group "Asthma and Wheez* RCT" register was searched using the terms: a) Asthma OR Wheez* b) Glucocorticoid OR Steroid* AND c) Exacerbat* OR Relapse* OR Emerg*. In addition, authors of all included studies were contacted to determine if unpublished studies which met the inclusion criteria were available. Bibliographies from included studies, known reviews and texts were also searched for additional citations. SELECTION CRITERIA: Only randomized controlled trials were eligible for selection. Studies were included in this review if they dealt with the outpatient treatment of asthmatic exacerbations using glucocorticoids at discharge and reported either relapse rate or PFTs. Two independent reviewers first identified potentially relevant studies and then selected articles for inclusion. Methodological quality was assessed independently by two reviewers. Agreement was assessed using kappa (k) statistics. DATA COLLECTION AND ANALYSIS: Data were extracted independently by two reviewers; authors were contacted to verify the extracted data and clarify missing information. When author contact was unsuccessful, missing data were estimated from graphs where possible. Sensitivity, sub-group and overall analyses were performed using the Cochrane Review Manager. MAIN RESULTS: A search that yielded 229 references identified 169 (73%) original publications. Reviewers identified 8 studies for potential inclusion (k =0.76); 18 references were added by searching publication reference lists and contact with authors. Of these 26 articles, a total of 7 were included in the overview. Two studies used intramuscular corticosteroids, five studies used oral corticosteroids. Significantly fewer patients in the corticosteroid group relapsed to receive additional care in the first week (odds ratio (OR) 0.35; 95% confidence interval (CI): 0.17, 0.73). This favourable effect was maintained over the first 21 days (OR 0.33; 95% CI: 0.13, 0.82). Patients receiving corticosteroids had less need for beta-agonists (weighted mean difference (WMD) -3.3 activations/day; 95% CI: -5.5, -1.0). Changes in pulmonary function tests (SMD 0.045; 95% CI: -0.47, 0.56) and side effects (SMD 0.03; 95% CI : -0.38, 0.44) in the first 7-10 days, while rarely reported, showed no differences between the treatment groups. Statistically significant heterogeneity was identified for the side effect results; all other outcomes were homogeneous. It appears that IM corticosteroids are similarly efficacious to a 7-10 day tapering course of oral agents. From these results, as few as 13 patients need to be treated to prevent relapse to additional care after an exacerbation of asthma. REVIEWER'S CONCLUSIONS: A short course of corticosteroids following assessment for an acute exacerbation of asthma significantly reduces the number of relapses to additional care and decreases beta-agonist use without an apparent increase in side effects. Intramuscular corticosteroids appear as effective as oral agents.

Early emergency department treatment of acute asthma with systemic corticosteroids.

BACKGROUND: The airway edema and secretions associated with acute asthma are most effectively treated with anti-inflammatories such as corticosteroids delivered by inhaled, oral, intravenous or intra-muscular routes. There is an unresolved debate about the use of systemic corticorticoids in the early treatment of acute asthma for emergency department patients. OBJECTIVES: To determine the benefit of treating patients with acute asthma with systemic corticosteroids within an hour of presenting to the emergency department (ED). SEARCH STRATEGY: Randomised controlled trials were identified from the Cochrane Airways Group Asthma Register. Primary authors and content experts were contacted to identify eligible studies. Bibliographies from included studies and known reviews were searched. SELECTION CRITERIA: Only randomised controlled trials (RCTs) or quasi-randomised trials were eligible for inclusion. Studies were included if patients presenting to the ED with acute asthma were treated with IV/IM or oral corticosteroids (CS) vs. placebo within 1 hour of arrival and either admission rate or pulmonary function results were reported. DATA COLLECTION AND ANALYSIS: Trial selection, data extraction and quality assessment were carried out independently by two reviewers, and confirmed with corresponding authors. MAIN RESULTS: Twelve studies involving 863 patients (435 corticosteroids; 428 placebo) were included. Early use of CS for acute asthma in the ED significantly reduced admission rates (N = 11; pooled OR: 0.40, 95% CI: 0.21 to 0.78). This would correspond with a number needed to treat of 8 (95% CI: 5 to 21). This benefit was more pronounced for those not receiving systemic CS prior to ED presentation (N = 7; OR: 0.37, 95% CI: 0.19 to 0.70) and those with more severe asthma (N = 7; OR: 0.35, 95% CI: 0.21 to 0.59). Oral CS therapy in children was particularly effective (N = 3; OR: 0.24, 95% CI: 0.11 to 0.53); no trials in adults used the oral route. Side effects were not significantly different between corticosteroid treatments and placebo. A further search was conducted in September 2000 which did not yield any further trials. REVIEWER'S CONCLUSIONS: Use of corticosteroids within 1 hour of presentation to an ED significantly reduces the need for hospital admission in patients with acute asthma. Benefits appear greatest in patients with more severe asthma, and those not currently receiving steroids. Children appear to respond well to oral steroids.

Intravenous magnesium sulfate treatment for acute asthma in the emergency department: a systematic review of the literature.

STUDY OBJECTIVES: There is some evidence that magnesium, when infused into asthmatic patients, can produce bronchodilation in addition to that obtained from standard treatments. This systematic review examined the effect of intravenous magnesium sulfate used for patients with acute asthma managed in the emergency department. METHODS: Only randomized controlled trials were eligible for inclusion. Studies were included if patients presented with acute asthma and were treated with intravenous magnesium sulfate versus placebo. Trials were identified from the Cochrane Airways Review Group register, which consists of a combined search of EMBASE, MEDLINE, and CINAHL databases and hand-searching of 20 key respiratory journals. Bibliographies from included studies and known reviews were searched. Primary authors and content experts were contacted. Data were extracted and methodologic quality was assessed independently by 2 reviewers. Missing data were obtained from authors. RESULTS: Seven trials (5 adult, 2 pediatric) involving a total of 668 patients were included. Overall, admission to hospital was not statistically reduced using magnesium sulfate (odds ratio [OR] 0.31, 95% confidence interval [CI] 0.09 to 1.02). In the severe subgroup, admissions were reduced in those receiving magnesium sulfate (OR 0.10, 95% CI 0.04 to 0.27). Overall, patients receiving magnesium sulfate demonstrated nonsignificant improvements in peak expiratory flow rates (PEFR) when all studies were pooled (weighted mean difference [WMD] 29 L/min, 95% CI -3 to 62). In studies of patients with severe acute asthma, PEFR WMD improved by 52 L/min (95% CI 27 to 78) favoring magnesium sulfate treatment. The absolute FEV(1) also improved by 10% predicted (95% CI 4 to 16) in patients with severe acute asthma. No clinically important changes in vital signs or side effects were reported. CONCLUSION: Current evidence does not clearly support routine use of intravenous magnesium sulfate in all patients with acute asthma presenting to the ED. However, magnesium sulfate appears to be safe and beneficial for patients who present with severe acute asthma. Practice guidelines need to be changed to reflect these results.

Corticosteroids for preventing relapse following acute exacerbations of asthma.

BACKGROUND: Acute asthma is responsible for many emergency department visits annually. Between 12-16% will relapse to require additional interventions within two weeks of ED discharge. Treatment of acute asthma is based on rapid reversal of bronchospasm and reducing airway inflammation and this review examines the evidence for using systemic corticosteroids to improve outcomes after discharge from the ED. OBJECTIVES: To determine the benefit of corticosteroids (oral, intramuscular, or intravenous) for the treatment of asthmatic patients discharged from an acute care setting (i.e. usually the emergency department) after assessment and treatment of an acute asthmatic exacerbation. SEARCH STRATEGY: The Cochrane Airways Group "Asthma and Wheez* RCT" register was searched using the terms: a) Asthma OR Wheez* b) Glucocorticoid OR Steroid* AND c) Exacerbat* OR Relapse* OR Emerg*. In addition, authors of all included studies were contacted to determine if unpublished studies which met the inclusion criteria were available. Bibliographies from included studies, known reviews and texts were also searched for additional citations. SELECTION CRITERIA: Only randomized controlled trials were eligible for selection. Studies were included in this review if they dealt with the outpatient treatment of asthmatic exacerbations using glucocorticoids at discharge and reported either relapse rate or PFTs. Two independent reviewers first identified potentially relevant studies and then selected articles for inclusion. Methodological quality was assessed independently by two reviewers. Agreement was assessed using kappa (k) statistics. DATA COLLECTION AND ANALYSIS: Data were extracted independently by two reviewers; authors were contacted to verify the extracted data and clarify missing information. When author contact was unsuccessful, missing data were estimated from graphs where possible. Sensitivity, sub-group and overall analyses were performed using the Cochrane Review Manager. MAIN RESULTS: A search that yielded 229 references identified 169 (73%) original publications. Reviewers identified 8 studies for potential inclusion (k =0.76); 18 references were added by searching publication reference lists and contact with authors. Of these 26 articles, a total of 7 were included in the overview. Two studies used intramuscular corticosteroids, five studies used oral corticosteroids. Significantly fewer patients in the corticosteroid group relapsed to receive additional care in the first week (odds ratio (OR) 0.35; 95% confidence interval (CI): 0.17, 0.73). This favourable effect was maintained over the first 21 days (OR 0.33; 95% CI: 0.13, 0.82). Patients receiving corticosteroids had less need for beta-agonists (weighted mean difference (WMD) -3.3 activations/day; 95% CI: -5.5, -1.0). Changes in pulmonary function tests (SMD 0.045; 95% CI: -0.47, 0.56) and side effects (SMD 0.03; 95% CI : -0.38, 0.44) in the first 7-10 days, while rarely reported, showed no differences between the treatment groups. Statistically significant heterogeneity was identified for the side effect results; all other outcomes were homogeneous. It appears that IM corticosteroids are similarly efficacious to a 7-10 day tapering course of oral agents. From these results, as few as 13 patients need to be treated to prevent relapse to additional care after an exacerbation of asthma. REVIEWER'S CONCLUSIONS: A short course of corticosteroids following assessment for an acute exacerbation of asthma significantly reduces the number of relapses to additional care and decreases beta-agonist use without an apparent increase in side effects. Intramuscular corticosteroids appear as effective as oral agents.

Magnesium sulfate for treating exacerbations of acute asthma in the emergency department.

BACKGROUND: Treatment of acute asthma is based on rapid reversal of bronchospasm and arresting airway inflammation. There is some evidence that intravenous magnesium can provide additional bronchodilation when given in conjunction with standard bronchodilating agents and corticosteroids. No systematic review of this literature has been completed on this topic. OBJECTIVES: To examine the effect of additional intravenous magnesium sulfate in patients with acute asthma managed in the emergency department. SEARCH STRATEGY: Randomised controlled trials were identified from the Cochrane Airways Review Group register. Bibliographies from included studies, known reviews and texts were searched. Primary authors and content experts were contacted. SELECTION CRITERIA: Randomised controlled trials or quasi-randomised trials were eligible for inclusion. Studies were included if patients presented with acute asthma and were treated with IV magnesium sulfate vs placebo. DATA COLLECTION AND ANALYSIS: Data were extracted and methodological quality was assessed independently by two reviewers. Missing data were obtained from authors. MAIN RESULTS: Seven trials were included (5 adult, 2 pediatric). A total of 665 patients were involved. Patients receiving magnesium sulfate demonstrated non-significant improvements in peak expiratory flow rates when all studies were pooled (weighted mean difference: 29.4 L/min; 95% confidence interval: -3.4 to 62). In studies of people with severe acute asthma, peak expiratory flow rate improved by 52.3 L/min (95% confidence interval: 27 to 77.5). The forced expiratory volume in one second also improved by 9.8 % predicted (95% confidence interval: 3.8 to 15.8). Overall, admission to hospital was not reduced, odds ratio: 0.31 (95% confidence interval: 0.09 to 1.02). In the severe subgroup, admissions were reduced in those receiving magnesium sulfate (odds ratio: 0.10, 95% confidence interval: 0.04 to 0.27). No clinically important changes in vital signs or adverse side effects were reported. REVIEWER'S CONCLUSIONS: Current evidence does not support routine use of intravenous magnesium sulfate in all patients with acute asthma presenting to the emergency department. Magnesium sulfate appears to be safe and beneficial in patients who present with severe acute asthma.

Early emergency department treatment of acute asthma with systemic corticosteroids.

BACKGROUND: The airway edema and secretions associated with acute asthma are most effectively treated with anti-inflammatories such as corticosteroids delivered by inhaled, oral, intravenous or intra-muscular routes. There is an unresolved debate about the use of systemic corticorticoids in the early treatment of acute asthma for emergency department patients. OBJECTIVES: To determine the benefit of treating patients with acute asthma with systemic corticosteroids within an hour of presenting to the emergency department (ED). SEARCH STRATEGY: Randomised controlled trials were identified from the Cochrane Airways Group Asthma Register. Primary authors and content experts were contacted to identify eligible studies. Bibliographies from included studies and known reviews were searched. SELECTION CRITERIA: Only randomised controlled trials (RCTs) or quasi-randomised trials were eligible for inclusion. Studies were included if patients presenting to the ED with acute asthma were treated with IV/IM or oral corticosteroids (CS) vs. placebo within 1 hour of arrival and either admission rate or pulmonary function results were reported. DATA COLLECTION AND ANALYSIS: Trial selection, data extraction and quality assessment were carried out independently by two reviewers, and confirmed with corresponding authors. MAIN RESULTS: Twelve studies involving 863 patients (435 corticosteroids; 428 placebo) were included. Early use of CS for acute asthma in the ED significantly reduced admission rates (N = 11; pooled OR: 0.40, 95% CI: 0.21 to 0.78). This would correspond with a number needed to treat of 8 (95% CI: 5 to 21). This benefit was more pronounced for those not receiving systemic CS prior to ED presentation (N = 7; OR: 0.37, 95% CI: 0.19 to 0.70) and those with more severe asthma (N = 7; OR: 0.35, 95% CI: 0.21 to 0. 59). Oral CS therapy in children was particularly effective (N = 3; OR: 0.24, 95% CI: 0.11 to 0.53); no trials in adults used the oral route. Side effects were not significantly different between corticosteroid treatments and placebo. REVIEWER'S CONCLUSIONS: Use of corticosteroids within 1 hour of presentation to an ED significantly reduces the need for hospital admission in patients with acute asthma. Benefits appear greatest in patients with more severe asthma, and those not currently receiving steroids. Children appear to respond well to oral steroids.

Inhaled budesonide in addition to oral corticosteroids to prevent asthma relapse following discharge from the emergency department: a randomized controlled trial.

CONTEXT: Relapses of acute asthma following emergency department (ED) discharge can be reduced with systemic corticosteroid treatment. However, whether inhaled corticosteroids (ICSs) provide additional benefit is not known. Objective To determine whether the addition of ICSs to oral corticosteroid treatment would reduce relapses in patients with acute asthma discharged from the ED. DESIGN AND SETTING: Placebo-controlled, double-blind, randomized clinical trial conducted in a community teaching hospital ED in Canada between November 1995 and September 1997, with a 21-day follow-up. PARTICIPANTS: A total of 1006 consecutive patients aged 16 to 60 years presented to the ED with acute asthma; after excluding those using oral and/or inhaled corticosteroids as well as those meeting other exclusion criteria, 188 were included in the study. INTERVENTIONS: Patients were discharged with a nontapering course of oral prednisone (50 mg/d) for 7 days. In a double-blind fashion, patients were randomly assigned to 1600 microg/d of inhaled budesonide (n = 94) or identical placebo (n = 94) for 21 days. MAIN OUTCOME MEASURES: Incidence of relapse, defined as an unscheduled visit for worsening asthma symptoms, in budesonide vs placebo groups. Secondary outcomes included response to the Asthma Quality of Life Questionnaire, beta2-agonist use, symptom score, global asthma improvement assessment, and pulmonary function. RESULTS: Five patients in the budesonide group and 3 in the placebo group either dropped out or were lost to follow-up but were included in primary analyses. After 21 days, 12 (12.8%) of 94 patients in the budesonide group experienced a relapse compared with 23 (24.5%) of 94 in the placebo group, a 48% relapse reduction (P=.049). Asthma Quality of Life Questionnaire scores were higher (better quality) in the budesonide group (P=.001), as well as for all domain scores (P=.001 to .01). Fewer beta2-agonist activations were used at the end of the trial by patients receiving budesonide (2.4/d vs 4.2/d; P=.01). Symptom scores (P=.001 to .004) and self-assessed asthma improvement scores (based on a 7-point Likert scale) (6.2 vs 5.2; P<.001) were higher (indicating fewer symptoms) for budesonide vs placebo. There were no differences in pulmonary function between the groups (peak expiratory flow rate: budesonide, 437 vs placebo, 453 L/min; P= .39) at 21 days. Using this approach, as few as 9 patients would require budesonide to prevent 1 relapse. CONCLUSIONS: Patients discharged from the ED following treatment for acute asthma benefit from added treatment with high-dose inhaled budesonide for 21 days compared with oral corticosteroids alone.

Factors associated with seat belt use: an evaluation from the Ontario Health Survey.

This study examines the factors associated with seat belt use for drivers and passengers in Ontario. Using the 1990 Ontario Health Survey, a population-based survey of non-institutionalized Ontario residents, factors associated with seat belt use among drivers and passengers were identified and are reported as unadjusted and adjusted odds ratios (OR; 95% CI). Seat belt non-use in Ontario drivers was most strongly associated with younger age (p < 0.0001), high risk health behaviours (drinking and driving (OR: 2.43), speeding (OR: 2.04), smoking (OR: 1.66)), being male (OR: 1.87), living in northern (OR: 1.80) or rural (OR: 1.69) regions, and achieving lower education (OR: 1.46). Seat belt non-use in passengers was associated with younger age (p < 0.0001), smoking (OR: 1.62), being male (OR: 1.68), living in northern (OR: 1.63) or rural (OR: 1.46) regions, and low education (OR: 1.31). Vehicular trauma is a major public health problem and seat belt use has been shown to reduce injuries in the event of a crash. Any strategy to increase seat belt use in Ontario should be targeted to involve both drivers and passengers. Attention should be paid to increasing seat belt usage by younger adults, males, and especially those living in northern and rural regions.

The effect of a community-based police surveillance program on snowmobile injuries and deaths.

Serious snowmobile injuries are preventable and associated with late-night travel, alcohol use, and speed. We studied the effectiveness of a community-based policing (STOP) program in the prevention of serious injuries related to snowmobile trauma in Sudbury, Ontario. Volunteers were trained in police protocol and were appointed special constables to increase policing on snowmobile trails from 1993-95. Snowmobile admissions and deaths in Sudbury were examined; the pre- (1990-1992) and post- (1993-1995) STOP seasons were compared. In the pre-STOP period, 102 injuries, 87 admissions, and 15 deaths occurred compared to 57 injuries (p = 0.0004), 53 admissions (p = 0.00001) and 4 deaths (p = 0.13) in the post-STOP period. All other event and demographic features of the crashes remained similar. Significant economic savings were realized from this intervention; acute care costs savings exceeded $70,000/year and costs from death decreased by $5 million. An intervention involving enforcement on snowmobile trails can reduce the incidence of injuries from snowmobile-related trauma.

Outcomes after severe trauma at a northern Canadian regional trauma centre.

OBJECTIVE: To evaluate outcomes of trauma patients at a northern community trauma referral centre that does not meet several of the guidelines for a trauma centre. DESIGN: A retrospective study. SETTING: Sudbury General Hospital in northern Ontario. PARTICIPANTS: All trauma patients admitted between 1991 and 1994 who had an Injury Severity Score (ISS) greater than 12. OUTCOME MEASURES: Actual survival to discharge was compared to survival predicted by TRISS analysis. Z, W and M scores were calculated by standard TRISS techniques. RESULTS: Of 526 patients with an ISS greater than 12, 416 (79%) were suitable for TRISS analysis. Of these 416 patients, 310 (74%) were men. The mean age was 39 years. Two hundred and sixty-one (63%) patients were admitted directly to the Sudbury General Hospital, whereas 155 (37%) were transferred from other hospitals. The leading causes of injury were motor vehicle-traffic accidents in 48%, motor vehicle-nontraffic in 21% and falls in 8%. Overall, there were more unexpected survivors than patients who died. The Z score for survivors was 4.95, and the W score was 5.65. CONCLUSIONS: In the setting of a geographically isolated, medium-volume trauma centre where blunt injuries predominate, excellent trauma survival can be achieved without meeting all trauma centre guidelines for staffing and facilities. Relaxing stringent requirements for the availability of physicians may facilitate surgical recruitment and retention.

Head, neck, and facial injuries in ice hockey: the effect of protective equipment.

OBJECTIVES: To determine the factors and behaviors associated with facial, head, and/or neck injuries to those engaged in ice hockey; the use of protective equipment was also examined. DESIGN: Prospective case series. SETTING: Emergency Department of Sudbury General Hospital. PATIENTS: All patients presenting to the emergency department with a head, neck, or facial injury while playing hockey between the months of October and March 1993-94 and 1994-95 were included in the study. Physicians completed data forms on each patient. Information was validated by review of the emergency-room records; further information was obtained by telephone. RESULTS: A total of 226 patients were identified with ice-hockey-related head, neck, or facial injuries. Most injuries involved males (99%), and the mean age of patients was 23.9 (range, 4-63). Injuries occurred most frequently to the face [192 (85%)]. Many of the injuries were minor, with a mean injury severity score of 1.5 (range, 1-25). However, three patients (1%) required hospital admission, and one teenager suffered a serious spinal fracture. Protective facial hockey equipment use was low in our sample, except among younger injured players. Most of the facial injuries occurred in mature athletes playing recreational hockey. Full facial protection reduced the chance of upper facial injury (p = 0.0001), but the risk of such injury while wearing a half-visor was the same as while wearing no facial protection at all (p > 0.05). From the current study, we estimate that these hockey injuries result in approximately 2.7-3.0 million dollars of direct acute-care medical expenditure per year in emergency departments throughout Ontario. CONCLUSIONS: Head, neck, and facial injuries suffered during ice hockey participation are common problems presented to emergency departments. Moreover, serious injuries can occur while playing this sport. Most injuries appear to be preventable, and facial protection appears to be less frequently used, especially by older men, than is currently recommended. Prevention strategies are discussed.

A truncated E-code system for injury surveillance in the emergency department: description and clinometric testing.

OBJECTIVES: ED injury surveillance requires accurate information about mechanism. This study explored the clinometric properties of an E-code system specifically designed to track ED injuries. METHODS: All patients assessed in the ED had cause-of-injury information documented using a truncated E-code system. Patient records were hand-searched to determine coding compliance. A selection of 98 charts (50 injury/48 noninjury) were coded by 7 physicians, 2 nurses, and 2 nosologists. Agreements (interrater and intrarater) on the diagnosis of trauma and exact E-codes were determined (using kappa; kappa). RESULTS: E-coding compliance was high (overall 90%: 95% CI: 85-93%), and accuracy of injury classification was 99%. Compared with an expert's coding, agreement on injury classification was excellent for physicians (kappa = 0.91; 95% CI: 0.80-1.0), nurses (kappa = 0.88; 95% CI: 0.75-1.0), and nosologists (kappa = 0.92; 95% CI: 0.81-1.0). Agreement was substantial for the exact E-codes between physicians (kappa = 0.77; 95% CI: 0.60-0.94) and nurses (kappa = 0.72; 95% CI: 0.54-0.90). Recode reliability was also excellent for physicians (kappa = 0.88; 95% CI: 0.75-1.0) and nurses (kappa = 0.96; 95% CI: 0.88-1.0). CONCLUSIONS: Injury coding using a truncated E-code system can provide valid and reliable data from the ED. Differences between nurses, physicians, and nosologists in the ability to accurately code using this system were minimal, thus eliminating the need for additional staff and resources.

Life-threatening luminal obstruction due to mucous plugging in chronic tracheostomies: three case reports and a review of the literature.

Tracheotomy is a common treatment option for a number of acute and chronic medical conditions. Emergency personnel may be required to deal with one or more of the complications associated with tracheostomy tubes. One of the more common, and potentially serious, problems involves luminal obstruction. These case reports describe three patients with luminal obstruction of long standing tracheostomy tubes. We propose that emergency medical personnel must act swiftly to eliminate the possibility of respiratory difficulties due to the result of tracheostomy tube obstruction. Prompt removal of the tracheostomy tube in cases of subtotal and total obstruction may prevent rapid deterioration or cardiopulmonary arrest.

Regional variations of northern health: the epidemic of fatal trauma in northeastern Ontario.

OBJECTIVE: To examine the causes of traumatic death in a northern region of Ontario. METHODS: Prevalence study of trauma deaths occurring within the region of Northeastern Ontario over the years 1989-1991; regional data were compared with provincial data. RESULTS: 1,027 patient records were identified over the study period (51.4 deaths per 100,000 population/year). Non-intentional trauma accounted for 70% of all trauma deaths in the region; suicide (25%; 12.8/100,000) and homicide (5%; 2.4/100,000) were less common. Motorized vehicle trauma accounted for most of the non-intentional traumatic death (39%; 20.4/100,000). Age-standardized mortality ratios were 67% above the provincial average for non-intentional trauma, 71% above the provincial average for suicides, 55% above the provincial average for homicides, and 68% higher for all forms of traumatic death. CONCLUSIONS: Traumatic death is a major health problem in northern areas; reduction of these rates depends on the development of an effective injury prevention strategy.

Continuous monitoring of oxygen saturation in prehospital patients with severe illness: the problem of unrecognized hypoxemia.

The continuous measurement of arterial oxygen saturation using pulse oximetry (SpO2) has become popular for critically ill hospitalized patients. Its use in the ambulance transfer of similarly ill patients has been infrequently documented. This study examines the use of prehospital pulse oximetry, with special reference to the ability of ambulance attendants to recognize hypoxemia. Using a prospective single-blind case series method, a convenience sample of adult patients transferred by ambulance designated Code 3 (serious but not life threatening) or Code 4 (serious and life threatening) to a regional base hospital were examined for the presence of hypoxemia. An Ohmeda finger pulse oximeter probe was attached to all patients. Prior to the study, oxygen treatment was reviewed and ambulance personnel were instructed on the use of the instrument. The continuous oxygen saturation record was not revealed to the attendant(s) during the cell. Administration of oxygen was monitored, and a study form was completed by the attendant at the completion of the call. Overall, 50 patients were included in the study. The most common complaints were chest pain 21 (37%) and shortness of breath 15 (27%). The average age was 64 years, with a range of 32-82. Hypoxemia, defined as SpO2 of less than 90% for more than 1 minute, was detected in 14 patients. Attendants recognized hypoxemia on clinical grounds in only 4 patients (sensitivity = 28%). Forty-one (82%) patients received various amounts of supplemental oxygen; many patients remained hypoxemic despite therapy.(ABSTRACT TRUNCATED AT 250 WORDS)

Bicycle helmet use and compliance: a northeastern Ontario roadside survey.

OBJECTIVE: To determine the prevalence of helmet use, compliance with helmet-wearing recommendations and attitudes to bicycle helmet legislation in a northern Ontario community. DESIGN: Prospective roadside survey of pedal cyclists. PARTICIPANTS: Cyclists riding in the city of Sudbury completed a survey and trained interviewers examined helmet fit. RESULTS: Of 1134 cyclists encountered at 28 locations; 472 (42%) completed surveys. Males predominated and the mean age was 19.7 years. Overall, helmet use was 20% but helmet ownership was higher (32%). Only 49% of helmets were worn correctly. Support for legislation for those under the age of 16 (81%) and for all ages (57%) was high. CONCLUSIONS: Helmet use in this community is low; one third of helmet owners were found not to be using helmets regularly. Efficacy was reduced by nonadherence to helmet-wearing standards. Education aimed at correcting these findings should be included in safety campaigns.

Bicyclist and environmental factors associated with fatal bicycle-related trauma in Ontario.

OBJECTIVE: To identify bicyclist and environmental factors associated with fatal bicycle-related trauma in Ontario. DESIGN: Retrospective study. SETTING: Ontario. PARTICIPANTS: Information was extracted from the provincial coroner's reports on 212 people who had died of bicycle-related injuries in Ontario between 1986 and 1991. OUTCOME MEASURES: Age, sex and helmet use of the bicyclist, time and place of the event, type of bicyclist or motorist error(s) and use of alcohol by bicyclist or motorist. RESULTS: Only 32% of the deaths involved bicyclists under 15 years of age. The male-female ratio was 3.5. Over 75% of the cases involved head injury; however, only 8 (4%) of the bicyclists had been wearing a helmet. In 91% of the cases death occurred as the result of a bicycle-motor vehicle collision. Most (65%) of the deaths for which the time was known occurred between 4 pm and 8 am. Bicyclist error was the main cause of crash for 26 (79%) of the children less than 10 years old; it was also the main cause of crash among the bicyclists aged 10 to 19 years (43 [55%]) and those aged 45 years or more (15 [44%]). However, motorist error was the most common cause of collision in the group of cyclists 20 to 44 years of age (42 [63%]). Alcohol was detected in the blood of 7% of the bicyclists killed; alcohol had been consumed by 30% of the motorists who claimed not to have seen the cyclist. CONCLUSIONS: Bicycle-related deaths result from factors that are generally avoidable. Identifiable risk factors other than lack of helmet use suggest that additional research is required to determine the benefits of preventive interventions aimed at reducing the number of such deaths. Age-specific strategies appear warranted.

Sledding trauma in a northeastern Ontario community.

GOALS AND OBJECTIVES: To determine the incidence of sledding trauma in a northeastern Ontario community. Factors and behaviors associated with these events were also examined. DESIGN: Prospective case series. SETTING: Emergency departments of the Sudbury General and Memorial Hospitals. PATIENTS: All patients arriving at the two emergency departments in Sudbury with an injury sustained while sledding were included in the study. Physicians completed data forms on each patient. Information was validated by review of the ER records. Follow-up was completed by telephone in one to two weeks to determine residual disability. RESULTS: A total of 101 patients were identified with sledding-related injuries. There was a higher incidence of injuries among males (59%); the mean age of injured patients was 16 years (range, 16-46 years). Injuries occurred most frequently on weekends (51%). GT-racers were the most common device used by injured sledders (44%). Most injuries occurred on non-designated sledding hills in the community (71%). Many of the injuries were mild with a mean Injury Severity Score of 2.3 (range, 1-16). However, 7 (7%) patients required hospital admission, while 58% required follow-up by either their family physician or a specialist. Patients injured while sledding missed an average of 3.7 days of work or school. CONCLUSIONS: Sledding injuries are uncommon emergency department problems in this community; however, serious injury and absenteeism from work or school may result. Most injuries appear to be preventable and strategies of prevention are discussed.