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To compare post-concussion symptoms in patients who sustained a sports-related mild traumatic brain injury (TBI) to those with non-sports-related mild TBI at 7 and 90 days post-injury.This prospective multicentre cohort study took place in seven Canadian Emergency Departments (ED). Non-hospitalized patients aged ≥ 14 years with a documented mild TBI that occurred ≤ 24 h of ED visit and a Glasgow Coma Scale score ≥ 13 were included. Main outcome measure was the presence of ≥ 3 symptoms on the Rivermead Post-concussion Questionnaire at 90 days post-injury. Secondary outcomes were the prevalence of (1) individual Rivermead Post-concussion Questionnaire symptom, (2) total Rivermead Post-concussion Questionnaire score ≥ 21 and (3) return to normal daily activities. Adjusted risk ratios (RR) were calculated.1727 patients were included, 363 (21.0%) sustained a sports-related mild TBI. Similar proportions of patients with ≥ 3 symptoms, a Rivermead Post-concussion Questionnaire score ≥ 21 and those who returned to their normal daily activities were observed at 7 and 90 days post-injury. Sports-related mild TBI patients were at higher risk of poor concentration [RR: 1.3 (95% CI 1.05-1.54)] and non-return to sports activities [RR: 2.2 (95% CI 1.69-2.94)] at 7 days post-injury. At 90 days, sports-relate -mild TBI patients reported less fatigue [RR: 0.7 (95% CI 0.51-0.98)] and feeling of dizziness [RR: 0.6 (95% CI 0.35-0.99)].Patients who sustained sports-related mild TBI could be at lower risk of experiencing symptoms such as fatigue and dizziness 90 days post-injury. Clinicians should be mindful that non-sports-related mild TBI patients may experience more post-concussion symptoms and that the level of physical activity may influence the patient's rehabilitation.RéSUMé: OBJECTIFS: Comparer les symptômes post-commotionnels chez les patients ayant subi un traumatisme cranio-cérébral léger (TCCL) lié au sport à ceux qui ont un TCCL non lié au sport à 7 et 90 jours post-traumatisme. MéTHODES: Cette étude prospective de cohorte multicentrique s'est déroulée dans sept Départements d’urgence (DU) du Canada. Les patients non hospitalisés âgés de ≥ 14 ans ayant subi un TCCL ≤ 24 heures avant leur visite au DU et présentant un score de Glasgow de ≥ 13 ont été inclus. Le critère principal de jugement était la présence d’au moins 3 symptômes au Rivermead Post-concussion Questionnaire 90 jours après le traumatisme. Les critères de jugement secondaires étaient la prévalence de 1) chacun des symptômes du Rivermead Post-concussion Questionnaire 2) score total du Rivermead Post-concussion Questionnaire ≥ 21 et 3) retour aux activités habituelles. Des risques relatifs ajustés (RR) ont été calculés. RéSULTATS: Un total de 1727 patients a été inclu, dont 363 (21,0 %) ont subi un TCCL lié au sport. Des proportions similaires de patients présentant ≥ 3 symptômes, un score ≥ 21 au Rivermead Post-concussion Questionnaire et de participants ayant repris leurs activités habituelles ont été observés à 7 et 90 jours après la blessure. Les patients avec TCCL lié au sport présentaient un risque plus élevé de manque de concentration (RR: 1,3 [IC à 95 % = 1,05-1,54]) et de non-retour aux activités sportives (RR: 2,2 [IC à 95 % = 1,69-2,94]) à 7 jours après la blessure. À 90 jours, les patients avec TCCL lié au sport ont signalé moins de fatigue (RR: 0,7 [IC à 95 % = 0,51-0,98]) et de sensation de vertige (RR: 0,6 [IC à 95 % = 0,35-0,99]). CONCLUSION: Les patients qui ont subi un TCCL lié au sport seraient moins à risque de présenter des symptômes tels que de la fatigue et des étourdissements 90 jours après la blessure. Les cliniciens doivent être conscients que les patients avec TCCL non lié au sport peuvent présenter davantage de symptômes post-commotionnels et que le niveau d’activité physique peut influencer la réadaptation du patient.

ObjectivePatient sleep quality has a significant impact on recovery. However, most hospital units do not provide an optimal environment for sleep and there are currently no data available on how well patients sleep during their emergency department stay. The main objective of this study was to assess the subjective quality of nighttime sleep and factors that affect sleep in the emergency department (ED).MethodsA prospective sample of patients aged 18 years and older who presented to the ED from July 2015 to October 2015 was investigated. All participants were on stretcher and slept at least one night in the ED. Participants were asked to complete a sleep questionnaire adapted to the ED environment on sleep quality and its potentially modifying factors.ResultsA total of 235 patients participated in the study (mean age: 64±20 years, 51% women). Compared to the week at home prior to admission, subjective sleep quality was lower in the ED (pConclusionsSubjective sleep quality in the emergency department is not optimal, and is influenced by stress, noise, pain, and stretcher comfort, all potentially modifiable factors.

ObjectiveThe management of acute pain constitutes an essential skill of emergency department (ED) physicians. However, the accurate assessment of pain intensity and relief represents a clinically challenging undertaking. Some studies have proposed to define effective pain relief as the patient’s refusal for additional analgesic administration. The aim of this study was to verify whether such a refusal is effectively indicative of pain relief.MethodsThis prospective cohort study included ED patients who received single or multiple doses of pain medication for an acute pain problem. Patients were evaluated for pain relief using one Likert scale and two dichotomous questions: Is your pain relieved? and Do you want more analgesics? Non-relieved patients were further analysed using a checklist as to the reasons behind their refusal for supplemental pain medication.ResultsWe have recruited 378 adult patients with a mean age of 50.3 years (±19.1); 60% were women and had an initial mean pain level of 7.3 (±2.0) out of 10. We observed that 68 out of 244 patients who were adequately relieved from pain asked for more analgesics (28%), whereas 51 out of 134 patients who were not relieved from pain refused supplemental drugs (38%). Reasons for refusal included wanting to avoid side effects, feeling sufficiently relieved, and disliking the medication’s effects.ConclusionOver a third of ED patients in acute pain were not relieved but refused supplemental pain medication. Patients have reported legitimate reasons to decline further analgesics, and this refusal cannot be used as an indication of pain relief.

Introduction: Patients hospitalized following a trauma will be frequently treated with opioids during their stay and after discharge. We examined the relationship between acute phase (< 3 months) opioid use after discharge and the risk of opioid poisoning (OP) or opioid use disorder (OUD) in older trauma patients Methods: In a retrospective multicenter cohort study conducted on registry data, we included all patients aged 65 years and older admitted (hospital stay >2 days) for injury in 57 trauma centers in the province of Quebec (Canada) between 2004 and 2014. We searched for OP and OUD from ICD-9 and ICD-10 code diagnosis that resulted in a hospitalization or a medical consultation after their initial injury. Patients that filled an opioid prescription within a 3-month period after sustaining the trauma were compared to those who did not fill an opioid prescription during that period using Cox proportional hazards regressions. Results: A total of 70,314 participants were retained for analysis; median age was 82 years (IQR: 75-87), 68% were women, and 34% of the patients filled an opioid prescription within 3-months of the initial trauma. During a median follow-up of 2.6 years (IQR: 1-5), 192 participants (0.30%; 95%CI: 0.25%-0.35%) were hospitalized for OP and 73 (0.10%; 95%CI: 0.07%-0.13%) were diagnosed with OUD. Having filled an opioid prescription within 3-months of injury was associated with an increased hazard ratio of OP (2.6; 95%CI: 1.9-3.5) and OUD (4.0; 95%CI: 2.3-7.0). However, history of OP (2.7; 95%CI: 1.2-6.1), of substance use disorder (4.3; 95%CI: 2.4-7.9), or of opioid prescription filled (2.7; 95%CI: 2.1-3.5) before trauma were also related to OP or OUD. Conclusion: Opioid poisoning and opioid use disorder are rare events after hospitalization for trauma in older patients. However, opioids should be used cautiously in patients with history of substance use disorder, opioid poisoning or opioid use during the past year.

Introduction: The Brain Injury Guidelines (BIG) stratifies complicated mild traumatic brain injury (mTBI) patients into 3 groups to guide hospitalization, neurosurgical consultation and repeat head-CT. BIG-1 patients could be managed safely without neurosurgical consultation or transfer. Systematic transfer to neurotrauma centers provide few benefits to this subgroup leading to overtriage. Similarly, unnecessary clinical and radiological follow-ups utilize significant health-care resources. Objective: to validate the safety and efficacy of the BIG for complicated mTBIs. Methods: We performed a multicenter historical cohort study in 3 level-1 trauma centers in Quebec. Patients ≥16 years old assessed in the Emergency Department (ED) with complicated mTBI between 2014 and 2017 were included. Patients with penetrating trauma, cerebral aneurysm or tumor were excluded. Clinical, demographic and radiological data, BIG variables, TBI-related death and neurosurgical intervention were collected using a standardized form. A second reviewer assessed all ambiguous files. Descriptive statistics, over- and under-triage were calculated. Results: A total of 342 patients’ records were assessed. Mean age was 63 ± 20,7 and 236 (69 %) were male. Thirty-five patients were classified under BIG-1 (10.2%), 110 under BIG-2 (32.2%) and 197 under BIG-3 (57.6%). Twenty-six patients (7%) required neurosurgical intervention, all were BIG-3. 90% of TBI-related deaths occurred in BIG-3 and none were classified BIG-1. Among the 192 transfers (51%), 14 were classified under BIG-1 (7.3%) and should not have been transferred according to the guidelines and 50 under BIG-2 (26%). In addition, 40% of BIG-1 received a repeat head computed tomography, although not indicated. Similarly, 7 % of all patients had a neurosurgical consult even if not required. Projected implementation of BIG would lead to 47% of overtriage and 0.3% of undertriage. Conclusion: Our results suggest that the Brain Injury Guidelines could safely identify patients with negative outcomes and could lead to a safe and effective management of complicated mTBI. Applying these guidelines to our cohort could have resulted in significantly fewer repeat head CTs, neurosurgical consults and transfers to level 1 neurotrauma centers.

Introduction: Malgré les progrès au niveau des soins de réanimation lors des dernières années, le pronostic des patients souffrant d'un arrêt cardiorespiratoire (ACR) demeure abyssal et aucun médicament ne semble influencer leur devenir au long cours. Cependant, les résultats de quelques études évaluant l'impact des bêtabloqueurs chez cette population s'avèrent cependant très encourageants. L'objectif de cette revue systématique, est d’évaluer l’évidence disponible quant à l'impact des bêtabloqueurs sur le devenir des patients traités pour un ACR dont le rythme initial est défibrillable. Methods: La présente revue systématique a été préalablement enregistrée sur Prospero (CRD42018105453). Les moteurs de recherche Medline, Embase et CENTRAL ont été fouillés de leur création jusqu'au 17 octobre 2018. La recherche de littérature grise s'est faite via Web of Science et Google Scholar. Les références de tous les articles inclus ainsi que des méta-analyses existantes sur le sujet ont également été révisées. Tous les types de devis ont été considérés, sauf les études de cas et les séries de cas. Les études devaient inclure des adultes (16 ans et plus) en ACR dont le rythme initial était défibrillable, dont une partie avait reçu un médicament bêtabloquants par voie intraveineuse pendant leur ACR et l'autre un traitement standard, et présenter une mesure de résultat centrée sur le patient (retour de circulation spontanée [RCS], survie ou bon devenir neurologique). La qualité des articles a été évaluée à l'aide du ‘Newcastle Ottawa scale’. Results: Deux études observationnelles rétrospectives, menées auprès d'un total de 66 patients, ont été incluses. Il y avait une association positive entre l'administration de bêtabloquants et l'occurrence d'un RCS (rapport de cotes [RC] = 5.76 [intervalle de confiance {IC} à 95% = 1.79-18.52], p = 0.003), ainsi qu'avec la présence d'un bon devenir neurologique (RC = 4.42 [IC95% = 1.05 - 18.56], p = 0.04). Une telle association n'a cependant pas été observée par rapport à la survie au congé hospitalier. Conclusion: L'administration de bêtabloquants semble associé à un meilleur devenir chez les patients en ACR avec un rythme initial défibrillable. Étant donné la nature du devis de ces études et leur petite taille, une étude prospective de qualité serait nécessaire afin de déterminer l'efficacité de cette classe de médicament et de faire une recommandation forte à ce sujet.

Introduction: Each year, 3/1000 Canadians sustain a mild traumatic brain injury (mTBI). Many of those mTBI are accompanied by various co-injuries such as dislocations, sprains, fractures or internal injuries. A number of those patients, with or without co-injuries will suffer from persistent post-concussive symptoms (PPCS) more than 90 days post injury. However, little is known about the impact of co-injuries on mTBI outcome. This study aims to describe the impact of co-injuries on PPCS and on patient return to normal activities. Methods: This multicenter prospective cohort study took place in seven large Canadian Emergency Departments (ED). Inclusion criteria: patients aged ≥ 14 who had a documented mTBI that occurred within 24 hours of ED visit, with a Glasgow Coma Scale score of 13-15. Patients who were admitted following their ED visit or unable to consent were excluded. Clinical and sociodemographic information was collected during the initial ED visit. A research nurse then conducted three follow-up phone interviews at 7, 30 and 90 days post-injury, in which they assessed symptom evolution using the validated Rivermead Post-concussion Symptoms Questionnaire (RPQ). Adjusted risk ratios (RR) were calculated to estimate the influence of co-injuries. Results: A total of 1674 patients were included, of which 1023 (61.1%) had at least one co-injury. At 90 days, patients with co-injuries seemed to be at higher risk of having 3 symptoms ≥2 points according to the RPQ (RR: 1.28 95% CI 1.02-1.61) and of experiencing the following symptoms: dizziness (RR: 1.50 95% CI 1.03-2.20), fatigue (RR: 1.35 95% CI 1.05-1.74), headaches (RR: 1.53 95% CI 1.10-2.13), taking longer to think (RR: 1.50 95% CI 1.07-2.11) and feeling frustrated (RR: 1.45 95% CI 1.01-2.07). We also observed that patients with co-injuries were at higher risk of non-return to their normal activities (RR: 2.31 95% CI 1.37-3.90). Conclusion: Patients with co-injuries could be at higher risk of suffering from specific symptoms at 90 days post-injury and to be unable to return to normal activities 90 days post-injury. A better understanding of the impact of co-injuries on mTBI could improve patient management. However, further research is needed to determine if the differences shown in this study are due to the impact of co-injuries on mTBI recovery or to the co-injuries themselves.

ObjectivesPatients suffering from an out-of-hospital cardiac arrest (OHCA) associated with an initial shockable rhythm have a better prognosis than their counterparts. The implications of recurrent or refractory malignant arrhythmia in such context remain unclear. The objective of this study is to evaluate the association between the number of prehospital shocks delivered and survival to hospital discharge among patients in OHCA.MethodsThis cohort study included adult patients with an initial shockable rhythm over a 5-year period from a registry of OHCA in Montreal, Canada. The relationship between the number of prehospital shocks delivered and survival to discharge was described using dynamic probabilities. The association between the number of prehospital shocks delivered and survival to discharge was assessed using multivariable logistic regression.ResultsA total of 1,788 patients (78% male with a mean age of 64 years) were included in this analysis, of whom 536 (30%) received treatments from an advanced care paramedic. A third of the cohort (583 patients, 33%) survived to hospital discharge. The probability of survival was highest with the first shock (33% [95% confidence interval 30%-35%]), but decreased to 8% (95% confidence interval 4%-13%) following nine shocks. A higher number of prehospital shocks was independently associated with lower odds of survival (adjusted odds ratio=0.88 [95% confidence interval 0.85-0.92], p < 0.001).ConclusionSurvival remains possible even after a high number of shocks for patients suffering from an OHCA with an initial shockable rhythm. However, requiring more shocks is independently associated with worse survival.

Introduction: Les patients ayant un retour de circulation spontanée (RCS) durant la phase préhospitalière de leur réanimation suite à un arrêt cardiaque extrahospitalier (ACEH) ont un meilleur taux de survie que ceux n'en ayant pas. La durée des efforts de réanimation avant l'initiation d'un transport ne varie généralement pas en fonction du rythme initial observé. Cette étude vise à comparer la durée des manœuvres de réanimation nécessaire afin de générer la majorité des RCS préhospitaliers et des RCS préhospitaliers menant à une survie en fonction du rythme initial. Methods: La présente étude de cohorte a été réalisée à partir des bases de données collectées de la Corporation d'Urgences-santé dans la région de Montréal entre 2010 et 2015. Les patients avec un ACEH d'origine médicale ont été inclus. Les patients dont l'ACEH était témoigné par les paramédics ont été exclus, tout comme ceux dont le rythme initial était inconnu. Nous avons comparé entre les groupes (rythme défibrillable [RD], activité électrique sans pouls [AESP] et asystolie) les taux de RCS préhospitalier et le temps nécessaires pour obtenir une majorité des RCS préhospitaliers et des RCS préhospitaliers menant à une survie. Results: Un total de 6002 patients (3851 hommes et 2151 femmes) d'un âge moyen de 52 ans ( ±10) ont été inclus dans l’étude, parmi lesquels 563 (9%) ont survécu jusqu’à leur congé hospitalier et 1310 (22%) ont obtenu un RCS préhospitalier. Un total de 1545 (26%) patients avaient un RD, 1654 (28%) une AESP et 2803 (47%) une asystolie. Les patients avec un RD ont obtenu plus fréquemment un RCS préhospitalier et un RCS préhospitalier menant à une survie que les patients avec une AESP qui eux même avaient un meilleur pronostic que ceux avec une asystolie initial (777 patients [55%] vs 385 [23%] vs 148 [5%], p < 0,001; 431 [28%] vs 85 [5%] vs 7 [0,2%], p < 0,001, respectivement). Les RCS survenaient également plus rapidement lorsque le rythme initial était un RD (13 minutes [ ±12] vs 18 [ ±13] vs 25 [ ±12], p < 0,001). Cependant, une période de réanimation plus longue était nécessaire afin d'obtenir 95% des RCS préhospitaliers menant à une survie pour les patients avec un RD (26 minutes vs 21 minutes vs 21 minutes). Conclusion: Les patients avec un rythme initial défibrillable suite à leur ACEH sont à meilleur pronostic. Il serait envisageable de transporter plus rapidement vers l'hôpital les patients avec une AESP ou une asystolie que ceux avec un rythme défibrillable si l'arrêt des manœuvres n'est pas envisagé.

Introduction: Les patients dont l'arrêt cardiaque extrahospitalier (ACEH) n'a pas été témoigné sont généralement exclus des protocoles de réanimation par circulation extracorporelle puisque le délai avant l'initiation de leur réanimation est inconnu. Il a été proposé que la présence d'un rythme initial défibrillable (RD) est fortement suggestif une très courte période avant l'initiation des manœuvres de réanimation. La présente étude vise à décrire l'association entre la durée avant l'initiation de la réanimation et la présence d'un RD chez des patients souffrant d'un ACEH. Methods: Cette étude de cohorte a été réalisée à partir des bases de données collectées de la Corporation d'Urgences-santé dans la région de Montréal entre 2010 et 2015. Les patients dont l'arrêt était témoigné, mais dont les témoins n'ont pas entamé de manœuvres de réanimation, ont été inclus. Nous avons également inclus les patients dont l'arrêt était témoigné par les paramédics comme groupe contrôle (durée avant l'initiation de la réanimation = 0 minute). Les patients avec un retour de circulation spontanée avant l'arrivée des services préhospitaliers ont été exclus, tout comme ceux dont le rythme initial était inconnu. Nous avons décrit l’évolution de la proportion de chacun des rythmes et construit une régression logistique multivariée ajustant pour les variables sociodémographiques et cliniques pertinentes. Results: Un total de 1751 patients (1173 hommes et 578 femmes) d'un âge moyen de 69 ans (±16) ont été inclus dans l'analyse principale, parmi lesquels 603 (34%) avaient un RD. Un total de 663 autres patients ont vu leur ACEH témoigné directement par les paramédics. Un plus court délai avant l'initiation des manœuvres est associé à la présence d'un RD (rapport de cotes ajusté = 0,97 [intervalle de confiance à 95% 0,94-0,99], p = 0,016). Cependant, cette relation n'est pas linéaire et la proportion de RD ne diminue pas avant notablement jusqu’à ce que 15 minutes s’écoulent avant le début de la réanimation (0 min = 35%, 1-5 min = 37%, 5-10 min = 35%, 10-15 min = 34%, +de 15 min = 16%). Conclusion: Bien que la proportion de patients avec un RD diminue lorsque le délai augmente avant l'initiation des manœuvres, cette relation ne semble pas linéaire. La baisse principale de la proportion de patients avec RD semble se produire suite à la quinzième minute de délai avant le début de la réanimation.

Introduction: Mild traumatic brain injury (mTBI) with intracranial hemorrhage (ICH) is a common cause of Emergency Department (ED) visits. Over the past years, several authors have debated the relevance of radiological and clinical follow-up of these patients, as the main challenge is to identify patients at risk of clinical deterioration. Objectives: To determine whether demographic, clinical or radiological variables can predict patient deterioration. Methods: Design: An historical cohort was constituted in two level-1 trauma centers (Chu de Quebec - Hôpital de l'Enfant-Jésus (Québec City) and Hôpital du Sacré-Coeur (Montréal)). Participants: Medical records of mTBI patients aged ⩾16 with an ICH were reviewed using a standardized data collection tool. Consecutive medical records were reviewed from the end of 2017 backwards until sample saturation. Measures: Deterioration was defined as either death, deterioration of the control CT scan according to the radiologist, clinical deterioration or neurosurgical intervention. Analyses: Logistic regression analyses were performed to ascertain predictors of deterioration. Interobserver agreement was calculated. Results: A total of 274 patients were included in our analyses. Mean age was 60.8 and 68.9% (n = 188) were men. Four variables were found to be associated with all outcomes: radiological deterioration, clinical deterioration, death, and neurosurgical intervention. Diabetes (odds ratio (OR) = 2.6, 95% CI [0.97-6.94]), confusion as an initial symptom (OR = 2.8, 95% CI [1.42-5.61]), anticoagulation (OR = 2.8, 95% CI [1.01-7.84]) and significant subdural hemorrhage (≥4 mm) (OR = 3.4, 95% CI [1.42-5.61]) seen on the first computed tomography scan were strongly associated with these outcomes. Age had a neutral effect (OR = 1.01, 95% CI [0.99-1.03]) while high initial Glasgow Coma score seemed to have a protective effect (OR = 0.4, 95% CI [0.24-0.69]). Radiological deterioration was not systematically associated with clinical deterioration. As for the 46 patients with a deterioration of CT scan, only 30.4% vs. 69.5% without deterioration (p = 0.0035) showed a clinical deterioration. Conclusion: Diabetes, anticoagulation, significant subdural hemorrhage and confusion as an initial symptom seem to be predictors of deterioration following a mild traumatic brain injury with positive CT scan.

ObjectivesThis 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.MethodsWe 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.ResultsWe 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.ConclusionHealth care professionals cannot use vital signs to estimate or substantiate self-reported pain intensity levels or changes over time.

Introduction: Le syndrome aortique aigu (SAA) est une condition rare et généralement mortelle qui demeure difficile à diagnostiquer. Le Score de détection de la dissection aortique (DDA) et le ratio de neutrophiles sur lymphocytes (NL) ont été proposés comme des éléments pouvant contribuer à exclure le diagnostic du SAA. Lobjectif primaire de cette étude est de déterminer la valeur diagnostique (sensibilité et spécificité et rapport de vraisemblance négatif [RV-]) de ces deux éléments de façon indépendante et combinée chez les patients suspectés de SAA au département durgence. Methods: Les patients ayant subi une angiographie par tomodensitométrie (angioCT) à la recherche dune dissection aortique entre 2008 et 2014 à lurgence dun hôpital tertiaire montréalais ont été inclus dans cette étude de cohorte rétrospective. Le score DDA a été établi à partir des dossiers médicaux et le ratio NL calculé à partir de la première formule sanguine prélevée chez ces patients. Pour le score DDA, un score de 1 ou plus et de 2 ou plus ont été évalués comme seuils de positivité. Pour le ratio NL, une valeur de plus de 4,6 a été choisie comme seuil puisquil sagissait du ratio proposé afin de différencier les patients atteints dun SAA de ceux souffrant dun anévrysme chronique. Pour lévaluation de la combinaison des deux tests, afin de maximiser la sensibilité, un score DAA de 1 ou plus ou un ratio NL de plus de 4,6 serait considéré comme positif. Le test de référence pour tous les patients était langiographie par tomodensitométrie. À partir de cela, la sensibilité, la spécificité et le rapport de vraisemblance négatif de chacun de ces tests/combinaison de tests et leurs intervalles de confiance (IC) ont été calculés. Results: Un total de 198 patients (99 hommes et 99 femmes) dun âge moyen de 63 ans (±16) ont été inclus dans létude, parmi lesquels 26 (13%) souffraient dun SAA. Un score DDA de 1 ou plus avait une sensibilité de 84,6% (IC 95% 65,1-95,6), une spécificité de 65,7% (IC 95% 58,1-72,8) et un VR- de 0,23 (IC 95% 0,09-0,58). Un score DDA de 2 ou plus avait une sensibilité de 23,1% (IC 95% 9,0-43,7), une spécificité de 95,3% (IC 95% 91,0-98,0) et un VR- de 0,81 (IC 95% 0,65-1,00). La sensibilité dun ratio NL de plus de 4,6 était de 42,3% (IC 95% 23,4-63,1), la spécificité de 58,7% (IC 95% 51,0-66,3) et le VR- de 0,98 (0,69-1,40). La combinaison du score DDA et du ratio NL avait une sensibilité de 88,5% (IC 95% 69,9-97,6), une spécificité de 38,4% (IC 95% 30,9-46,0) et un VR- de 0,30 (IC 95% 0,10-0,89). Conclusion: Avoir un score de DDA inférieur à 1 diminue significativement les chances davoir un SAA, nélimine pas cette possibilité et ne devrait pas être utilisé, sauf chez les patients ayant une probabilité pré-test déjà très faible. Le ratio NL en utilisant un seuil de 4,6 na aucune utilité diagnostique pour le SAA.

Introduction: Overcrowding in emergency departments (EDs) is a constant problem. One of the major factors contributing to this situation is the inappropriate ED use by patients with low-acuity problems. In order to reduce overuse, EDs have developed agreements with clinics to reorient low-acuity ambulatory patients toward them. These agreements often leave the burden of decision on the triage personnel as to which patients can be safely redirected. The aim of this study was to evaluate the safety of redirecting patients to nearby medical clinics and to evaluate their satisfaction with this program. Methods: In the ED of a tertiary care facility, a computer-based algorithm allowing triage personnel to reorient patients presenting with one of 52 medical complaints, was implemented in 2016. Our prospective cohort study was composed of reorientation admissible ED patients between March 2017 and August 2017. Patient safety was evaluated with patient follow-up phone interviews one week after their visit to the ED to identify the number of patients who needed to return to a medical facility after their reorientation. Patient satisfaction with the reorientation program was evaluated during the same follow-ups. Results: Of the 980 reoriented patients interviewed, only 57 (5.9%; 95% confidence interval [CI] 4.57.5) had to unexpectedly go back to a health care facility. None of these returns were for severe complications. Over 84% of the reoriented patients were satisfied with their reorientation and 89% say they would use this program again. Having a transportation problem was most common reason mentioned by patients for refusing to be reoriented. Conclusion: Reorientation to medical clinics using a new computer-based algorithm was safe and no case of urgent return was seen during the 6-month study period. In addition, patients who were reoriented to medical clinics were satisfied by their treatment experience.

Introduction: Parmi les patients souffrant d'un arrêt cardiaque extrahospitalier (ACEH), ceux ayant un retour de circulation spontanée (RCS) durant la phase préhospitalière de leur réanimation ont un meilleur taux de survie. Il est plausible que les patients ayant un RCS plus précocement durant leur réanimation préhospitalière aient de meilleur taux de survie que les patients ayant un RCS plus tardif. Cette étude visait à décrire l'association entre la survie et la durée de la réanimation par les paramédics avant le RCS préhospitalier. Methods: La présente étude de cohorte a été réalisée à partir des bases de données collectées de la Corporation d'Urgences-santé dans la région de Montréal entre 2010 et 2015. Tous les patients adultes avec un RCS préhospitalier suite à un ACEH d'origine médicale ont été inclus. Les patients ayant eu un arrêt devant les paramédics ont été exclus, tout comme ceux avec un RCS avant l'arrivée des services préhospitaliers. L'association entre la survie et le temps de réanimation avant le RCS a été évaluée à l'aide d'une régression logistique multivariée ajustant pour les variables sociodémographiques et cliniques pertinentes (âge, sexe, rythme initial, heure de l'appel initial, arrêt témoigné, manœuvre par témoin, présence de premiers répondants ou de paramédics de soins avancés, délai avant l'arrivée des intervenants préhospitaliers). Results: Un total de 1194 patients (818 hommes et 376 femmes) d'un âge moyen de 64 ans ( ±17) ont été inclus dans l’étude, parmi lesquels 433 (36%) ont survécu jusqu’à leur congé hospitalier. Le délai moyen avant leur RCS était de 17 minutes ( ±12). Nous avons observé une association indépendante entre la survie au congé hospitalier et le délai avant le RCS préhospitalier (rapport de cotes ajusté = 0,91 [intervalle de confiance à 95% 0,89-0,92], p < 0,001). Plus de 50% des survivants avaient obtenu un RCS moins de 9 minutes après l'initiation des manœuvres de réanimation par les intervenants préhospitaliers, et plus de 95% avant 26 minutes. Aucun (0%) des 17 patients ayant eu un RCS plus de 56 minutes après l'initiation de la réanimation préhospitalière n'a survécu. Conclusion: Un RCS précoce semble être un facteur de bon pronostic parmi les patients souffrant d'un ACEH. La majorité des patients avec un RCS préhospitalier allant survivre à leur hospitalisation ont obtenus leur RCS dans les 9 minutes suivant l'initiation des manœuvres de réanimation.

Introduction: La réanimation par circulation extracorporelle (R-CEC) permet potentiellement d'améliorer la survie de patients souffrant d'un arrêt cardiaque extrahospitalier (ACEH) réfractaire aux traitements habituels. Cette technique, se pratiquant généralement en centre hospitalier (CH), doit être réalisée le plus précocement possible. Un transport vers le CH en temps opportun est donc nécessaire. Cette étude vise à décrire la durée nécessaire des manœuvres de réanimation préhospitalières afin d'optimiser le moment du départ vers le CH dans le but d'obtenir un maximum de retour de circulation spontanée (RCS) préhospitalier. Methods: La présente étude de cohorte a été réalisée à partir des bases de données collectées de la Corporation d'Urgences-santé dans la région de Montréal entre 2010 et 2015. Les patients éligibles à une R-CEC selon les critères locaux ont été inclus (Results: Un total de 236 patients (207 hommes et 29 femmes) d'un âge moyen de 52 ans (±10) ont été inclus dans l’étude, parmi lesquels 93 (39%) ont survécu jusqu’à leur congé hospitalier et 136 (58%) ont obtenu un RCS préhospitalier. Le délai moyen avant leur RCS était de 13 minutes (±10). Plus de 50% des survivants avaient eu un RCS moins de 8 minutes après l'initiation des manœuvres de réanimation par les intervenants préhospitaliers, et plus de 90% avant 24 minutes. Plus de 50% de tous les RCS survenaient dans les 10 premières minutes de réanimation et plus de 90% dans les 31 premières minutes. La courbe ROC montrait visuellement que le délai avant le RCS maximisant la sensibilité et la spécificité pour prédire la survie chez ces patients était à 22 minutes (Sensibilité = 90%, spécificité = 78%; aire sous la courbe = 0,89 [intervalle de confiance à 95% 0,84-0,93]). Conclusion: Le départ vers le CH pourrait être considéré pour ces patients entre 8 et 24 minutes après l'initiation des manœuvres. Une période de réanimation de 22 minutes semble être le meilleur compromis à cet égard.

Introduction: The radiological and clinical follow-up of patients with a mild traumatic brain injury (mTBI) and an intracranial hemorrhage (ICH) is often heterogeneous, as there is no official guideline for CT scan control. Furthermore, public sector health expenditure has increased significantly as the number of MRI and CT scan almost doubled in Canada in the last decade. Therefore, the main objective of this study was to describe the current management practices of mTBI patients with intracranial hemorrhage at two level-1 trauma centers. Methods: Design: An historical cohort was created at the CHU de Québec – Hôpital de l'Enfant-Jésus (Québec City) and Hôpital du Sacré-Coeur (Montréal). Consecutive medical records were reviewed from the end of 2017 backwards until sample saturation using a standardized checklist. Participants: mTBI patients aged ⩾16 with an ICH were included. Measures: The main and secondary outcomes were the presence of a control CT scan and neurosurgical consultation/admission. Analyses: Univariate descriptive analyses were performed. Inter-observer measures were calculated. Results: Two hundred seventy-four patients were included, of which 51.1% (n = 140) came from a transfer. Mean age was 60.8 and 68.9% (n = 188) were men. Repeat CT scan was performed in 73.6% (n = 201) of our patients as 12.5% showed a clinical deterioration. The following factors might have influenced clinician decision to proceed to a repeat scan: anticoagulation (association of 87.1% with scanning; n = 27), antiplatelet (84.1%; 58), GCS of 13 (94.1%; 16), GCS of 14 (75%; 72) and GCS of 15 (70.2%; 111). 93.0% (n = 254) of patients had a neurosurgical consultation and only 6.7% (17) underwent a neurosurgical intervention. Conclusion: The management of mild traumatic brain injury with hemorrhage uses a lot of resources that might be disproportionate with regards to risks. Further research to identify predictive factors of deterioration is needed.

ObjectiveThe aim of this study was to determine the incidence of delayed complications, specifically hemothorax, and functional outcome in patients with isolated sternal fracture discharged from the emergency department (ED) compared to patients with other minor thoracic trauma.MethodsThis prospective cohort study was conducted in four university-affiliated Canadian EDs. Patients ages 16 and older discharged from the ED with an isolated minor thoracic injury were included and categorized as isolated sternal fracture, rib fracture, or no fracture. A standardized clinical and radiological follow-up was performed at 7 and 14 days as well as a phone follow-up at 30 and 90 days post-injury. Functional outcome was determined using the Medical Outcome Short-Form Health Survey (SF-12).ResultsA total of 969 patients were included, of whom 32 (3.3%) had an isolated sternal fracture, 304 (31.3%) had rib fracture, and 633 (65.3%) had no fracture. Within 14 days, 112 patients presented with a delayed hemothorax: 12.5% of sternal fracture patients, 23% of rib fracture(s) patients, and 6% of minor thoracic injury patients without fracture (ppConclusionIn this prospective study, we found that 12.5% (n=4,p

Introduction: A 2008 survey found that 1.9% of the entire US population was using prescription pain medication non-medically and that 56% obtained them from a friend or relatives. Diversion of pain medication may occur when a portion of the prescription is unused for pain relief after an ED visit. We hypothesized that at least 10 pills (~40%) of an opioid prescription 2 weeks after an ED visit, will not be consumed and become available for potential misuse. Objective: Determine the quantity of unused opioids pills for common acute pain diagnoses, 2 weeks after an ED visit for acute pain. Methods: Prospective observational cohort study of consecutive ED patients from a tertiary academic urban hospital with 60,000 ED visits annually. Inclusion criteria: aged ≥18 years, acute pain conditions present ≤2 weeks, pain intensity at triage of ≥4 (on a 0-10 numeric rating scale; NRS), and discharged with a new opioid prescription. ED physicians identified (24/7) eligible patients. They recorded the pain complaint/location, the final diagnosis, the quantity and type of prescribed pain medication. Discharged patients completed paper or electronic 14-day diary (REDCap database) to document their pain medication consumption. As a mitigation strategy, they were also contacted by phone at 2 weeks for the same information. A paired t-test was used to test the difference between the amounts of opioids prescribed and consumed. Results: 350 patients were recruited. Mean age 50 (SD ±16) and 54.2% were men. Painful diagnosis: fracture (18.2%), acute back pain (15.3%), renal colic (15.3%), Sprain (excluding back/neck pain) (6.9%), Contusion (6.4%), acute neck pain (5.8%), abdominal pain (4.9%), and other (27.2%). Opioids prescribed: oxycodone (47%), morphine (37%) and hydromorphone (16%). Means quantity of opioid pills prescribed: 24 (IC95%: 23-26). Filled opioid prescription: 92%. Means quantity of opioid pills consumed: 8 (IC95%: 7-9). Means quantity of unused opioids pills: 16. Opioid pills available for misuse in our cohort: 5,600 pills. Conclusion: After an ED visit for acute pain a significant portion of opioids prescribed is unused and available for misuse. A large pragmatic study should be done to confirm that an opioid prescription strategy based on our results will limit unused opioid pills while maintaining pain relief.

Introduction: Les patients souffrant dun arrêt cardiaque extra hospitalier (ACEH) sont fréquemment traités à laide de soins avancés en réanimation cardiovasculaire (SARC). Dans ce contexte, des bicarbonates de sodium sont parfois administrés à des patients en arrêt cardiaque réfractaire chez qui une acidose métabolique importante, une hyperkaliémie ou une intoxication est suspectée. Puisquil ny a que peu dévidences quant à cet usage, lobjectif de la présente étude est dévaluer lassociation entre le traitement à laide de bicarbonate de sodium (une dose ou plus) et le devenir (retour de circulation spontané et survie au congé) chez les patients souffrant dun ACEH. Methods: La présente étude de cohorte a été réalisée à partir des bases de données de la Corporation dUrgences-santé dans la région de Montréal entre 2010 et 2015. Les patients adultes ayant souffert dun ACEH dorigine médicale traités en préhospitalier par des paramédics de soins avancés prodiguant des SARC ont été inclus. Les associations dintérêt ont été évaluées initialement à laide de régressions logistiques univariées, puis à laide de régressions logistiques multivariées ajustant pour les variables sociodémographiques et cliniques pertinentes. Results: Un total de 1973 patients (1349 hommes et 683 femmes) dun âge moyen de 66 ans (±17) ont été inclus dans cette étude, parmi lesquels 77 (3,8%) ont reçu une dose de bicarbonate, 763 (37,5%) ont retrouvés un pouls en préhospitalier et 222 (10,9%) ont survécu jusquà leur congé de lhôpital. Sans ajustement, il y avait une association négative entre le traitement à laide de bicarbonates et le retour de circulation spontané (rapport de cotes [RC]=0,46 [intervalle de confiance {IC} 95% 0,27-0,79], p=0,005) et la survie au congé (RC=0,21 [IC 95% 0,05-0,86], p=0,030). Cependant, ces associations nétaient plus significatives suite à lajustement pour les autres covariables (RC ajusté=0,63 [IC 95% 0,34-1,18], p=0,15 et RC ajusté=1,69 [95% IC 0,29-10,01], p=0,56). Conclusion: Il ny a pas dassociation indépendante entre le traitement à laide de bicarbonates et le devenir chez les patients souffrant dun ACEH. Dans ce contexte, il serait adéquat de réaliser un essai clinique afin de trancher définitivement sur cette question.

Introduction: Patients suffering from out-of-hospital cardiac arrest (OHCA) with an initial shockable rhythm (ventricular tachycardia or ventricular fibrillation) have higher odds of survival than those suffering from non-shockable rhythm (asystole or pulseless electrical activity). Because of that prognostic significance, patients with an initial non-shockable rhythm are often not considered for advanced resuscitation therapies such as extracorporeal resuscitation. However, the prognostic significance of the conversion to a shockable rhythm from an initially non-shockable rhythm remains uncertain. This study aimed to determine the degree of association between the conversion (or not) of a non-shockable rhythm to a shockable rhythm and resuscitation outcomes in patients with OHCA. It was hypothesized that such a conversion would be associated with a higher survival to discharge. Methods: The present study used a registry of adult OHCA between 2010 and 2015 in Montreal, Canada. Adult patients with non-traumatic OHCA and an initial non-shockable rhythm were included. The primary outcome measure was survival to hospital discharge, and the secondary outcome measure was prehospital return of spontaneous circulation (ROSC). The associations of interest were evaluated with univariate logistic regressions and multivariate models controlling for demographic and clinical variables (e.g. age, gender, type of initial non-shockable rhythm, witnessed arrest, bystander cardiopulmonary resuscitation). Assuming a survival rate of 3% and 25% of the variability explained by the control variables, including more than 4580 patients would allow to detect an absolute difference of 4% in survival between both groups with a power of more than 90%. Results: A total of 4893 patients (2869 men and 2024 women) with a mean age of 70 years (standard deviation 17) were included, of whom 450 (9.2%) experienced a conversion to a shockable rhythm during the course of their prehospital resuscitation. Among all patients, 146 patients (3.0%) survived to discharge and 633 (12.9%) experienced prehospital ROSC. In the univariate models, there was no association between the conversion to a shockable rhythm and survival (odds ratio [OR] 1.14 [95% confidence interval {CI} 0.66-1.95]), but a significant assocation was observed with ROSC (OR 2.00 [95% CI 1.57-2.55], pConclusion: There is no clinically significant association between the conversion to a shockable rhythm and resuscitation outcomes in patients suffering from OHCA. The initial rhythm remains a much better outcome predictor than subsequent rhythms and should be preferred when evaluating the eligibility for advanced resuscitation procedures.

Introduction: Most studies evaluating prescription opioid dependence or misuse are retrospective and are based on prescription filling rates from pharmaceutical databases. These studies cannot evaluate if opioids are really consumed nor differentiate if used for a new pain, chronic pain, or for misuse/dependence. The aim of this study was to assess the opioid consumption in emergency department (ED) patients three months after discharge with an opioid prescription. Methods: This prospective cohort study was conducted in the ED of a tertiary care centre with a convenience sample of patients aged 18 years and older, recruited 24/7, who consulted and were discharged for an acute pain condition ( 2 weeks). We excluded patients who: did not speak French or English, were using opioid medication prior to their ED visit, with an ED stay > 48 hours, or suffering from cancer or chronic pain. Three months post-ED visit, participants were contacted by phone for a structured interview on their past two-week opioid use, their reasons for consuming them, and also answered the Rapid Opioid Dependence Screen (RODS) questionnaire. Results: In the 524 participants interviewed at three months (mean age ± SD: 51±16 years, 47% women), 44 (8.4%) patients consumed opioids in the previous two weeks. Among those, 72% consumed opioids for their initial pain, 19% for a new unrelated pain, and 9% for another reason. In this entire cohort, only five patients (1%) tested positive to opioid dependence from the RODS test. The low dependence incidence could be affected by a social desirability bias. Conclusion: This study suggests that opioid use at 3-month, for patients initially treated for acute pain, is associated with opioid dependency in 1% or possible misuse in only 9%. Additional prospective studies using multiple methods to measure opioids consumption, misuse, and dependence are needed.

Introduction: Le syndrome aortique aigu (SAA) comprend les dissections aortiques, les hématomes intramuraux et les ulcères de lintima, trois conditions difficiles à diagnostiquer, potentiellement létales et nécessitant une prise en charge immédiate et fréquemment chirurgicale. Lutilisation dun test de D-dimère a été proposé afin dexclure ces diagnostics et éviter une investigation plus poussée par angiographie par tomodensitométrie (angioCT). Cependant, il est peu plausible que les patients souffrant dhématomes intramuraux aient une valeur de D-dimères très élevée. Dans ce contexte, lobjectif primaire de la présente étude est de déterminer la valeur diagnostique (sensibilité et spécificité et rapport de vraisemblance négatif [RV-]) dun test de D-dimères chez les patients suspectés de SAA au département durgence. Methods: Les patients ayant subi une angiographie par tomodensitométrie (angioCT) à la recherche dune dissection aortique entre 2008 et 2014 à lurgence dun hôpital tertiaire montréalais ont été inclus dans cette étude de cohorte rétrospective. Les patients nayant pas eu de dosage de D-dimères en ont par la suite été exclus. La valeur diagnostique dun test de D-dimères de plus de 500 mcg/L a été comparée à celle du test de référence (angioCT) afin de calculer la sensibilité, la spécificité et le rapport de vraisemblance négatif et leurs intervalles de confiance (IC). Results: Un total de 139 patients ont été inclus dans létude, parmi lesquels 12 (8,6%) souffraient dun SAA. La sensibilité dun test de D-dimères avec un seuil de positivité de 500 mcg/L était de 83,3% (IC 95% 51,6-97,9), la spécificité de 52,8% (IC 95% 47,8-66,4) et le VR- de 0,32 (IC 95% 0,09-1,13). Les deux patients pour qui le résultat du test de D-dimère était un faux négatif souffraient dun hématome intramural. Les sept patients avec un D-Dimères de plus de 4000 mcg/L semblaient souffrir dun diagnostic grave (dissection aortique : n=5, liquide libre intra-abdominal avec état de choc : n=1 et tamponnade cardiaque : n=1). Conclusion: Avoir un test de D-dimères inférieur à 500 mcg/L ne permet pas déliminer un SAA, particulièrement un hématome intramural.

Introduction: Mild traumatic brain injury (mTBI) is a common problem and until now, ED physicians don’t have any tool to predict when the patient will return to work. The purpose of this study is to develop and validate a clinical decision rule to identify the ED patients who are at risk of non-return to work or to school three months after a mTBI. Methods: Patients were recruiting in five Level I and II Trauma Centers ED in the province of Québec. All patients were referred for a systematic telephone follow-up after three months. Information about their return to work/school, partial or complete, was collected. Log binomial regression was used to develop a predictive model and the validation of this model was performed on a different prospective cohort. Results: 13,7% of the patients did not return to work/school at three months. The final model was derived from a prospective cohort of 398 patients and included three risk factors: motor vehicle accident (2 points), loss of consciousness (1 point) and headache during the emergency department assessment (1 point). With a one-point threshold, this model has a sensitivity of 97% and a negative predictive value (NPV) of 98%. However, the specificity is only 23% and the positive predictive value (PPV) is 17%. The area under the curve is 0.786. Validation of the model was performed with a new prospective cohort of 517 patients, and demonstrated a sensitivity of 86% and a NPV of 91%. Conclusion: Although this model is not very specific, its high sensitivity and NPV indicate to the clinician that mTBI patients who don’t have any of the three criteria are at low risk of prolonged work stoppage after their trauma.

Introduction: Trauma remains the primary cause of death in people under 40 in Québec. Although trauma care has dramatically improved in the last decade, no empirical data on the effectiveness of trauma care in rural Québec are available. This study aims to establish a portrait of trauma and trauma-related mortality in rural versus urban pre-hospital and hospital settings. Methods: Data for all trauma victims treated in the 26 rural hospitals and 32 Level-1 and Level-2 urban trauma centres was obtained from Québec’s trauma registry (2009-2013). Rural hospitals were located in rural small towns (Statistics Canada definition), provided 24/7 physician coverage and admission capabilities. Study population was trauma patients who accessed eligible hospitals. Transferred patients were excluded. Descriptive statistics were used to compare rural with urban trauma case frequency, severity and mortality and descriptive data collected on emergency department (ED) characteristics. Using logistic regression analysis we compared rural to urban in-hospital mortality (pre-admission and during ED stay), adjusting for age, sex, severity (ISS), injury type and mode of transport. Results: Rural hospitals (N=26) received on average 490 000 ED visits per year and urban trauma centres (N=32), 1 550 000. Most rural hospitals had 24/7 coverage and diagnostic equipment e.g. CT scanners (74 %), intensive care units (78 %) and general surgical services (78 %), but little access to other consultants. About 40% of rural hospitals were more than 300 km from a Level-1 or Level-2 trauma centre. Of the 72 699 trauma cases, 4703 (6.5%) were treated in rural and 67 996 (93.5%) in urban hospitals. Rural versus urban case severity was similar: ISS rural: 8.6 (7.1), ISS urban: 7.2 (7.2). Trauma mortality was higher in rural than urban pre-hospital settings: 7.5% vs 2.6%. Reliable pre-hospital times were available for only a third of eligible cases. Rural mortality was significantly higher than urban mortality during ED stays (OR (95% IC): 2.14 (1.61-2.85)) but not after admission (OR (95% IC): 0.87 (0.74-1.02)). Conclusion: Rural hospitals treat equally severe trauma cases as do urban trauma centres but with fewer resources. The higher pre-hospital and in-ED mortality is of grave concern. Longer rural transport times may be a factor. Lack of reliable pre-hospital times precluded further analysis.

Introduction: Recruitment and retention of healthcare staff are difficult in rural communities. Poor quality of work life (QWL) may be an underling factor as rural healthcare professionals are often isolated and work with limited resources. However, QWL data on rural emergency (ED) staff is limited. We assessed QWL among nurses and physicians as part of an ongoing study on ED care in Québec. Methods: We selected EDs offering 24/7 medical coverage, with hospitalization beds, in rural or small towns (Stats Canada definition). Of Québec’s 26 rural EDs, 23 (88%) agreed to participate. The online Quality of Work Life Systemic Inventory (QWLSI, with 1 item per 34 “life domains”), was sent to all non-locum ED nurses and physicians (about 500 potential participants). The QWLSI is used for comparing QWL scores to those of a large international database. We present overall and subscale QWL scores as percentiles (PCTL) of scores in the large database, and comparisons of nurses’ and physicians’ scores (t test). Results: Thirty-three physicians and 84 nurses participated. Mean age was 39.8 years (SD=10.1): physicians=37 (7.7) and nurses=40.9 (10.7). Overall QWL scores for all were in the 32nd PCTL, i.e. low. Nurses were in the 28th PCTL and physicians in the 44nd (p>0.05). For both groups, QWL was below the 25th PCTL i.e. very low, for “sharing workload during absence of an employee”, “working equipment”, “flexibility of work schedule”, “impact of working hours on health”, “possibility of being absent for familial reasons”, “relations with employees”. The groups differed (pConclusion: Overall QWL among rural ED staff is poor. Groups had similar QWL scores except on career path, with physicians perceiving better long-term prospects. Given difficulties in rural recruitment and retention, these findings suggest that QWL should be assessed in rural and urban EDs nationwide.

Introduction: Extracorporeal cardiopulmonary resuscitation (E-CPR) has been used successfully to increase survival in patients suffering from out-of-hospital cardiac arrest (OHCA). However, few OHCA patients can benefit from E-CPR since this procedure is only performed in dedicated centers. Prehospital triage systems have helped decrease mortality from other acute conditions, by directly transporting patients to dedicated centers, often bypassing primary care centers. Our study aimed to quantify the possible impact of a prehospital triage system on the proportion of E-CPR eligible patients transported to E-CPR centers. Methods: We used a registry of adult OHCA collected between 2010 and 2015 from the city of Montréal, Canada. Included patients were adults with non-traumatic witnessed OHCA refractory to 15 minutes of resuscitation. Using this cohort, we created 3 scenarios in which potential E-CPR candidates could be redirected to E-CPR centers. We used strict eligibility criteria in our first pair (e.g. age Results: A total of 3136 patients (2054 men and 982 women) with a mean age of 69 years (standard deviation 15) were included. In each simulation, prehospital redirection would have significantly increased the proportion of patients transported to an E-CPR center (pair 1: 1.3% vs 3.8%, pConclusion: In an urban setting, a prehospital triage system could triple the number of patients with refractory OHCA who would have an access to E-CPR. This implies that centers with E-CPR capability should prepare themselves accordingly for such a system to effectively improve survival following OHCA.

Introduction: Lors d’un traumatisme cranio-cérébral léger, les complications hémorragiques sont rares et ne nécessitent qu’exceptionnellement une intervention neurochirurgicale (Choosing Wisely s’est récemment positionnée avec CAEP afin de recommander l’usage de la Canadian CT Head Rule (CCHR) suite un à TCCL. L’objectif principal de cette étude vise à évaluer l’observance des médecins d’urgence concernant l’utilisation de la règle CCHR chez les patients ayant subi un TCCL. L’objectif secondaire consiste à identifier les facteurs associés au risque de non-observance dans cette situation clinique. Methods: Des analyses univariées et multivariées ont été effectuées sur les données de 854 patients ayant subi un TCCL et ayant été recrutés dans les 24 heures suivant leur visite dans un centre tertiaire québécois de traumatologie. Des analyses descriptives ont permis d’estimer la proportion de médecins d’urgence ayant utilisé les critères de la règle CCHR et ceux n’ayant pas été observants. Nous avons ensuite évalué les facteurs potentiellement associés au risque de non-observance. Results: 62.9% des patients avec TCCL ont subi une TDM au département d’urgence. La non observance globale des médecins face à la règle était de 29.9%. De plus, la proportion de TDM effectuée sans indication selon la règle est égale à 20% (177/854). Les facteurs suivants semblent associés au risque de surutilisation de la TDM: la prise d’acide acétylsalicylique (RR=1.8, [IC 1.3-2.6]), la présence de céphalée décrite par le patient au moment de l’évaluation (RR=1.5, [IC 1.2-1.9]), et l'âge (55-64 ans versus moins de 55 ans) (RR=1.6 [IC 1.2-1.9]). Conclusion: L’évaluation de l’observance des médecins face à ces recommandations, combinée à l’identification des facteurs en cause lors de la non-observance favoriseront une meilleure orientation des interventions de transfert de connaissances dans le futur en plus d’améliorer la qualité des soins et l’efficience des ressources.

Introduction: Patients suffering from out-of-hospital cardiac arrest (OHCA) are frequently transported to the closest hospital after return of spontaneous circulation (ROSC). Percutaneous coronary intervention (PCI) is often indicated as a diagnostic and therapeutic procedure following OHCA. This study aimed to determine the association between the type of destination hospital (PCI-capable or not) and survival to discharge for patients with OHCA and prehospital ROSC. We hypothesized that being transported to a PCI-capable hospital would be associated with a higher survival to discharge. Methods: The present study used a registry of adult OHCA between 2010 and 2015 in Montréal, Canada. We included adult patients with non-traumatic OHCA and prehospital ROSC. The association of interest was evaluated with a multivariate logistic regression model to control for demographic and clinical variables (age, gender, time of day, initial rhythm, witnessed arrest, bystander CPR, presence of first responders or advanced care paramedics, prehospital supraglottic airway placement, delay before paramedics’ arrival). Assuming a survival rate of 40% and 75% of the variability explained by other factors included in the model, more than 1200 patients needed to be included to detect an absolute difference of 10% in survival between both groups with a power of more than 90%. Results: A total of 1691 patients (1140 men and 551 women) with a mean age of 64 years (standard deviation 17) were included, of which 1071 (63%) were transported to a PCI-capable hospital. Among all patients, 704 patients (42%) survived to hospital discharge. We observed a significant independent association between survival to discharge and being transported to a PCI-capable hospital (adjusted odds ratio [AOR] 1.46 [95% confidence interval 1.09-1.96]) after controlling for confounding variables. Having an initial shockable rhythm and presence of first responders also increased survival to discharge (AORs 3.67 [95% confidence interval 2.75-4.88] and 1.53 [95% confidence interval 1.12-2.09], respectively). Conclusion: Patients experiencing ROSC after OHCA could benefit from a direct transport to a PCI-capable hospital. This benefit might also be related to unmeasured interventions other than PCI these hospitals can provide (e.g. high-level intensive care or cardiovascular surgery).

Objectives:The objectives of this study are to determine the prevalence, risk factors, and time to onset of delayed hemothorax and pneumothorax in adults who experienced a minor blunt thoracic trauma.Method:A prospective cohort of 450 consecutive patients was recruited. Eligible patients had to be over 16 years of age, consulted within 72 hours for a trauma, and available for outpatient follow-up at 2, 7, and 14 days posttrauma. The clinical outcome investigated was the presence of delayed pneumothorax or hemothorax on the follow-up chest x-ray.Outcomes:Delayed hemothorax occurred in 11.8% (95% CI 8.8–14.8), and delayed pneumothorax occurred in 0.9% (95% CI 0.2–2.3) of participants. During the 14-day follow-up period, 87.0% of these delayed complications developed in the first week. In the multivariate analysis, the only statistically significant risk factor for delayed complications was the location of fractures on the x-ray of the hemithorax. The adjusted odds ratio was 1.52 (95% CI 0.62–3.73) for the lower ribs (tenth to twelfth rib), 3.11 (95% CI 1.60–6.08) for the midline ribs (sixth to ninth rib), and 5.05 (95% CI 1.80–14.19) for the upper ribs (third to fifth rib) versus patients with no fractures.Conclusion:The presence of at least one rib fracture between the third and ninth rib on the x-ray of the hemithorax is a significant risk factor for delayed hemothorax and pneumothorax.

The objectives of this study are to determine the prevalence, risk factors, and time to onset of delayed hemothorax and pneumothorax in adults who experienced a minor blunt thoracic trauma.A prospective cohort of 450 consecutive patients was recruited. Eligible patients had to be over 16 years of age, consulted within 72 hours for a trauma, and available for outpatient follow-up at 2, 7, and 14 days posttrauma. The clinical outcome investigated was the presence of delayed pneumothorax or hemothorax on the follow-up chest x-ray.Delayed hemothorax occurred in 11.8% (95% CI 8.8-14.8), and delayed pneumothorax occurred in 0.9% (95% CI 0.2-2.3) of participants. During the 14-day follow-up period, 87.0% of these delayed complications developed in the first week. In the multivariate analysis, the only statistically significant risk factor for delayed complications was the location of fractures on the x-ray of the hemithorax. The adjusted odds ratio was 1.52 (95% CI 0.62-3.73) for the lower ribs (tenth to twelfth rib), 3.11 (95% CI 1.60-6.08) for the midline ribs (sixth to ninth rib), and 5.05 (95% CI 1.80-14.19) for the upper ribs (third to fifth rib) versus patients with no fractures.The presence of at least one rib fracture between the third and ninth rib on the x-ray of the hemithorax is a significant risk factor for delayed hemothorax and pneumothorax.

Introduction: Near-infrared spectroscopy (NIRS) is a non-invasive, continuous and painless method of monitoring oxygen saturation of hemoglobin in any given superficial tissue. Given that hemodynamic instability can affect the oxygen saturation, NIRS could prove to be an interesting tool in quantifying tissue oxygenation, consequently guiding clinical management. The aim of this study was to compare the reliability of two commonly used tissue oximeters, the INVOS 5100c from Covidien and the Equanox 7600 from Nonin. We postulated the Equanox (a more recent tissue oximeter) would have a better reliability than the INVOS. As a secondary outcome, we evaluated whether the measures given by the two oximeters were comparable. Methods: The study population was composed of healthy adult volunteers. Three measurements were taken at six different sites on both sides of the body in a randomized order. Two different sensors were used for each measure. From these measures, two intra-class correlations (ICC) - one inter-sensor and the other intra-sensor - were calculated for each device and compared using the Fisher’s r-to-z transformation method. An additional inter-device ICC was also calculated. We considered ICCs over 0.75 as an indicator of good reliability, while ICCs under 0.40 were considered to represent poor reliability. The sample size was calculated based on the calculation of a unidirectional confidence interval for a parametric ICC. Expecting a 0.75 ICC value, we concluded that 53 participants needed to be recruited in order to attain 80% power and a range of 0.1 towards the low values. Results: Fifty-three healthy volunteers (27 men and 26 women) with a mean age of 31 years (standard deviation 10) were recruited. We found no differences between the repeatability of the INVOS and the Equanox for both inter and intra-sensor reliability (ICC=0.94 (95% confidence interval (CI) 0.86-0.97) versus ICC=0.92 (95%CI 0.86-0.95), p=0.42 and ICC=0.94 (95%CI 0.89-0.96) versus ICC=0.96 (95%CI 0.93-0.98), p=0.21, respectively). However, when compared directly, we found that the readings produced by the two oximeters varied considerably (ICC 0.18 (95%CI -0.10 to 0.43). Conclusion: When taken individually, both tissue oximeters displayed good inter and intra-sensor reliability. However, they oximeters displayed poor inter-devices agreement, their readings varying considerably amongst each other.

Introduction: Tissue oximetry using near-infrared spectroscopy (NIRS) is a non-invasive monitor of cerebral oxygenation. This new technology has been used during cardiac arrest because of its ability to give measures in low blood flow situations. The aim of this systematic review was to assess the evidence regarding the association between NIRS values and resuscitation outcomes in patients undergoing cardiopulmonary resuscitation. We hypothesized that higher NIRS values would be associated with better outcomes and that the strength of that association would differ depending on the timing of the NIRS measurements. Methods: This review was registered (Prospero CRD42015017380) and is reported as per the PRISMA guidelines. Medline, Embase and CENTRAL were searched from their inception to September 18th, 2015 using a specifically designed search strategy. Grey literature was also searched using Web of Science and Google Scholar. NIRS manufacturers and authors of included citations were contacted to inquire on unpublished results. Finally, the references of all retained articles were reviewed in search of additional relevant studies. Studies reporting NIRS monitoring in adults during cardiac arrest were eligible for inclusion. Case reports and case series of fewer than five patients were automatically excluded. Two reviewers assessed the quality of included articles and extracted the data. Results: Out of 3275 unique citations, 19 non-randomized observational studies (15 articles and four conference abstracts) were included in this review, for a total of 2436 patients. Six studies were evaluated at low risk of bias, nine at intermediate risk and four at high risk. We found a stronger association between the return of spontaneous circulation (ROSC) and the highest NIRS value measured during resuscitation (standard mean deviation (SMD) 3.46 (95%CI 2.31-4.62)) than between ROSC and the mean NIRS measures (SMD 1.33 (95%CI 0.92-1.74)) which was superior to the one between ROSC and initial measures (SMD 0.45 (95%CI 0.02-0.88)). Conclusion: Patients with good outcomes have significantly higher NIRS value during resuscitation than their counterparts. The association between ROSC and NIRS measurements was influenced the timing of measurements during resuscitation.

Introduction: Patient handoffs have been identified as the primary cause of error affecting patient safety. The lack of standardization - and the often-avoidable errors that occur as a result - profoundly affect patient care and emergency department (ED) administration. Our study set out to evaluate emergency doctors’ awareness of these safety concerns, as well as their satisfaction with handoff practices currently used in their respective EDs. We also aimed to identify the potential barriers to the use of a standardized approach to patient transition of care. Methods: Guided by a modified Delphi method, a 29-question survey was developed by a panel of experts on patient transition of care. A printed version of the survey was distributed to ED doctors attending a local emergency medicine conference. An electronic version was subsequently distributed to all ED doctors registered as members of our provincial professional organizations. Results: We achieved a 68% response rate. Amongst the 309 participants, 51% (95%CI 44-56%) acknowledged that handoffs between emergency doctors are a frequent cause of error related to patient care. Frequent interruptions (77% (95%CI 72-82%)) and heavy workloads (73% (95%CI 68-79%)) were identified as the main factors negatively influencing the quality of handoffs. Despite 61% (95%CI 56-68%) satisfaction with the currently employed methods, 74% (95%CI 68-79%) of the respondents believe that handoffs would benefit from standardization and 83% (95%CI 79-88%) are open to changing their current practices. In addition, 53% (95%CI 48-60%) believe that the tools used for transition of care can be improved. Apprehension regarding the increase of handoff burden (86% (95%CI 81-90%)) was identified as the primary barrier to the implementation of a standardized handoff protocol. Conclusion: Doctors are generally satisfied with current handoff practices used in the ED. Nevertheless, their awareness of the possible risks associated with transition of care may be driving their openness to adapting their practice, potentially towards a more standardized approach given the conceivable benefits to patient safety. In light of these results, we aim to develop a comprehensive, standardized handoff protocol, and to evaluate its applicability in the ED with a prospective study.