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Objective: To identify the prevalence of renal insufficiency (RI) in children with a history of prematurity and acute kidney injury (AKI). Study design: This prospective cohort study evaluated renal function in children born preterm at 5–9 years of age. Univariable analyses compared perinatal and follow-up data from subjects with and without AKI history, and with and without current RI. Regression analyses were attempted to model RI as a function of AKI and other clinical risk factors. Results: Fifteen of 43 (35%) participants had previously undiagnosed RI. Only children with no AKI history or neonatal stage 1 AKI presented for follow-up. Children born preterm with a history of stage 1 AKI had higher serum creatinine (sCr) at follow-up, but were not more likely to have RI compared to children without stage 1 AKI history (RI prevalence 30% and 36% in AKI and non-AKI group, respectively). Conclusion: The high prevalence of RI in this preterm cohort at middle childhood follow-up highlights the need for routine kidney health assessments in this population. Large multicenter studies are needed to further characterize the impact of premature birth and mild AKI on renal function throughout childhood.

Objectives: Limited data exist on pre-hospital pediatric trauma mortality in Canada. The Nova Scotia Trauma Registry is a provincial population-based registry that captures data from the Medical Examiner Service. This study examined the characteristics of pediatric trauma patient mortality in the pre-hospital and in-hospital settings. Methods: We conducted a cohort study of major pediatric traumas recorded in our provincial database from April 1, 2001 to March 31, 2018. Characteristics of pre-hospital and in-hospital deaths were compared with t tests and Chi-square analyses. Multivariate regression modeling was used to identify predictors of pre-hospital mortality. The geographic distribution of pre-hospital trauma was assessed using choropleth maps. Results: We identified 1,258 pediatric traumas, resulting in 217 deaths (137 pre-hospital, 80 in-hospital). Males accounted for 62.7% of fatalities. The 15–17 age group accounted for most deaths in both groups (pre-hospital 61.3%; in-hospital 41.3%). Injuries sustained in rural areas resulted in 74.7% of all deaths. For both groups, blunt trauma was the predominant injury type and motor vehicle collisions, the most prevalent injury mechanism. Patients who died pre-hospital had a higher mean age (13.3 vs. 10.7, p= 0.002) and a greater proportion were intentional injuries (23.4% vs. 15%; p= 0.02). Urban residency was more frequently observed in in-hospital deaths (57.5% vs. 36.5%, p< 0.001). Pre-hospital mortality was associated with increasing age (OR 1.1), higher injury severity score (OR 1.1), and intentional injury (OR 15.6). Conclusion: Over 10% of major pediatric traumas resulted in pre-hospital death, primarily from motor vehicle collisions in rural areas. Compared to in-hospital mortality, patients who died pre-hospital were older with more severe injuries and more likely to have intentionally injured themselves. These results underscore the importance for emergency physicians and EMS systems to consider geographic factors and injury patterns, advocate for improved injury prevention programs, mental health supports, and delivery of on-scene critical care services.

BACKGROUND Few data are available to guide the choice of colloid or crystalloid for fluid resuscitation in patients with severe sepsis or septic shock. (1,2) A large randomized controlled trial [...]

RESUME Introduction: La prise en charge optimale du sepsis grave dans les departements d'urgence a connu une evolution rapide. Le but des presentes lignes directrices est de revoir pour le [...]

ABSTRACT Introduction: Optimal management of severe sepsis in the ED has evolved rapidly. The purpose of these guidelines is to review key management principles for Canadian emergency physicians, utilizing an [...]

ABSTRACT Objective: Inducing mild hypothermia in survivors of cardiac arrest has been demonstrated to improve outcomes. Despite this, other studies have found that few resuscitation physicians have used hypothermia in [...]

Prognosis after cardiac arrest is dismal, with an overall survival rate of less than 6%. Outcomes vary with cardiac arrest rhythm: less than 2% of patients with asystolic or pulseless [...]

ABSTRACT Hockey is enjoyed by millions of people around the world and is a sport in which aggression is encouraged and injuries are common. Although body-checking is the most common [...]

ABSTRACT Objective: Several randomized controlled trials have suggested that mild induced hypothermia may improve neurologic outcome in comatose cardiac arrest survivors. This systematic review of randomized controlled trials was designed [...]

Respiratory failure and acute respiratory distress syndrome can occur in burn patients with or without inhalational injury and can significantly increase mortality. For patients with severe respiratory failure who fail conventional therapy with mechanical ventilation, the use of venovenous extracorporeal membrane oxygenation (ECMO) may be a life-saving salvage therapy. There have been a series of case reports detailing the use of ECMO in burn patients over the last 20 years, but very little is currently known about the status of ECMO use at burn centers in North America. Using a web-based survey of burn center directors in Canada and the United States, we examined the rate of usage of ECMO in burn care, barriers to its use, and the perioperative management of burn patients receiving ECMO therapy. Our findings indicate that approximately half of the burn centers have used ECMO in the care of burn patients, but patient volume is very low on average (less than 1 per year). Of centers that do use ECMO in burn care, only 40% have a specified protocol for doing so. Approximately half have operated on patients being actively treated with ECMO therapy, but perioperative management of anticoagulation varies widely. A lack of experience and institutional support and a perceived lack of evidence to support ECMO use in burn patients were the most commonly identified barriers to more widespread uptake. Better collaboration between burn centers will allow for the creation of consensus statements and protocols to improve outcomes for burn patients who require ECMO.

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Objective: Mandatory gunshot wound reporting laws have been enacted in much of Canada, yet there is a lack of evidence on whether these laws are effective in preventing firearm injuries. Our objective was to determine if the Gunshot Wounds Reporting Act in Nova Scotia had an effect on the number of firearm-related injuries in the province. Methods: Pre–post-study of major trauma patients in Nova Scotia who sustained a gunshot wound injury before and after enactment of the Gunshot Wounds Reporting Act (Bill 10) in 2008. Data were collected from the Nova Scotia Trauma Registry and the Nova Scotia Medical Examiner Service for a 6-year pre-period (2002–2007) and an 11-year post-period (2009–2019), allowing for a 1-year washout period. Patient characteristics in the pre- and post-periods were compared using t tests and Chi-square analysis. Gunshot wound traumas were analyzed as a time series using the AutoRegressive Integrated Moving Average (ARIMA) model. Results: A total of 722 firearm injuries were observed during the study period (pre-period = 259, post-period = 463). Mean age was 45.2 ± 19.3 years with males accounting for 95.3% (688/722) of cases. The majority of injuries were self-inflicted (65.1%; 470/722). The mean overall annualized rate of firearm injuries was 4.61 per 100,000 population in the pre-period and 4.45 per 100,000 in the post-period (reduction of 3.4%). No linear trends in the annual number of firearm injuries were observed over the study period. ARIMA modelling was an extremely poor predictor for gunshot wound trauma (R2= 0.012). Conclusions: Although our findings suggest that there is no association between the Gunshot Wounds Reporting Act and the incidence of firearm injury, it is difficult to draw firm conclusions due to the complexity of this topic. Physicians need to be aware of the legal requirements of mandatory reporting when they encounter patients with gunshot wounds.

Objective: To determine how many Level 1 and Level 2 trauma centres in Canada have implemented a resuscitative endovascular balloon occlusion of the aorta (REBOA) program, and to identify facilitators and barriers to successful implementation of REBOA programs. Methods: An electronic survey was developed and administered in November 2019 (updated in July 2021) via email to directors at all 32 Level 1 and Level 2 trauma centres across Canada, and to the medical director in PEI (no Level 1 or Level 2 capacity). Survey responses were supplemented by an online search in PubMed and the grey literature. Responses were analyzed using simple descriptive statistics including frequencies and proportions. Results: We received responses from directors at 22 sites (17 Level 1 trauma centres, 4 Level 2 trauma centres, PEI) for a response rate of 66.7%. There are 6 Level 1 trauma centres with REBOA programs; all were implemented between 2017 and 2019. One additional Level 1 trauma centre that did not respond was found to have a REBOA program; thus, 21.9% (7/32) of Canadian Level 1 and Level 2 trauma centres have an existing REBOA program. These programs are located in three provinces (British Columbia, Ontario, Quebec). Five other centres are planning on implementing a REBOA program in the next 2 years. The number of REBOA cases performed ranged from 0 to 30 (median 2). Factors contributing most to successful program implementation were having physician champions and patient populations with sufficient REBOA candidates, while cost and lack of expertise were the greatest barriers identified. Conclusion: As of July 2021, 21.9% (7/32) of Canadian Level 1 and Level 2 trauma centres have a REBOA program. Physician champions and a patient population with sufficient numbers of REBOA candidates were the most important factors contributing to successful implementation of these programs.

Objectives: To perform a province-wide evaluation of adult major traumas and determine the proportion of patients who met clinical and/or anatomical criteria for resuscitative endovascular balloon occlusion of the aorta (REBOA). Methods: This is a retrospective analysis of all major trauma patients (age?>?16) presenting to the sole adult level 1 trauma centre in Nova Scotia over a 5-year period (2012–2017). Data were collected from the Nova Scotia Trauma Registry and medical charts. We identified potential REBOA candidates using either: (1) clinical criteria (primary survey, Focused Assessment with Sonography for Trauma, pelvic/chest X-ray); or (2) anatomical criteria (ICD-10-CA codes). Potential candidates with persistent hypotension were considered true REBOA candidates. Results: Overall 2885 patients were included in the analysis, of whom 248 (8.6%) patients were in shock (including 106 transfer patients) and had their charts reviewed. A total of 137 patients met clinical criteria for REBOA; 44 (1.5%) had persistent hypotension 10–20 min into resuscitation and were considered true REBOA candidates. There were 59 patients who met anatomical criteria for REBOA, of whom 15 (0.5%) patients had persistent hypotension and were true REBOA candidates. The 15 REBOA candidates based on anatomical criteria also met clinical criteria for REBOA. Conclusions: In this registry-based retrospective analysis, 1.5% of adult major trauma patients Nova Scotia were REBOA candidates based on resuscitative clinical presentation, while 0.5% were candidates based on post hoc anatomical injury patterns. Our findings suggest that using clinical findings and bedside imaging modalities as criteria may overestimate the number of candidates for REBOA.

Abstract: Inspired by the 1980 movie Urban Cowboy, many drinking establishments offered mechanical bull riding to their patrons. As the use of mechanical bulls became more popular, associated injuries became [...]

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Aim:Extrauterine growth restriction (EUGR) is common in premature infants, but the progression after neonatal intensive care unit (NICU) discharge is not well described. We aimed to assess EUGR after NICU discharge and to identify factors associated with catch-up growth (CUG) and neurodevelopmental outcomes at 2 years of age.Methods:Growth parameters at birth, 36 weeks postmenstrual age (PMA), and two neurodevelopmental follow-up visits for preterm graduates of our NICU were reviewed. EUGR was assessed using Fenton and Intergrowth-21 standards. Factors associated with outpatient growth and neurodevelopmental outcomes at 2 years of age were evaluated using logistic and linear regression.Results:369 infants born at 24–32 weeks gestation comprised the cohort. EUGR prevalence was 14.9% for Intergrowth-21 versus 56.4% for Fenton (p< .001). Although there was a significant decrease in weight z-score from birth to 36 weeks PMA, weight z-scores returned to their birth weight values at the second clinic visit (86 weeks PMA). Infants who received formula as opposed to human milk (HM) showed faster CUG. Higher scores in the Bayley-III scale at 2 years of age were associated with HM feeding.Discussion/Conclusion:Fewer infants were identified as EUGR when Intergrowth-21 versus Fenton growth standards were used, which categorizes infants with adverse clinical courses and poorer neurodevelopmental outcomes more distinctly. While growth failure during the birth hospitalization is common in preterm infants, outpatient CUG was demonstrated, with return to birth weight z-score. Our findings suggest that HM feeding may have a positive impact on cognitive, language, and motor developmental outcomes for preterm infants despite less rapid CUG.

A case study is reported of an infant with a transection (break) of the spinal cord at the neck, which is the cervical portion of the spinal cord. The transection was eventually diagnosed by magnetic resonance imaging (MRI), a technique for visualizing the soft tissues of the body. The infant was born vaginally, but because he was in the breech position, forceps were used to turn him without apparent difficulty. At birth, the infant did not have any spontaneous movement or breathing. A breathing tube was inserted and the baby was placed on a respirator. He did not respond to stimuli and reflexes were absent. Marks from the forceps were present on the brain and neck. On day three, the newborn was still not breathing on his own and there was no spontaneous movement. X-rays of the spine were normal. Ultrasound examination of the head showed dilation of the cavities, but no bleeding. Computerized tomography (CT) showed evidence of bleeding in the brain. CT was repeated on day 18, showing similar results. The neurological status was appearing to improve, with a few spontaneous movements and the development of a few reflexes. On day 25, an MRI was performed, which showed the transection of the spinal cord. MRI provides excellent visualization of the spinal cord and is an important technique in the diagnosis of spinal cord injuries. The infant remained in the intensive care unit for eight weeks, with little improvement. He was then transferred to another hospital. Cervical spinal cord injury is not common, but can occur during vaginal delivery of infants in the breech position that are turned with forceps. (Consumer Summary produced by Reliance Medical Information, Inc.)

ABSTRACT Anoxic brain injury is a common outcome after cardiac arrest. Despite substantial research into the pathophysiology and management of this injury, a beneficial treatment modality has not been previously [...]

ABSTRACTObjectivesTo determine the rate of recurrent major trauma (i.e., trauma recidivism) using a provincial population-based trauma registry. We compared outcomes between recidivists and non-recidivists, and assessed factors associated with recidivism and mortality.MethodsReview of all adult (>17 years) major trauma patients in Nova Scotia (2001–2015) using data from the Nova Scotia Trauma Registry. Outcomes of interest were mortality, duration of hospital stay, and in-hospital complications. Multiple regression was used to assess factors associated with recidivism and mortality.ResultsOf 9,365 major trauma patients, 2% (150/9365) were recidivists. Mean age at initial injury was 52 ± 21.5 years; 73% were male. The mortality rate for both recidivists and non-recidivists was 31%. However, after adjusting for potential confounders the likelihood of mortality was over 3 times greater for recidivists compared to non-recidivists (OR 3.67, 95% CI 2.06–6.54). Other factors associated with mortality included age, male gender, penetrating injury, Injury Severity Score, trauma team activation (TTA) and admission to the intensive care unit. The only variables associated with recidivism were age (OR 0.98, 95% CI 0.97–1.00) and TTA (OR 0.59, 95% CI 0.34–0.96).ConclusionsThis is the first provincial investigation of major trauma recidivism in Canada. While recidivism was infrequent (2%), the adjusted odds of mortality were over three times greater for recidivists. Further research is warranted to determine the effectiveness of strategies for reducing rates of major trauma recidivism such as screening and brief intervention in cases of violence or substance abuse.

Despite advances in burn care, mortality in adult patients with extensive burn injuries remains a concern, particularly in those who develop concurrent acute respiratory distress syndrome (ARDS). In cases of ARDS refractory to conventional treatments, venovenous extracorporeal membrane oxygenation (ECMO) may represent a viable salvage therapy, even in the major burn population. We present the case of a 38-year-old man with full thickness burns to over 80% of his body, who developed severe ARDS 4 days postburn. After failing to respond to deep sedation, paralysis, and proning, ECMO therapy was initiated to maintain oxygenation and ventilation. Over the next 14 days, while the patient was treated with ECMO, he successfully underwent three major operations to debride and allograft approximately 65% of his body surface area, including one in the prone position. ECMO therapy was discontinued on postburn day 18, and the patient had his wounds reconstructed and survived his injuries. To the best of our knowledge, this is the first report of a burn patient with such severe burns requiring surgical intervention that has been treated with ECMO and survived, and the first case of a burn patient on ECMO having surgery in the prone position. They conclude this case serves as a “proof of concept” that ECMO is a potential treatment for appropriately selected major burn patients with ARDS who fail to respond to other therapies.

ABSTRACTObjectivesThe objective of this study was to systematically review the published literature for risk factors associated with adverse outcomes in older adults sustaining blunt chest trauma.MethodsEMBASE and MEDLINE were searched from inception until March 2017 for prognostic factors associated with adverse outcomes in older adults sustaining blunt chest trauma using a pre-specified search strategy. References were independently screened for inclusion by two reviewers. Study quality was assessed using the Quality in Prognostic Studies tool. Where appropriate, descriptive statistics were used to evaluate study characteristics and predictors of adverse outcomes.ResultsThirteen cohort studies representing 79,313 patients satisfied our selection criteria. Overall, 26 prognostic factors were examined across studies and were reported for morbidity (8 studies), length of stay (7 studies), mortality (6 studies), and loss of independence (1 study). No studies examined patient quality of life or emergency department recidivism. Prognostic factors associated with morbidity and mortality included age, number of rib fractures, and injury severity score. Although age and rib fractures were found to be associated with adverse outcomes in more than 3 studies, meta-analysis was not performed due to heterogeneity amongst included studies in how these variables were measured.ConclusionsWhile blunt chest wall trauma in older adults is relatively common, the literature on prognostic factors for adverse outcomes in this patient population remains inadequate due to a paucity of high quality studies and lack of consistent reporting standards.

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We aimed to evaluate the association between transfusion practices and clinical outcomes in patients with traumatic brain injury.

BackgroundTwo distinct Emergency Medical Services (EMS) systems exist in Atlantic Canada. Nova Scotia operates an Advanced Emergency Medical System (AEMS) and New Brunswick operates a Basic Emergency Medical System (BEMS). We sought to determine if survival rates differed between the two systems.MethodsThis study examined patients with trauma who were transported directly to a level 1 trauma centre in New Brunswick or Nova Scotia between 1 April 2011 and 31 March 2013. Data were extracted from the respective provincial trauma registries; the lowest common Injury Severity Score (ISS) collected by both registries was ISS≥13. Survival to hospital and survival to discharge or 30 days were the primary endpoints. A separate analysis was performed on severely injured patients. Hypothesis testing was conducted using Fisher’s exact test and the Student’s t-test.Results101 cases met inclusion criteria in New Brunswick and were compared with 251 cases in Nova Scotia. Overall mortality was low with 93% of patients surviving to hospital and 80% of patients surviving to discharge or 30 days. There was no difference in survival to hospital between the AEMS (232/251, 92%) and BEMS (97/101, 96%; OR 1.98, 95% CI 0.66 to 5.99; p=0.34) groups. Furthermore, when comparing patients with more severe injuries (ISS>24) there was no significant difference in survival (71/80, 89% vs 31/33, 94%; OR 1.96, 95% CI 0.40 to 9.63; p=0.50).ConclusionOverall survival to hospital was the same between advanced and basic Canadian EMS systems. As numbers included are low, individual case benefit cannot be excluded.

AbstractObjectivesVarious medications and devices are available for facilitation of emergent endotracheal intubations (EETIs). The objective of this study was to survey which medications and devices are being utilized for intubation by Canadian physicians.MethodsA clinical scenario-based survey was developed to determine which medications physicians would administer to facilitate EETI, their first choice of intubation device, and backup strategy should their first choice fail. The survey was distributed to Canadian emergency medicine (EM) and intensive care unit (ICU) physicians using web-based and postal methods. Physicians were asked questions based on three scenarios (trauma; pneumonia; heart failure) and responded using a 5-point scale ranging from “always” to “never” to capture usual practice.ResultsThe survey response rate was 50.2% (882/1,758). Most physicians indicated a Macintosh blade with direct laryngoscopy would “always/often” be their first choice of intubation device in the three scenarios (mean 85% [79%-89%]) followed by video laryngoscopy (mean 37% [30%-49%]). The most common backup device chosen was an extraglottic device (mean 59% [56%-60%]). The medications most physicians would “always/often” administer were fentanyl (mean 45% [42%-51%]) and etomidate (mean 38% [25%-50%]). EM physicians were more likely than ICU physicians to paralyze patients for EETI (adjusted odds ratio 3.40; 95% CI 2.90-4.00).ConclusionsMost EM and ICU physicians utilize direct laryngoscopy with a Macintosh blade as a primary device for EETI and an extraglottic device as a backup strategy. This survey highlights variation in Canadian practice patterns for some aspects of intubation in critically ill patients.

AbstractObjectiveWe sought to conduct a major objective of the CAEP Academic Section, an environmental scan of the academic emergency medicine programs across the 17 Canadian medical schools.MethodsWe developed an 84-question questionnaire, which was distributed to academic heads. The responses were validated by phone by the lead author to ensure that the questions were answered completely and consistently. Details of pediatric emergency medicine units were excluded from the scan.ResultsAt eight of 17 universities, emergency medicine has full departmental status and at two it has no official academic status. Canadian academic emergency medicine is practiced at 46 major teaching hospitals and 13 specialized pediatric hospitals. Another 69 Canadian hospital EDs regularly take clinical clerks and emergency medicine residents. There are 31 full professors of emergency medicine in Canada. Teaching programs are strong with clerkships offered at 16/17 universities, CCFP(EM) programs at 17/17, and RCPSC residency programs at 14/17. Fourteen sites have at least one physician with a Master’s degree in education. There are 55 clinical researchers with salary support at 13 universities. Sixteen sites have published peer-reviewed papers in the past five years, ranging from four to 235 per site. Annual budgets range from $200,000 to $5,900,000.ConclusionThis comprehensive review of academic activities in emergency medicine across Canada identifies areas of strengths as well as opportunities for improvement. CAEP and the Academic Section hope we can ultimately improve ED patient care by sharing best academic practices and becoming better teachers, educators, and researchers.

Premature babies at risk for periventricular-intraventricular hemorrhage (PV-IVH), brain hemorrhage, often experience periods of severe hypoxia (lack of oxygen). When this occurs, dilator substances, prostaglandins, are produced which increase the flow of blood to the brain. The drug indomethacin slows the production of these dilator prostaglandins. Because of this effect it is believed to help prevent intracranial hemorrhage. A group of 141 premature babies having birth weight of less than three and a half pounds, were divided into treatment and control groups. None of the babies showed any evidence of PV-IVH at one hour after birth. The treatment group received three doses of indomethacin; the controls a placebo. The results showed that milder grades of PV-IVH occurred in 23 percent of the treatment group, and 39 percent of the controls. Severe PV-IVH occurred in three percent of the treatment group and 14 percent of the controls. The study also found boys to be at greater risk for developing severe PV-IVH than girls. The data indicated that giving indomethacin to prevent brain hemorrhage reduced the relative risk of developing milder and severe of PV-IVH, with no increase in complications. However, there are factors other than abnormalities in blood flow that cause brain hemorrhage. Before indomethacin can be recommended for routine clinical use, further study is needed regarding dosage and duration of therapy.

AbstractObjectivesA small proportion of pediatric sport- and recreation-related injuries are serious enough to be considered “major trauma.” However, the immediate and long-term consequences in cases of pediatric major trauma are significant and potentially life-threatening. The objective of this study was to describe the incidence and outcomes of pediatric major traumas related to sport and recreational activities in Nova Scotia.MethodsThis study was a retrospective case series. Data on major pediatric traumas related to sport and recreational activities on a provincial scope were extracted from the Nova Scotia Trauma Program Registry between 2000 and 2013. We evaluated frequency, type, severity, and outcomes of major traumas. Outcomes assessed included length of hospital stay, admission to a special care unit (SCU), and mortality.ResultsOverall, 107 children aged three to 18 years sustained a major trauma (mean age 12.5 [SD 3.8]; 84% male). Most injuries were blunt traumas (97%). The greatest proportion were from cycling (59, 53%), followed by hockey (8, 7%), skateboarding (7, 7%) and skiing (7, 7%). The Nova Scotia Pediatric Trauma Team was activated in 27% of cases. Mean in-hospital length of stay was five days (SD 5.6), and nearly half (49%) of patients required SCU admission. Severe traumatic brain injury occurred in 52% of cases, and mortality in five cases.ConclusionsOver a 13-year period, the highest incidence of pediatric major trauma related to sport and recreational activities was from cycling, followed by hockey. Severe traumatic brain injury occurred in over half of pediatric major trauma patients.

To determine the incidence of postintubation hypotension (PIH) and associated outcomes in critically ill patients requiring endotracheal intubation.

Severe sepsis and septic shock are common problems in the emergency department patient population and require expert clinical skill by members of the emergency department team to maximize optimal patient outcomes. Although various guidelines have been developed for the management of these patients, issues around antimicrobial-related considerations in critically ill patients require further evidence-based attention. In this review article, important factors related to patient illness, microorganism, timing of antimicrobial administration, and source control are discussed.

ABSTRACTObjective:Postintubation hemodynamic instability (PIHI) is a potentially life-threatening adverse event of emergent endotracheal intubation. The objectives of this study were to determine the incidence, risk factors, and impact on patient outcomes associated with PIHI in intubations performed in emergency medicine.Methods:A structured chart audit was performed of all consecutive adult patients requiring emergent endotracheal intubations over a 16-month period at a tertiary care emergency department (ED). Data collection included medications, comorbidities, vital signs in the 30 minutes before and after intubation, hospital length of stay, and in-hospital mortality. PIHI was defined as a decrease in systolic blood pressure (SBP) to = 90 mm Hg, a decrease in SBP of = 20% from baseline, a decrease in mean arterial pressure to = 65 mm Hg, or the initiation of any vasopressor medication at any time in the 30 minutes following intubation.Results:Overall, 218 patients intubated in the ED were identified, and 44% (96 of 218) developed PIHI. On multivariate analysis, increasing age (OR 1.03, 95% CI 1.01–1.05), chronic obstructive pulmonary disease (OR 3.00, CI 1.19–7.57), and pre–emergent endotracheal intubation hemodynamic instability (OR 2.52, 95% CI 1.27–4.99) were associated with the development of PIHI. The use of a neuromuscular blocking medication was associated with a decreased incidence of PIHI (OR 0.34, 95% CI 0.16–0.75).Conclusions:Based on our data, postintubation hypotension occurs in a significant proportion of ED patients requiring emergent airway control. Further investigation is needed to confirm the factors we found to be associated with PIHI and to determine if PIHI is associated with increased morbidity and mortality.

To determine the frequency of analgesic use in children (5 to 17 years inclusive) who present to a pediatric emergency department with acute abdominal pain.

A model based on the course of 31 infants with uncomplicated hyaline membrane disease is described. Based on data collected over the first 12 hr of life, it predicts the course of an infant for the next 60 hr, and estimates the outcome in terms of length of oxygen requirement and assisted ventilation. For the construction of the model, right-to-left intra- and extra-pulmonary shunting, expressed as venous admixture, was considered as the principal mechanism of hypoxemia in hyaline membrane disease and mean applied proximal airway pressure was used to quantify management. The model provides an objective estimate of severity early in the course of the disease, uses variables routinely available in an intensive care unit, and its use would strengthen the interpretation of clinical studies in which the comparability of experimental and control groups is critical.

ABSTRACT: Treatment of unanesthetized newborn pigs with indomethacin trihydrate (5 ± 1 mg/kg, intravenous) decreased cerebral blood flow uniformly throughout the brain by 18-28% without changing cardiac output, arterial pressure, or arterial blood gases and pH. Breathing 10% O2, 9% CO2with the balance N2(hypoxia/hypercapnia) caused cerebral blood flow to increase from 102 ± 12 to 218 ± 19 ml/100 g-min. Intravenous administration of indomethacin during hypoxia/hypercapnia caused a uniform decrease in cerebral flow throughout the brain to levels (94 ± 5 ml/100 g-min) indistinguishable from those when the piglet was breathing ambient air. Further, 2.5 h later, the cerebral hyperemia caused by hypoxia/hypercapnia was attenuated markedly (129 ± 19 ml/100 g-min). Vehicle treatment did not alter resting cerebral blood flow or cerebral hyperemia in response to hypoxia/hypercapnia. Measurements of 6-keto-prostaglandin F1α, thromboxane B2, and prostaglandin E2demonstrated that intravenously administered indomethacin crossed the blood-brain barrier of newborn pigs in sufficient quantity to inhibit prostanoid release into the cerebrospinal fluid passing over the surface of the brain. The mechanism by which indomethacin reduces cerebral blood flow and attenuates cerebral hyperemia cannot be determined from the present experiments. We conclude that intravenous administration of indomethacin decreases cerebral blood flow and attenuates cerebral hyperemia induced by severe, combined hypoxia/hypercapnia in newborn pigs.

Summary: Inhibition of prostaglandin cyclooxygenase augments hypoxic pulmonary vasoconstriction. We used a neonatal lamb lung preparation perfused with Krebs' bicarbonate buffer to characterize and quantify prostanoids produced by the pulmonary vasculature from endogenous arachidonic acid in the absence of formed blood elements during ventilation with normoxic and hypoxic gas mixtures. Prostaglandin (PG) I2synthesis increased from 6.4 ± 2.7 ng/min (SEM) during normoxic ventilation to 14.3 ± 5.4 ng/min during hypoxia and returned to 4.7 ± 1.2 ng/min with resumption of normoxia. These data demonstrate that hypoxia stimulates pulmonary vascular synthesis of prostaglandin I2from endogenous substrate in neonatal lambs and suggest that the augmentation of hypoxic pulmonary vasoconstriction by prostaglandin cyclooxygenase inhibition is due, at least in part, to interference with the synthesis of this vasodilator prostanoid.

To study the effects of Group B β-hemolytic Streptococcuson the pulmonary circulation and lung fluid balance, live and heat-killed bacteria and their toxin were infused into an awake sheep lung-lymph preparation. In every case, the response was biphasic; there was an initial period of marked pulmonary hypertension and high flow of protein-poor lymph associated with tachypnea, chills, and fever. A second phase followed during which pulmonary vascular pressures returned to near baseline and remained stable, but lymph flow remained high. The changes seen in the initial phase resemble the previously reported response to mechanically increased pulmonary vascular pressure and suggest that the increase in fluid filtration is secondary to increased microvascular pressure. During the second phase after toxin infusion, the increase in lung lymph flow was paralleled by an increase in lymph protein clearance. This cannot be accounted for by the hemodynamic changes alone and suggests that the permeability of lung microvascular walls to protein was increased. It is concluded that group B β-hemolytic streptococcal toxin in the sheep model causes pulmonary hypertension and increased pulmonary vascular permeability.