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Purpose: The coronavirus disease 2019 (COVID-19) pandemic has placed major limitations on trauma health care systems. This survey aims to identify how Canadian trauma centres altered their processes to care for injured patients and protect their staff during the pandemic. Methods: A survey was distributed to trauma directors at level 1 Canadian adult trauma centres in July 2020. Questions included changes made to the trauma service in preparation for the pandemic, modification to clinical practice and expected lasting modifications after the pandemic. Results: The response rate was 68.4%. All trauma centres modified their treatment and investigation protocols for the pandemic. Most respondents adopted online platforms for meetings and educational activities and used simulation to prepare for COVID-19-infected trauma patients. The approach to who would intubate trauma patients, which trauma patients should be tested for COVID-19 and who should use N95 ventilators, varied among the sites surveyed. Conclusion: All centres modified some of their treatment and investigation protocols for the pandemic but not all modifications were adopted universally. Knowing these steps and comparing them with other global centres will help organize disaster plans for the current and future pandemics.

Supplemental digital content is available in the text., BACKGROUND Timely and safe distribution of quality blood products is a major challenge faced by blood banks around the world. Our primary objective was to determine if simulated blood product delivery to an urban trauma center would be more rapidly achieved by unmanned aerial vehicle (UAV) than by ground transportation. A secondary objective was to determine the feasibility of maintaining simulated blood product temperatures within a targeted range. METHODS In this prospective pilot study, we used two distinct methods to compare UAV flight duration and ground transport times. Simulated blood products included packed red blood cells, platelet concentrate, and fresh frozen plasma. For each blood product type, three UAV flights were conducted. Temperature was monitored during transport using a probe coupled to a data logger inside each simulated blood product unit. RESULTS All flights were conducted successfully without any adverse events or safety concerns reported. The heaviest payload transported was 6.4 kg, and the drone speed throughout all nine flights was 10 m/s. The mean UAV transportation time was significantly faster than ground delivery (17:06 ± 00:04 minutes vs. 28:54 ± 01:12 minutes, p < 0.0001). The mean ± SD initial temperature for packed red blood cells was 4.4°C ± 0.1°C with a maximum 5% mean temperature variability from departure to landing. For platelet concentrates, the mean ± SD initial temperature was 21.6°C ± 0.5°C, and the maximum variability observed was 0.3%. The mean ± SD initial fresh frozen plasma temperature was −19°C ± 2°C, and the greatest temperature variability was from −17°C ± 2°C to −16°C ± 2°C. CONCLUSIONS Unmanned aerial vehicle transportation of simulated blood products was significantly faster than ground delivery. Simulated blood product temperatures remained within their respective acceptable ranges throughout transport. Further studies assessing UAV transport of real blood products in populated areas are warranted. LEVEL OF EVIDENCE Therapeutic/care management, level IV.

Summary Background Primary spontaneous pneumothorax occurs in otherwise healthy young patients. Optimal management is not defined and often results in prolonged hospitalisation. Data on efficacy of ambulatory options are poor. We aimed to describe the duration of hospitalisation and safety of ambulatory management compared with standard care. Methods In this open-label, randomised controlled trial, adults (aged 16–55 years) with symptomatic primary spontaneous pneumothorax were recruited from 24 UK hospitals during a period of 3 years. Patients were randomly assigned (1:1) to treatment with either an ambulatory device or standard guideline-based management (aspiration, standard chest tube insertion, or both). The primary outcome was total length of hospital stay including re-admission up to 30 days after randomisation. Patients with available data were included in the primary analysis and all assigned patients were included in the safety analysis. The trial was prospectively registered with the International Standard Randomised Clinical Trials Number, ISRCTN79151659. Findings Of 776 patients screened between July, 2015, and March, 2019, 236 (30%) were randomly assigned to ambulatory care (n=117) and standard care (n=119). At day 30, the median hospitalisation was significantly shorter in the 114 patients with available data who received ambulatory treatment (0 days [IQR 0–3]) than in the 113 with available data who received standard care (4 days [IQR 0–8]; p

Background: Shockable rythms are common among victims of witnessed public out-of-hospital cardiac arrest (OHCA), but bystander defibrillation with a public automated external defibrillator (PAED) is rare. Instructions from the emergency medical dispatcher and mobile applications were developed to expedite the localization of PAEDs, but their effectiveness has not been compared. Methods: Participants were enrolled in a three-armed randomized simulation where they witnessed a simulated OHCA on a university campus, were instructed to locate a PAED and provide defibrillation. Participants were stratified and randomized to: (1) no assistance in finding the PAED, (2) assistance from a geolocalization mobile application (AED-Quebec), or (3) verbal assistance. Data collectors tracked each participant’s time elapsed and distance traveled to shock. Results: Of the 52 volunteers participating in the study (46% male, mean age 37), 17 were randomized to the no assistance group, 18 to the mobile application group and 17 to the verbal group. Median (IQR) time to shock was respectively 10:00 min (7:49-10:00), 9:44 (6:30-10:00), and 5:23 (4:11-9:08), with statistically significant differences between the verbal group and the other groups (p≤0.01). The success rate for defibrillation in

IntroductionRapid access to defibrillation is a key element in the management of out-of-hospital cardiac arrests (OHCAs). Public automated external defibrillators (PAEDs) are becoming increasingly available, but little information exists regarding the relation between the proximity to the arrest and their usage in urban areas.MethodsThis study is a retrospective, observational, cross-sectional analysis of non-traumatic OHCA during a 24-month period in the greater Montreal area (Quebec, Canada). Using logistic regression, bystander shock odds are described with regards to distance from the OHCA scene to the nearest PAED, adjusted for prehospital care arrival delay and time of day, and stratifying for type of location.ResultsOut of a total of 2,443 OHCA victims identified, 77 (3%) received bystander PAED shock, 622 (26%) occurred out-of-home, and 743 (30%) occurred during business hours. When controlling for time (business hours versus other hours) and minimum response delay for prehospital care arrival, a marginal negative association was found between bystander shock and distance to the nearest PAED in logged meters (aOR=0.80; CI, 0.64-0.99) for out-of-home cardiac arrests. No significant association was found between distance and bystander shock for at-home arrests. Out-of-home victims had significantly higher odds of receiving bystander shock up to 175 meters of distance to a PAED inclusively (aOR=2.52; CI, 1.07-5.89).ConclusionFor out-of-home cardiac arrests, proximity to a PAED was associated with bystander shock in the greater Montreal area. Strategies aiming to increase accessibility and use of these life-saving devices could further expand this advantage by assisting bystanders in rapidly locating nearby PAEDs.Neves BriardJ, de MontignyL, RossD, de ChamplainF, SegalE. Is distance to the nearest registered public automated defibrillator associated with the probability of bystander shock for victims of out-of-hospital cardiac arrest?Prehosp Disaster Med. 2018;33(2):153–159.

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.

Article chosenEbinger M, Winter B, Wendt M, et al. Effect of the use of ambulance-based thrombolysis on time to thrombolysis in acute ischemic stroke: a randomized clinical trial. JAMA 2014;311(16):1622-31.Clinical questionDoes prehospital thrombolysis in specialized ambulances reduce delay to thrombolysis in acute ischemic stroke?ObjectiveTo determine the effect of prehospital thrombolysis for acute ischemic stroke administered in specialized ambulances on delay in thrombolytic administration, thrombolysis rate, post-thrombolysis intracerebral hemorrhage, and 7-day mortality.

Background. There is no foolproof strategy to identify a pulmonary embolism (PE) in the emergency department, and atypical presentations are common. Negative test results may mislead physicians away from the diagnosis of PE.Objectives. The current report aims to raise awareness of an unusual presentation of massive PE and its diagnosis and management, in the face of limited evidence in the scientific literature.Case Reports. We report the case of a patient with a negative D-Dimer and a negative Computed Tomography contrast angiography of the chest who was diagnosed twenty-seven hours later with a massive PE, as suggested by a bedside echocardiography. The patient was successfully treated with tenecteplase (TNK).Conclusions/Summary. Pulmonary embolism frequently presents atypically and is often a diagnostic challenge. There is limited literature about the treatment of massive PE. Further research on bedside echocardiography for diagnosing PE in unstable patients is warranted. In addition, further study into new thrombolytic agents like tenecteplase in the context of massive and submassive PE is warranted.