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Mild traumatic brain injury (mTBI) is a common problem. Depending on diagnostic criteria, 13 to 62% of those patients develop persistent post-concussion symptoms (PPCS). The main objective of this prospective multi-center study is to derive and validate a clinical decision rule (CDR) for the early prediction of PPCS. Patients aged ≥14 years were included if they presented to one of our seven participating emergency departments (EDs) within 24 h of an mTBI. Clinical data were collected in the ED, and symptom evolution was assessed at 7, 30 and 90 days post-injury using the Rivermead Post-Concussion Questionnaire (RPQ). The primary outcome was PPCS at 90 days after mTBI. A predictive model called the Post-Concussion Symptoms Rule (PoCS Rule) was developed using the methodological standards for CDR. Of the 1083 analyzed patients (471 and 612 for the derivation and validation cohorts, respectively), 15.6% had PPCS. The final model included the following factors assessed in the ED: age, sex, history of prior TBI or mental health disorder, headache in ED, cervical sprain and hemorrhage on computed tomography. The 7-day follow-up identified additional risk factors: headaches, sleep disturbance, fatigue, sensitivity to light, and RPQ ≥21. The PoCS Rule had a sensitivity of 91.4% and 89.6%, a specificity of 53.8% and 44.7% and a negative predictive value of 97.2% and 95.8% in the derivation and validation cohorts, respectively. The PoCS Rule will help emergency physicians quickly stratify the risk of PPCS in mTBI patients and better plan post-discharge resources.

OBJECTIVE Approximately 10% of patients with mild traumatic brain injury (mTBI) have intracranial bleeding (complicated mTBI) and 3.5% eventually require neurosurgical intervention, which is mostly available at centers with a higher level of trauma care designation and often requires interhospital transfer. In 2018, the Brain Injury Guidelines (BIG) were updated in the United States to guide emergency department care and patient disposition for complicated mild to moderate TBI. The aim of this study was to validate the sensitivity and specificity of the updated BIG (uBIG) for predicting the need for interhospital transfer in Canadian patients with complicated mTBI. METHODS This study took place at three level I trauma centers. Consecutive medical records of patients with complicated mTBI (Glasgow Coma Scale score 13–15) who were aged ≥ 16 years and presented between September 2016 and December 2017 were retrospectively reviewed. Patients with a penetrating trauma and those who had a documented cerebral tumor or aneurysm were excluded. The primary outcome was a combination of neurosurgical intervention and/or mTBI-related death. Sensitivity and specificity analyses were performed. RESULTS A total of 477 patients were included, of whom 8.4% received neurosurgical intervention and 3% died as a result of their mTBI. Forty patients (8%) were classified as uBIG-1, 168 (35%) as uBIG-2, and 269 (56%) as uBIG-3. No patients in uBIG-1 underwent neurosurgical intervention or died as a result of their injury. This translates into a sensitivity for predicting the need for a transfer of 100% (95% CI 93.2%–100%) and a specificity of 9.4% (95% CI 6.8%–12.6%). Using the uBIG could potentially reduce the number of transfers by 6% to 25%. CONCLUSIONS The patients in uBIG-1 could be safely managed at their initial center without the need for transfer to a center with a higher level of neurotrauma care. Although the uBIG could decrease the number of transfers, further refinement of the criteria could improve its specificity.

The no-flow time (NFT) can help establish prognosis in out-of-hospital cardiac arrest (OHCA) patients. It is often used as a selection criterion for extracorporeal resuscitation. In patients with an unwitnessed OHCA for whom the NFT is unknown, the initial rhythm has been proposed to identify those more likely to have had a short NFT. Our objective was to determine the predictive accuracy of an initial shockable rhythm for an NFT of 5 minutes or less (NFT ≤ 5).Retrospective analysis of prospectively collected data.Prehospital OHCA in eight U.S. and three Canadian sites.A total of 28,139 adult patients with a witnessed nontraumatic OHCA were included, of whom 11,228 (39.9%) experienced an emergency medical service-witnessed OHCA (NFT = 0), 695 (2.7%) had a bystander-witnessed OHCA, and an NFT less than or equal to 5, and 16,216 (57.6%) with a bystander-witnessed OHCA and an NFT greater than 5.Sensitivity, specificity, and likelihood ratios of an initial shockable rhythm to identify patients with an NFT less than or equal to 5 minutes.The sensitivity of an initial shockable rhythm to identify patients with an NFT less than or equal to 5 was poor (25% [95% CI, 25-26]), but specificity was moderate (70% [95% CI, 69-71]). The positive and likelihood ratios were inverted (negative accuracy) (positive likelihood ratio, 0.76 [95% CI, 0.74-0.79]; negative likelihood ratio, 1.12 [95% CI, 1.10-1.12]). Including only patients with a bystander-witnessed OHCA improved the sensitivity to 48% (95% CI, 45-52), the positive likelihood ratio to 1.45 (95% CI, 1.33-1.58), and the negative likelihood ratio to 0.77 (95% CI, 0.72-0.83), while slightly lowering the specificity to 67% (95% CI, 66-67).Our analysis demonstrated that the presence of a shockable rhythm at the time of initial assessment was poorly sensitive and only moderately specific for OHCA patients with a short NFT. The initial rhythm, therefore, should not be used as a surrogate for NFT in clinical decision-making.

Objectives To determine the predicting demographic, clinical and radiological factors for neurosurgical intervention in complicated mild traumatic brain injury (mTBI) patients. Methods Design: retrospective multicenter cohort study. Participants: patients aged ≥16 presenting to all level-I trauma centers in Quebec between 09/2016 and 12/2017 with mTBI(GCS 13-15) and complication on initial head CT (intracranial hemorrhage/skull fracture). Procedure: Consecutive medical records were reviewed and separated into two groups: no neurosurgical intervention and neurosurgical intervention (NSI). Main outcome: neurosurgical intervention. Analysis: multiple logistic regression model. Results Four hundred and seventy-eight patients were included and 40 underwent NSI. One patient had radiological deterioration but no clinical deterioration prior to surgery. Subdural hemorrhage ≥4 mm width (OR:3.755 [95% CI:1.290-10.928]) and midline shift (OR:7.507 [95% CI: 3.317-16.989]) increased the risk of NSI. Subarachnoid hemorrhage was associated with a lower risk of NSI (OR:0.312 [95% CI: 0.136-0.713]). All other intracranial hemorrhages were not associated with NSI. Conclusion Radiological deterioration was not associated with the incidence of NSI. Subdural hemorrhage and midline shift should be predicting factors for neurosurgery. Some patients with isolated findings such as subarachnoid hemorrhage could be safely managed in their original center without being transferred to a level-I trauma center.

The trauma team leader (TTL) is a "model" of a specifically dedicated team leader in the emergency department (ED), but its benefits are uncertain. The primary objective was to assess the impact of the TTL on 72-hour mortality. Secondary objectives included 24-hour mortality and admission delays from the ED.Major trauma admissions (Injury Severity Score (ISS)≥12) in 3 Canadian Level-1 trauma centres were included from 2003 to 2017. The TTL program was implemented in centre 1 in 2005. An interrupted time series (ITS) analysis was performed. Analyses account for the change in patient case-mix (age, sex, and ISS). The two other centres were used as control in sensitivity analyses RESULTS: Among 20,193 recorded trauma admissions, 71.7% (n=14,479) were males. The mean age was 53.5 ± 22.0 years. The median [IQR] ISS was 22 [16-26]. TTL implementation was not associated with a change in the quarterly trends of 72-hour or 24-hour mortality: adjusted estimates with 95% CI were 0.32 [-0.22;0.86] and -0.07 [-0.56;0.41] percentage-point change. Similar results were found for the proportions of patients admitted within 8 hours of ED arrival (0.36 [-1.47;2.18]). Sensitivity analyses using the two other centres as controls yielded similar results.TTL implementation was not associated with changes in mortality or admission delays from the ED. Future studies should assess the potential impact of TTL programs on other patient-centred outcomes using different quality of care indicators.

IntroductionRecent evidence has shown that vitamin C has some analgesic properties in addition to its antioxidant effect and can, therefore, reduce opioid use during recovery time. Vitamin C analgesic effect has been explored mostly during short-term postoperative context or in disease-specific chronic pain prevention, but never after acute musculoskeletal injuries, which are often seen in the emergency department (ED). The protocol’s primary aim is to compare the total morphine 5 mg pills consumed during a 2-week follow-up between patients receiving vitamin C or a placebo after ED discharge for an acute musculoskeletal pain complaint.Methods and analysisWe will conduct a two-centre double-blind randomised placebo-controlled trial with 464 participants distributed in two arms, one group receiving 1000 mg of vitamin C two times a day for 14 days and another one receiving a placebo. Participants will be ≥18 years of age, treated in ED for acute musculoskeletal pain present for less than 2 weeks and discharged with an opioid prescription for home pain management. Total morphine 5 mg pills consumed during the 2-week follow-up will be assessed via an electronic (or paper) diary. In addition, patients will report their daily pain intensity, pain relief, side effects and other types of pain medication or other non-pharmacological approach used. Three months after the injury, participants will also be contacted to evaluate chronic pain development. We hypothesised that vitamin C, compared with a placebo, will reduce opioid consumption during a 14-day follow-up for ED discharged patients treated for acute musculoskeletal pain.Ethics and disseminationThis study has received approval from the Ethics Review Committee from the ‘Comité d'éthique de la recherche du CIUSSS du Nord-de-l'Île-de-Montréal (No 2023–2442)’. Findings will be disseminated through scientific conferences and peer-reviewed journal publication. The data sets generated during the study will be available from the corresponding author on reasonable request.Trial registration numberNCT05555576ClinicalTrials.Gov PRS.

Treatment of acute pain after emergency department (ED) discharge remains a challenge in the opioid crisis context. Our objective was to determine the proportion of patients using opioid vs non-opioid pain medication following discharge from the ED with acute pain, and the association of type of pain medication with average pain intensity before pain medication intake and report of pain relief.This was a prospective cohort study of ED patients aged ≥ 18 years with an acute pain (≤ 2 weeks) who were discharged with an opioid prescription. Patients completed a 14-day diary assessing daily pain intensity level before each pain medication intake (0-10 numeric rating scale), type of pain medication use (opioid vs non-opioid), and if pain was relieved by the medication used that day. Multilevel analyses were used to compare the effect of type of analgesic used on pain intensity and relief.A total of 381 participants completed the 14-day diary; 50% were women and median age was 54 years (IQR = 43-66). Average daily pain intensity before pain medication intake was significantly higher for patients who used opioids (5.9; 95% CI 5.7-6.2) as compared to non-opioid analgesics (4.2; 95% CI 4.0-4.5) or no pain medication (2.2; 95% CI 1.9-2.5). Controlling for pain intensity, patients using opioids were more likely to report a pain relief (OR = 1.3; 95% CI 1.1-1.8) as compared to those who used non-opioid analgesics.Overall, opioids appear to be effective and used as intended by the prescribing physician.RéSUMé: OBJECTIFS: Le traitement de la douleur aiguë après la sortie des départements d’urgence (DU) reste un défi dans le contexte de la crise des opioïdes. Notre objectif était de déterminer la proportion de patients utilisant des analgésiques opioïdes par rapport aux analgésiques non opioïdes après leur sortie des urgences avec une douleur aiguë, et l'association du type d'analgésique avec l'intensité moyenne de la douleur avant la prise d'analgésiques et le soulagement de la douleur rapporté. LES MéTHODES: Il s'agissait d'une étude de cohorte prospective de patients (DU) âgés de ≥18 ans souffrant de douleurs aiguës (≤ 2 semaines) et ayant reçu une ordonnance d'opioïdes à leur sortie de l'hôpital. Les patients ont rempli un journal de 14 jours évaluant le niveau d'intensité de la douleur quotidienne avant chaque prise de médicaments anti-douleur (échelle d'évaluation numérique de 0 à 10), le type d'utilisation des médicaments anti-douleur (opioïdes contre non opioïdes), et si la douleur était soulagée par les médicaments utilisés ce jour-là. Des analyses multiniveaux ont été utilisées pour comparer l'effet du type d'analgésique utilisé sur l'intensité et le soulagement de la douleur. RéSULTATS: Au total, 381 participants ont rempli le journal de 14 jours; 50% étaient des femmes et l'âge médian était de 54 ans (EI = 43–66). L'intensité moyenne de la douleur quotidienne avant la prise d'analgésiques était significativement plus élevée chez les patients qui prenaient des opioïdes (5.9; 95% IC: 5.7–6.2) par rapport aux analgésiques non opioïdes (4.2; 95% IC: 4.0–4.5) ou à l'absence d'analgésiques (2.2; 95% IC: 1.9–2.5). En contrôlant l'intensité de la douleur, les patients utilisant des opioïdes étaient plus susceptibles de déclarer un soulagement de la douleur (OR = 1.3; 95% CI: 1.1−1.8) par rapport à ceux qui utilisaient des analgésiques non opioïdes. CONCLUSION: Dans l'ensemble, les opioïdes semblent être efficaces et utilisés comme prévu par le médecin prescripteur.

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

Background Older adults have become a significant portion of the trauma population. Exploring their specificities is crucial to better meet their specific needs. The primary objective was to evaluate the temporal changes in the incidence, demographic and trauma characteristics, injury pattern, in-hospital admission, complications, and outcome of older trauma patients. Methods A multicenter retrospective cohort study was conducted using the Quebec Trauma Registry. Patients aged ≥16 years admitted to one of the three adult level-I trauma centers between 2003 and 2017 were included. Descriptive analyses and trend-tests were performed to describe temporal changes. Results A total of 53,324 patients were included, and 24,822 were aged ≥65 years. The median [IQR] age increased from 57[36–77] to 67[46–82] years, and the proportion of older adults rose from 41.8% in 2003 to 54.1% in 2017. Among those, falls remain the main mechanism (84.7%-88.3%), and the proportion of severe thorax (+8.9%), head (+8.7%), and spine (+5%) injuries significantly increased over time. The proportion of severely injured older patients almost doubled (17.6%-32.3%), yet their mortality decreased (-1.0%). Their average annual bed-days consumption also increased (+15,004 and +1,437 in non-intensive care wards and ICU, respectively). Conclusions Since 2014, older adults have represented the majority of admissions in Level-I trauma centers in Québec. Their bed-days consumption has greatly increased, and their injury pattern and severity have deeply evolved, while we showed a decrease in mortality.

BackgroundClinical assessment of patients with mild traumatic brain injury (mTBI) is challenging and overuse of head CT in the ED is a major problem. Several studies have attempted to reduce unnecessary head CTs following a mTBI by identifying new tools aiming to predict intracranial bleeding. Higher levels of S100B protein have been associated with intracranial haemorrhage following a mTBI in previous literature. The main objective of this study is to assess whether plasma S100B protein level is associated with clinically significant brain injury and could be used to reduce the number of head CT post-mTBI.MethodsStudy design: secondary analysis of a prospective multicentre cohort study conducted between 2013 and 2016 in five Canadian EDs. Inclusion criteria: non-hospitalised patients with mTBI with a GCS score of 13–15 in the ED and a blood sample drawn within 24 hours after the injury. Data collected: sociodemographic and clinical data were collected in the ED. S100B protein was analysed using ELISA. All CT scans were reviewed by a radiologist blinded to the biomarker results. Main outcome: the presence of clinically important brain injury.Results476 patients were included. Mean age was 41±18 years old and 150 (31.5%) were women. Twenty-four (5.0%) patients had a clinically significant intracranial haemorrhage. Thirteen patients (2.7%) presented a non-clinically significant brain injury. A total of 37 (7.8%) brain injured patients were included in our study. S100B median value (Q1–Q3) was: 0.043 µg/L (0.008–0.080) for patients with clinically important brain injury versus 0.039 µg/L (0.023–0.059) for patients without clinically important brain injury. Sensitivity and specificity of the S100B protein level, if used alone to detect clinically important brain injury, were 16.7% (95% CI 4.7% to 37.4%) and 88.5% (95% CI 85.2% to 91.3%), respectively.ConclusionPlasma S100B protein level was not associated with clinically significant intracranial lesion in patients with mTBI.

IntroductionOlder adults have become a significant portion of the trauma population. The primary objective was to evaluate the temporal changes in the incidence, demographic and trauma characteristics, injury pattern, in-hospital admission, complications, and outcome of older trauma patients. MethodsA multicentre retrospective study was conducted using the Quebec Trauma Registry. Patients aged ≥16 years, admitted to one of the three adult level-I trauma centre between 2003 and 2017 were included. Descriptive analyses were performed.ResultsWe included 53,324 patients and 24,822 were aged ≥65 years. The median age increased from 57[IQR 36-77] to 67[IQR 46-82] years and the proportion of older adults rose from 41.8% to 54.1%. Among those, fall remained the main mechanism (84.7%-88.3%) and the proportion of severe thorax (+8.9%), head (+8.7%), and spine (+5%) injuries increased over time. The proportion of severely injured older patients almost doubled (17.6%-32.3%), yet their mortality decreased (-1%). Their average number of annual bed-days consumption also increased (+15,004 and +1,437 in non-intensive care ward and ICU, respectively).ConclusionsSince 2014, older adults represent the majority of admissions in Level-I trauma centres in Québec. Their bed-days consumption has greatly increased, their injury pattern and severity has deeply evolved, while we showed a decrease in mortality.

Studies evaluating the prognostic value of the pulseless electrical activity (PEA) heart rate in out-of-hospital cardiac arrest (OHCA) patients have reported conflicting results. The objective of this study was to evaluate the association between the initial PEA heart rate and favorable clinical outcomes for OHCA patients. The present post-hoc cohort study used the Resuscitation Outcomes Consortium Cardiac Epidemiologic Registry Version 3, which included OHCA patients in seven US and three Canadian sites from April 2011 to June 2015. The primary outcome was survival to hospital discharge and the secondary outcome was survival with a good functional outcome. For the primary analysis, the patients were separated into eight groups according to their first rhythms and PEA heart rates: (1) initial PEA heart rate of 1-20 beats per minute (bpm); (2) 21-40 bpm; (3) 41-60 bpm; (4) 61-80 bpm; (5) 81-100 bpm; (6) 101-120 bpm; (7) over 120 bpm; (8) initial shockable rhythm (reference category). Multivariable logistic regression models were used to assess the associations of interest. We identified 17,675 patients (PEA: 7,089 [40.1%]; initial shockable rhythm: 10,797 [59.9%]). Patients with initial PEA electrical frequencies ≤100 bpm were less likely to survive to hospital discharge than patients with initial shockable rhythms (1-20 bpm: adjusted odds ratio [AOR] = 0.15 [95%CI 0.11-0.21]; 21-40 bpm: AOR = 0.21 [0.18-0.25]; 41-60 bpm: AOR = 0.30 [0.25-0.36]; 61-80 bpm: AOR = 0.37 [0.28-0.49]; 81-100 bpm: AOR = 0.55 [0.41-0.65]). However, there were no statistical outcome differences between PEA patients with initial electrical frequencies of >100 bpm and patients with initial shockable rhythms (101-120 bpm: AOR = 0.65 [95%CI 0.42-1.01]; >120 bpm: AOR = 0.72 [95%CI 0.37-1.39]). Similar results were observed for survival with good functional outcomes (101-120 bpm: AOR = 0.60 [95%CI 0.31-1.15]; >120 bpm: AOR = 1.08 [95%CI 0.50-2.28]). We observed a good association between higher initial PEA electrical frequency and favorable clinical outcomes for OHCA patients. As there is no significant difference in outcomes between patients with initial PEA heart rates of more than 100 bpm and those with initial shockable rhythms, we can hypothesize that these patients could be considered in the same prognostic category.

Background Patients hospitalized following a traumatic injury will be frequently treated with opioids during their stay and after discharge. We examined the relationship between acute phase ( Methods In a retrospective multicenter cohort study conducted on registry data, we included all patients ≥65 years admitted (hospital stay >2 days) for injury in 57 trauma centers in the province of Quebec (Canada) between 2004 and 2014. We searched for opioid poisoning and opioid use disorder from ICD-9 to ICD-10 code diagnosis 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, using Cox proportional hazards regressions. Results A total of 70,314 admissions 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 (0.27%; 95% CI: 0.23%-0.31%) were hospitalized for opioid poisoning and 73 (0.10%; 95% CI: 0.08%-0.13%) were diagnosed with opioid use disorder. Having filled an opioid prescription within 3 months of injury was associated with an increased hazard ratio of opioid poisoning (2.8; 95% CI: 2.1-3.8) and opioid use disorder (4.2; 95% CI: 2.4-7.4) after the injury. However, history of opioid poisoning (2.6; 95% CI: 1.1-5.8), of substance use disorder (4.3; 95% CI: 2.4-7.7), or of the opioid prescription filled (2.8; 95% CI: 2.2-3.6) before the trauma, was also related to opioid poisoning or opioid use disorder after the injury. 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 a history of substance use disorder, opioid poisoning or opioid use.

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

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

This study aimed to evaluate the association between the quantity of subcutaneous fat (assessed by skinfold thickness) and the inter-device agreement of 2 tissue oximeters.This is a prospective cohort study.This study was conducted in a tertiary care academic urban hospital.Healthy volunteers were recruited.All patients recruited had their tissue saturations and skinfold thickness measured at 4 different sites (shoulder, forearm, knee, and calf) on both sides of the body using 2 tissue oximeters, the INVOS 5100C and the EQUANOX 7600.Higher skinfold measures were associated with an increase in the difference between measures provided by both oximeters (slope = -0.59, Pearson correlation coefficient = -0.51, p0.001). This observed association persisted in a linear mixed model (-0.48 [95% confidence interval [CI] -0.61 to -0.36], p0.001). The sex of the volunteers also influenced the inter-oximeter agreement (women: -5.77 [95% CI -8.43 to -3.11], p0.001), as well as the forearm sites (left forearm: -7.16 [95% CI -9.85 to -4.47], p0.001; right forearm:-7.01 [95% CI -9.61 to -4.40], p0.001).The inter-device agreement of the 2 studied oximeters is correlated to the quantity of subcutaneous fat. Monitoring using tissue oximetry should be interpreted with great care when sensors are placed on sites with a significant quantity of subcutaneous fat. In addition to the monitoring of cerebral oximetry, following the variations of saturations at the same peripheral site seems to remain the most secure way to use that technology for the monitoring of critically ill patients.

Analgesia with fentanyl can be associated with hyperalgesia (higher sensitivity to pain) and can contribute to escalating opioid use. Our objective was to assess the relationship between emergency department (ED) acute pain management with fentanyl compared to other opioids, and the quantity of opioids consumed two-week after discharge. We hypothesized that the quantity of opioids consumed would be higher for patients treated with fentanyl compared to those treated with other opioids.Patients were selected from two prospective cohorts assessing opioids consumed after ED discharge. Patients ≥18 years treated with an opioid in the ED for an acute pain condition (≤2 weeks) and discharged with an opioid prescription were included. Patients completed a 14-day paper or electronic diary of pain medication use. Quantity of 5 mg morphine equivalent tablets consumed during a 14-day follow-up by patients treated with fentanyl compared to those treated with other opioids during their ED stay were analyzed using a multiple linear regression and propensity scores.We included 707 patients (mean age ± SD: 50 ± 15 years, 47% women) in this study. During follow-up, patients treated with fentanyl (N = 91) during their ED stay consumed a median (IQR) of 5.8 (14) 5 mg morphine equivalent pills compared to 7.0 (14) for those treated with other opioids (p = 0.05). Results were similar using propensity score sensitivity analysis. However, after adjusting for confounding variables, ED fentanyl treatment showed a trend, but not a statistically significant association with a decreased opioid consumption during the 14-day follow-up (B = -2.4; 95%CI = -5.3 to 0.4; p = 0.09).Patients treated with fentanyl during ED stay did not consume more opioids after ED discharge, compared to those treated with other opioids. If fentanyl does cause more hyperalgesia compared to other opioids, it does not seem to have a significant impact on opioid consumption after ED discharge.

patients with mTBI from 7 Canadian Emergency Departments.Research assistants conducted telephone follow-ups using the Rivermead Postconcussion Symptoms Questionnaire (RPQ) at 7-, 30- and 90 days post-mTBI.Presence of PCS (RPQ: ≥3 symptoms) at 90 days.RPQ score ≥21, prevalence of individual RPQ symptoms and patients' return to normal activities, at 7- and 90-days. Adjusted risk ratios (RR) were calculated.

Aims For out-of-hospital cardiac arrest (OHCA) patients, the influence of the delay before the initiation of resuscitation, termed the no-flow time (NFT), and duration of bystander-only resuscitation low-flow time (BLFT) on the type of electrical rhythm observed has not been well described. The objective of this study is to determine the relationship between NFT, BLFT and the likelihood of a shockable rhythm over time. Methods Using a North American prospective registry (2005–2015; mostly urban settings), we selected adult (18 years and over) patients who experienced a witnessed OHCA from a suspected cardiac etiology. Patients with an emergency medical services witnessed OHCA were only included in sensitivity analyses. The association between the NFT, BLFT and the presence of a shockable rhythm was evaluated using a multivariable logistic regression adjusting for the registry version, age, sex, and public location. Results A total of 229,632 patients were logged in the registry, 50,957 of whom were included. Of these, 17,704 (34.7%) had an initial shockable rhythm. After the first minute, a significant decrease over time in the occurrence of shockable rhythm is observed but is slower when bystander cardiopulmonary resuscitation (CPR) is provided (each supplemental minute of BLFT: adjusted odds ratio = 0.95, 95 %CI = 0.94–0.95; each supplemental minute of NFT: adjusted odds ratio = 0.91, 95 %CI = 0.90–0.91]). Conclusions In this large observational study, we were able to demonstrate that longer NFT were associated with lower odds of shockable presenting rhythms. Bystander CPR significantly mitigates the degradation of shockable rhythms over time, strengthening the need to improve bystander CPR rates around the world.

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

This study assessed whether S-100β protein could be measured in urine when detectable in plasma after a mild traumatic brain injury (mTBI). Clinical data, plasma and urine samples were collected for the 46 adult patients prospectively enrolled in the emergency department (ED) of a Level 1 trauma center. S-100β protein concentrations were analysed using ELISA. S-100β protein was detectable in 91% and 71% of plasma and urine samples, but values were not correlated (r = 0.002). Urine sampling would have been a non-invasive procedure, but it does not appear to be useful in the ED during the acute phase after an mTBI.Détection de la protéine S-100β dans le plasma et l’urine à la suite d’un traumatisme cranio-cérébral léger (TCCL). Cette étude a cherché à évaluer dans quelle mesure la teneur en protéine S-100β peut être mesurée dans l’urine après avoir été détectée dans le plasma, et ce, à la suite d’un TCCL. Des données cliniques ainsi que des échantillons de plasma et d’urine ont alors été collectés chez quarante-six patients adultes recrutés de façon prospective dans le service d’urgence d’un centre tertiaire de traumatologie. La teneur en protéine S-100β a été analysée au moyen de la méthode immuno-enzymatique ELISA. La protéine S-100β s’est avérée détectable dans respectivement 91 % et 71 % des échantillons de plasma et d’urine. Cela dit, les valeurs obtenues ne sont pas apparues corrélées (r = 0,002). Le fait de recourir à des échantillons d’urine aurait pu représenter une procédure non-invasive ; cependant, elle ne semble pas utile dans un service d’urgence lors de la phase aigüe consécutive à un TCCL.

Purpose To evaluate the feasibility and accuracy of a combined magnetic resonance angiography (MRA) - magnetic resonance venography (MRV) protocol using contrast agents with blood pool properties, gadofosveset trisodium and gadobenate dimeglumine, in the evaluation of pulmonary embolus (PE) and deep venous thrombosis (DVT) as compared to the standard clinical reference imaging modalities; computed tomography pulmonary angiography (CTPA) and color-coded Duplex ultrasound (DUS). Materials and methods This prospective clinical study recruited patients presenting to the emergency department with clinical suspicion for PE and scheduled for a clinically indicated CTPA. We performed both MRA of the chest for the evaluation of PE as well as MRV of the pelvis and thighs to evaluate for DVT using a single contrast injection. MRA-MRV data was compared to the clinical reference standard CTPA and DUS, respectively. Results A total of 40 patients were recruited. The results on a per-patient basis comparing MRA to CTPA for pulmonary embolus yielded 100% sensitivity and 97% specificity. There was a small subset of patients that underwent clinical DUS to evaluate for DVT, which demonstrated a sensitivity and specificity of 100% for MRV. Conclusions This single-center, preliminary study using contrast agents with blood pool properties to perform a relatively rapid combined MRA-MRV exam to image for PE and above knee DVT shows potential as an alternative imaging choice to CTPA. Further large-scale, multicentre studies are warranted.

Limiting opioid overprescribing in the emergency department (ED) may be associated with decreases in diversion and misuse.To review and analyze interventions designed to reduce the rate of opioid prescriptions or the quantity prescribed for pain in adults discharged from the ED.MEDLINE, Embase, CINAHL, PsycINFO, and Cochrane Controlled Register of Trials databases and the gray literature were searched from inception to May 15, 2020, with an updated search performed March 6, 2021.Intervention studies aimed at reducing opioid prescribing at ED discharge were first screened using titles and abstracts. The full text of the remaining citations was then evaluated against inclusion and exclusion criteria by 2 independent reviewers.Data were extracted independently by 2 reviewers who also assessed the risk of bias. Authors were contacted for missing data. The main meta-analysis was accompanied by intervention category subgroup analyses. All meta-analyses used random-effects models, and heterogeneity was quantified using I2 values.The primary outcome was the variation in opioid prescription rate and/or prescribed quantity associated with the interventions. Effect sizes were computed separately for interrupted time series (ITS) studies.Sixty-three unique studies were included in the review, and 45 studies had sufficient data to be included in the meta-analysis. A statistically significant reduction in the opioid prescription rate was observed for both ITS (6-month step change, -22.61%; 95% CI, -30.70% to -14.52%) and other (odds ratio, 0.56; 95% CI, 0.45-0.70) study designs. No statistically significant reduction in prescribed opioid quantities was observed for ITS studies (6-month step change, -8.64%; 95% CI, -17.48% to 0.20%), but a small, statistically significant reduction was observed for other study designs (standardized mean difference, -0.30; 95% CI, -0.51 to -0.09). For ITS studies, education, policies, and guideline interventions (6-month step change, -33.31%; 95% CI, -39.67% to -26.94%) were better at reducing the opioid prescription rate compared with prescription drug monitoring programs and laws (6-month step change, -11.18%; 95% CI, -22.34% to -0.03%). Most intervention categories did not reduce prescribed opioid quantities. Insufficient data were available on patient-centered outcomes such as pain relief or patients' satisfaction.This systematic review and meta-analysis found that most interventions reduced the opioid prescription rate but not the prescribed opioid quantity for ED-discharged patients. More studies on patient-centered outcomes and using novel approaches to reduce the opioid quantity per prescription are needed.PROSPERO Identifier: CRD42020187251.

Aims Initial shockable rhythms may be a marker of shorter duration between collapse and initiation of cardiopulmonary resuscitation, known as no-flow time (NFT), for patients suffering an out-of-hospital cardiac arrest (OHCA). Eligibility for extracorporeal resuscitation is conditional on a short NFT. Patients with an unwitnessed OHCA could be candidate for extracorporeal resuscitation despite uncertain NFT if an initial shockable rhythm is a reliable stand-in. Herein, we sought to describe the sensitivity and specificity of an initial shockable rhythm for predicting a NFT of five minutes or less. Methods Using a registry of OHCA in Montreal, Canada, adult patients who experienced a witnessed non-traumatic OHCA, but who did not receive bystander cardiopulmonary resuscitation, were included. The sensitivity and specificity of an initial shockable rhythm for predicting a NFT of five minute or less were calculated. The association between the NFT and the presence of a shockable rhythm was evaluated using a multivariable logistic regression. Results A total of 2450 patients were included, of whom 863 (35%) had an initial shockable rhythm and 1085 (44%) a NFT of five minutes or less. The sensitivity of an initial shockable rhythm to predict a NFT of five minutes or less was 36% (95% confidence interval [95%CI] 33–39), specificity was 66% (95%CI 63–68), the positive likelihood ratio was 1.05 (95%CI 0.94–1.17) and the negative likelihood ratio of 0.97 (95%CI 0.92–1.03). The probabilities of observing a shockable rhythm stayed stable up to 15 minutes, while the probabilities of observing a PEA lowered rapidly initially. Longer NFT were associated with lower odds of observing an initial shockable rhythm (adjusted odds ratio = 0.97 [95%CI 0.94–0.99], p = 0.012). Conclusions An initial shockable rhythm is a poor predictor of a short NFT, despite there being an association between the NFT and the presence of a shockable rhythm.

Background Patients hospitalized following a traumatic injury will be frequently treated with opioids during their stay and after discharge. We examined the relationship between acute phase (2 days) for injury in 57 trauma centers in the province of Quebec (Canada) between 2004 and 2014. We searched for opioid poisoning and opioid use disorder from ICD-9 to ICD-10 code diagnosis 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, using Cox proportional hazards regressions. Results A total of 70,314 admissions 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 (0.27%; 95% CI: 0.23%-0.31%) were hospitalized for opioid poisoning and 73 (0.10%; 95% CI: 0.08%-0.13%) were diagnosed with opioid use disorder. Having filled an opioid prescription within 3 months of injury was associated with an increased hazard ratio of opioid poisoning (2.8; 95% CI: 2.1–3.8) and opioid use disorder (4.2; 95% CI: 2.4–7.4) after the injury. However, history of opioid poisoning (2.6; 95% CI: 1.1–5.8), of substance use disorder (4.3; 95% CI: 2.4–7.7), or of the opioid prescription filled (2.8; 95% CI: 2.2–3.6) before the trauma, was also related to opioid poisoning or opioid use disorder after the injury. 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 a history of substance use disorder, opioid poisoning or opioid use.

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.

There is still debate as to the safety of non-palliative opioid administration to chronic obstructive pulmonary disease (COPD) patients punctually treated for an acute complaint. All patients over 40 presenting at two university hospital emergency departments (Montréal Qc, Grenoble Fr) from March 2008 to September 2014 with dyspnea, abdominal pain or trauma were retrieved, and COPD patients were selected. Our primary endpoint was a composite criterion including invasive ventilation and death. Comparisons between visits in which opioid drugs were prescribed and those without opioids were performed using an inverse probability of treatment and censoring weight (IPTCW) estimator to adjust for baseline confounders. A survival weighted Cox model was used. 7799 visits by COPD patients were identified, corresponding to 4173 unique patients. Opioid drug prescription was reported in 1317 (16.9%) visits. After applying IPCTW weighting, opioid prescription was found to be associated with the composite criterion of poor clinical outcomes (HR = 4.73 (2.94; 7.61), p

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.

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

Objective. To identify factors, available at the time of trauma admission, associated with the development of chronic pain to allow testing of preventive approaches.Methods. In a retrospective observational cohort study, we included all patients ≥ 18 years old admitted for injury in 57 adult trauma centers in the province of Quebec (Canada) between 2004 and 2014. Chronic pain was defined as follows: treated in a chronic pain clinic, diagnosed with chronic pain, or received at least 2 prescriptions of chronic pain medications 3 to 12 months postinjury.Results. A total of 95,134 patients were retained for analysis. Mean age was 59.8 years (±21.7), and 52% were men. The causes of trauma were falls (63%) and motor vehicle accidents (22%). We identified 14,518 patients (15.3%; 95% CI: 15.1–15.5) who developed chronic pain. After controlling for confounding factors, the variables associated with chronic pain were spinal cord injury (OR = 3.9; 95% CI: 3.4–4.6), disc-vertebra trauma (OR = 1.6; 95% CI: 1.5–1.7), history of alcoholism (OR = 1.4; 95% CI: 1.2–1.7), history of anxiety (OR = 1.4; 95% CI: 1.2–1.5), history of depression (OR = 1.3; 95% CI: 1.1–1.4), and being female (OR = 1.3; 95% CI: 1.2–1.3). The area under the receiving operating characteristic curve derived from the model was 0.80.Conclusions. We identified risk factors present on hospital admission that can predict trauma patients who will develop chronic pain. These factors should be prospectively validated.

A change in prehospital redirection practice could potentially increase the proportion of E-CPR eligible patients with out-of-hospital cardiac arrest (OHCA) transported to extracorporeal cardiopulmonary resuscitation (E-CPR) capable centers. The objective of this study was to quantify this potential increase of E-CPR candidates transported to E-CPR capable centers.Adults with non-traumatic OHCA refractory to 15min of resuscitation were selected from a registry of adult OHCA collected between 2010 and 2015 in Montreal, Canada. Using this cohort, three simulation scenarios allowing prehospital redirection to E-CPR centers were created. Stringent eligibility criteria for E-CPR and redirection for E-CPR (e.g. age60years old, initial shockable rhythm) were used in the first scenario, intermediate eligibility criteria (e.g. age65years old, at least one shock given) in the second scenario and inclusive eligibility criteria (e.g. age70years old, initial rhythm ≠ asystole) in the third scenario. All three scenarios were contrasted with equivalent scenarios in which patients were transported to the closest hospital. Proportions were compared using McNemar's test.The proportion of E-CPR eligible patients transported to E-CPR capable centers increased in each scenario (stringent criteria: 48 [24.5%] vs 155 patients [79.1%], p0.001; intermediate criteria: 81 [29.6%] vs 262 patients [95.6%], p0.001; inclusive criteria: 238 [23.9%] vs 981 patients [98.5%], p0.001).A prehospital redirection system could significantly increase the number of patients with refractory OHCA transported to E-CPR capable centers, thus increasing their access to this potentially life-saving procedure, provided allocated resources are planned accordingly.

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

Objective Hypersomnia is frequently reported after mild traumatic brain injury (mTBI), but its cause(s) remain elusive. This study examined sleep/wake activity after mTBI and its association with pain, a comorbidity often associated with insomnia. Methods Actigraphy recording was performed for 7 ± 2 consecutive days in 56 individuals at one month post-mTBI (64% male; 38 ± 12 years), 24 individuals at one year post-mTBI (58% male; 44 ± 11years), and in 20 controls (50% male; 37 ± 12 years). Pain intensity and its effect on quality of life was assessed with a visual analogue scale and the Short Form Health Survey (SF-36) bodily pain subscale. Results Overall, few differences in sleep/wake patterns were found between mTBI patients and controls. However, higher percentages of mTBI individuals with moderate-to-severe pain were found to require more than eight hours of sleep per day (37% vs11%; p = 0.04) and to be frequent nappers (defined as those who took three or more naps per week) (42% vs 22%; p = 0.04) compared to those with mild or no pain at one month postinjury. Correcting for age and depression, The SF-36 score was found to be a significant predictor of sleep duration exceeding eight hours per day at one month (odds ratio = 0.95; 95% confidence interval = 0.92–0.99; p = 0.01), but not at one year post-mTBI. Pain and increased sleep need (in terms of hours per day or napping frequency) were found to co-exist in as much as 29% of mTBI patients at one month postinjury. Conclusion Pain could be associated with more pronounced sleep need in about one-third of mTBI patients during early recovery. Unalleviated pain, found in more than 60% of mTBI patients, should therefore be looked for in all mTBI patients reporting new onset of sleep disorder, not only in those with insomnia.

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.

The objective of this study is two-fold: to propose an alternative approach for computing the productivity of physicians in emergency departments (EDs); and, to allocate productivity-driven schedules to ED physicians so as to align physician productivity with demand (patient arrivals), without decreasing fairness between physicians, in order to improve patient wait times. Historical data between 2008 and 2017 from the Sacre-Coeur Montreal Hospital ED is analysed and used to predict the demand and to estimate the productivity of each physician. These estimates are incorporated into a mathematical programming model that identifies feasible schedules to physicians that minimise the difference between patients' demand and physicians' productivity, along with the violation of physicians' preferences and fairness in the distribution of shifts. Results on real-world-based data show that when physician productivity is included in the allocation of schedules, demand under-covering is reduced by 10.85% and the fairness between physicians is maintained. However, physicians' preferences (e.g., sum of the differences between the number of wanted shifts and the number of allocated shifts) deteriorates by 7.61%. By incorporating the productivity of physicians in the scheduling process, we see a reduction in EDs overcrowding and an improvement in the overall quality of health-care services.

Objectives This study seeks to evaluate the incidence rate of heterotopic ossification (HO) formation in patients afflicted by an isolated limb fracture (ILF) and a concomitant mild traumatic brain injury (mTBI). Methods The current study is an observational study including ILF patients with or without a concomitant mTBI recruited from an orthopedic clinic of a Level 1 Trauma Hospital. Patients were diagnosed with a mTBI according to the American Congress of Rehabilitation Medicine (ACRM) criteria. Radiographs taken on average 3 months post-trauma were analyzed separately by two distinct specialists for the presence of HO proximally to the fracture site (joints or extra joints). Both raters referred to Brooker's and Della's Valle's classification to establish signs of HO. First, analyses were conducted for the full sample. Secondly, a matched cohort was used in order to control for specific factors, namely age, sex, type of injury, and time elapsed between the accident and the analyzed radiograph. Results The full sample included a total of 183 patients with an ILF (94 females; 47.5 years old), of which 50 had a concomitant mTBI and 133 without. Radiographic evidence of HO was significantly higher in patients with an ILF and a mTBI compared to ILF patients (X2 = 6.50; p = 0.01). The matched cohort consisted of 94 participants (i.e.; 47 patients from the ILF + mTBI group and 47 patients from the ILF group). Again, ILF + mTBI patients presented significantly higher rates of HO signs in comparison to ILF patients (X2 = 3.69; p = 0.04). Presence of HO was associated with prolonged delays to return to work (RTW) only in ILF + mTBI patients (F = 4.055; p = 0.05) but not in ILF patients (F = 0.823; p = 0.37). Conclusions Study findings suggest that rates of HO are significantly higher proximally to fracture sites when ILF patients sustain a concomitant mTBI, even after controlling for factors known to influence HO. Moreover, results show that HO is associated with a prolonged RTW only in ILF patients with a concomitant mTBI but not in ILF-only patients. The impact of mTBI on HO formation warrants further attention to detect early signs of HO, to identify shared physiopathological mechanisms and, ultimately, to design targeted therapies., Highlights • Rates of HO are significantly higher in patients with a fracture and a mTBI compared to patients with a fracture only. • Factors such as sex, age, joint involvement, and surgical procedures were unrelated to the detection of signs of HO • Presence of HO negatively impacted RTW delays in patients with a concomitant mTBI