CJEM最新文献

Introduction: Patients requiring emergent endotracheal intubation are at higher risk of post-intubation hypotension due to altered physiology in critical illness. Post-intubation hypotension increases mortality and hospital length of stay, however, the impact of vasopressors on its incidence and outcomes is not known. This scoping review identified studies reporting hemodynamic data in patients undergoing emergent intubation to provide a literature overview on post-intubation hypotension in cohorts that did and did not receive vasopressors.

Methods: A systematic search of CINAHL, Cochrane, EMBASE and PubMed-Medline was performed from database inception until September 28, 2023. Two independent reviewers completed the title and abstract screen, full text review and data extraction per PRISMA guidelines. Studies including patients < 18 years or intubations during cardiac arrest were excluded. Primary outcome was the presence of hypotension within 30 min of emergent intubation. Secondary outcomes included mortality at 1 h and in-hospital.

Results: The systematic search yielded 13,126 articles, with 61 selected for final inclusion. There were 24,547 patients with a mean age of 57.2 years and a slight male predominance (63.8%). Respiratory failure was the most common intubation indication. Across 18 studies reporting on vasopressor use prior to intubation, 1171/7085 patients received vasopressors pre-intubation. Post-intubation hypotension occurred in 22.2% of patients across all studies, and in 34.3% of patients in studies where vasopressor administration pre-intubation was specifically reported. One-hour mortality of patients across all studies and within the vasopressor use studies was 1.2% and 1.6%, respectively. In-hospital mortality across studies was 21.5%, and 13.1% in studies which reported on vasopressor use pre-intubation.

Conclusion: Patients requiring emergent intubation have a high rate of post-intubation hypotension and in-hospital mortality. While there is an intuitive rationale for the use of vasopressors during emergent intubation, current evidence is limited to support a definitive change in clinical practice at this time.

Background: For emergency department (ED) patients with cardiac chest pain, introduction of high-sensitivity troponin (hsTnT) pathways has been associated with reductions in length of stay of less than 1 h.

Methods: At two urban Canadian sites, we introduced hsTnT on January 26, 2016. While the prior diagnostic algorithm required troponin testing at 0 and 6 h, serial hsTnT serial testing was conducted at 0 and 3 h. We identified consecutive patients who presented with cardiac chest pain from January 1, 2015, to March 31, 2017, along with 30-day outcomes. The primary outcome was a missed 30-day major adverse cardiac event, (MACE) defined as death, revascularization, or readmission for myocardial infarction occurring in a patient-discharged home with a minimizing diagnosis and without cardiac-specific follow-up. Secondary outcomes included admission rate, ED length of stay, and MACE. We compared pre- and post- implementation periods using descriptive methods and repeated this analysis in patients with noncardiac chest pain.

Results: We collected 5585 patients with cardiac chest pain, (2678 pre- and 2907 post-introduction) and 434 had (7.8%, 95% CI 7.1 to 8.5%) MACE, with 1 missed MACE. (0.2%, 95% CI 0.04 to 1.3%). Admission rate was stable at 24.1% pre- and 23.7% while median length of stay decreased from 464 to 285 min, a difference of 179 min. (95% CI 61 to 228 min). For 11,611 patients with noncardiac chest pain, admission rate (9%) and length of stay (191 versus 193 min) remained constant.

Conclusions: Implementation of hsTnT for evaluation of ED chest pain patients was safe and associated with a 3-h decrease in length of stay.

Introduction: Delays in promptly recognizing and appropriately managing hemorrhagic injuries contribute to preventable trauma related deaths nationwide. We sought to identify patient variables available at the time of emergency department arrival associated with meeting the critical administration threshold.

Methodology: We conducted a trauma registry review from September 2016 to March 2020 of trauma team activations at The Ottawa Hospital, a Level 1 Trauma Center. Our primary outcome was the frequency of meeting the critical administration threshold. Secondary outcomes included time to critical administration threshold, 24-h all-cause mortality, and 30-day all-cause mortality. Multivariate logistic regression identified factors independently associated with meeting the critical administration threshold.

Results: We assessed 762 patients, of which 78 (10.2%) met the critical administration threshold. The median time to critical administration threshold was 28.9 min. Mortality at 24 h occurred in 58 (7.6%) patients. Four variables available upon patient arrival predicted the critical administration threshold, including systolic blood pressure ≤ 90 mmHg (OR 6.6; 95% CI 3.7-12.0), Glasgow Coma Scale ≤ 8 (OR 5.9; 95% CI 3.2-10.6), heart rate ≥ 100 beats/minute (OR 4.4; 95% CI 2.4-8.1), and respiratory rate ≥ 20 breaths/min (OR 2.2; 95% CI 1.2-4.0).

Conclusion: We identified four clinical variables readily available to physicians upon patient arrival associated with meeting the critical administration threshold: systolic blood pressure ≤ 90 mmHg, Glasgow Coma Scale ≤ 8, heart rate ≥ 100 beats/minute, and respiratory rate ≥ 20 breaths/min. Patients presenting with any of these clinical parameters should prompt physicians to consider ordering blood products immediately.

Objectives: For the last two decades, more than half of Canadian medical students have been women, with an increasing number of medical trainees choosing emergency medicine as their careers. Despite a proportional increase of women in full-time faculty positions in emergency medicine, women are still underrepresented in leadership. The purpose of this study is to explore the experiences of women leaders in emergency medicine to identify common themes that may have contributed to their acquisition of leadership roles.

Methods: Participants included women emergency medicine physicians in Canada who currently or previously held a leadership position. Data were collected through semi-structured interviews. Inductive thematic analysis was performed on the interview transcripts. Transcribed data were coded and categorized into recurrent themes. A narrative summary of the most impactful themes was presented.

Results: Twenty participants were interviewed. Most participants perceived career opportunities were due to chance, related to personal skill set, or required additional training. Participants highlighted the importance of mentorship and sponsorship. Gender expectations and traditional gender roles were perceived as having a negative impact on career leadership success. Participants acknowledged the need for women in leadership to empower younger generations of women to become leaders. For future emergency medicine leaders, participants suggested applying for leadership positions early, networking, and seeking mentorship. Potential supportive changes to leadership structures included explicit parental leave policies, flexible scheduling, and job sharing to encourage women leaders.

Conclusion: To date, there has been no Canadian specific study exploring the factors contributing to the success of women leaders in emergency medicine. This study examines career advancement of women leaders in emergency medicine and provides useful insight to those aspiring to grow their careers, as well as to mentors and sponsors of women in emergency medicine.