CJEM Articles: John M. Tallon

Objectives: The optimal approach to airway management in penetrating neck injuries (PNIs) remains controversial. The primary objective of this study was to review the method of endotracheal intubation in PNI at a Canadian tertiary trauma centre. Secondarily, we sought to determine the incidence of PNI in our trauma population and to describe the epidemiologic elements of this population.

Methods: We conducted a review of patients with PNIs who were enrolled in the Nova Scotia Trauma Registry database. We included all penetrating injuries of the neck in patients ≥16 years of age from April 1, 1994 to March 31 2005 with an Injury severity Score (ISS) ≥ 9 or who underwent Trauma Team activation at our Tertiary Trauma Centre (regardless of ISS) and/or who were identified upon admission as a "major" trauma case. The variables of interest were patient age and sex, injury mechanism, injury location, place of intubation and method of intubation.

Results: There were 19 people who met inclusion criteria and they were enrolled in our study. The injury mechanisms involved knife (n = 13) or gunshot (n = 5) wounds (one patient's injuries were categorized as "other"). Three patients (15.8%) were not intubated. The remaining 16 patients were intubated during prehospital care (n = 5), in the emergency department (n = 6) or in the operating room (n = 5). Of these, 8 patients (42.1%) underwent awake intubation and 8 (42.1%) underwent rapid sequence intubation.

Conclusion: There is clear variability of airway management in PNI. We believe that such patients represent a heterogeneous group where the attending physician must have a conservative yet varied approach to airway management based on the individual clinical scenario.

Objectives: To examine the safety of emergency department (ED) procedural sedation and analgesia (PSA) and the patterns of use of pharmacologic agents at a Canadian adult teaching hospital.
Methods: Retrospective analysis of the PSA records of 979 patients, treated between Aug. 1, 2004, and July 31, 2005, with descriptive statistical analysis. This represents an inclusive consecutive case series of all PSAs performed during the study period.
Results: Hypotension (systolic blood pressure ≤ 85 mm Hg) was documented during PSA in 13 of 979 patients (1.3%; 95% confidence interval [CI] 0.3%-2.3%), and desaturation (SaO 2 ≤ 90) in 14 of 979 (1.4%; CI 0.1%-2.7%). No cases of aspiration, endotracheal intubation or death were recorded. The most common medication used was fentanyl (94.0% of cases), followed by propofol (61.2%), midazolam (42.5%) and then ketamine (2.7%). The most frequently used 2-medication combinations were propofol and fentanyl (P/F) followed by midazolam and fentanyl (M/F), used with similar frequencies 58.1% (569/979) and 41.0% (401/979) respectively. There was no significant difference in the incidence of hypotension or desaturation between the P/F and M/F treated groups. In these patients, 9.1% (90/979) of patients received more than 2 different drugs.
Conclusions: Adverse events during ED PSA are rare and of doubtful clinical significance. Propofol/fentanyl and midazolam/fentanyl are used safely, and at similar frequencies for ED PSA in this tertiary hospital case series. The use of ketamine for adult PSA is unusual in our facility.

Background: Riding all-terrain vehicles (ATVs) is a popular recreational activity, with approximately 1.5 million users in Canada. Despite legislation aimed at reducing injury rates, ATV-related incidents remain a major cause of trauma and death. This paper reviews the epidemiology of major injury associated with ATV use in Nova Scotia.
Methods: The Nova Scotia Trauma Registry was used to identify all adults over age 15 who sustained major ATV-related trauma (Injury Severity Score [ISS] >=12) within a 5-year period. Demographic variables, temporal statistics, alcohol use, helmet use, injury characteristics and injury outcome variables, including ISS, length of stay (LOS), Glasgow Coma Scale score and discharge status were evaluated.
Results: Twenty-five patients met the inclusion criteria. Most (92%) were males, and 64% were between 16 and 34 years of age. Most injuries occurred between 1300 hrs and 1900 hrs, 52% occurred on the weekend, and 40% occurred in the spring. The average ISS was 22.1, and injuries to the central nervous system comprised 39% of all major injuries. Alcohol was involved in up to 56% of all incidents, and only 4 patients (16%) were known to be wearing a helmet at the time of injury. Average hospital LOS was 21.6 days.
Interpretation: ATV-related incidents are a continuing source of major injury. This paper describes the epidemiology of ATV-related major trauma presenting to the sole tertiary care referral centre in one province. Information gained from this study should be used to influence ATV public education programs.