CJEM Articles: Robert S. Green
Displaying 1-8 of 8 results
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March
2012
14
2
Dean Fergusson, Elham Sabri, Janet Edwards, Robert S. Green
Objectives:
Postintubation hemodynamic instability (PIHI) is a potentially life-threatening adverse event of emergent endotracheal intubation. The objectives of this study were to determine the incidence, risk factors, and impact on patient outcomes associated with PIHI in intubations performed in emergency medicine.
Methods:
A structured chart audit was performed of all consecutive adult patients requiring emergent endotracheal intubations over a 16-month period at a tertiary care emergency department (ED). Data collection included medications, comorbidities, vital signs in the 30 minutes before and after intubation, hospital length of stay, and in-hospital mortality. PIHI was defined as a decrease in systolic blood pressure (SBP) to ≤ 90 mm Hg, a decrease in SBP of ≥ 20% from baseline, a decrease in mean arterial pressure to ≤ 65 mm Hg, or the initiation of any vasopressor medication at any time in the 30 minutes following intubation.
Results:
Overall, 218 patients intubated in the ED were identified, and 44% (96 of 218) developed PIHI. On multivariate analysis, increasing age (OR 1.03, 95% CI 1.01–1.05), chronic obstructive pulmonary disease (OR 3.00, CI 1.19–7.57), and pre–emergent endotracheal intubation hemodynamic instability (OR 2.52, 95% CI 1.27–4.99) were associated with the development of PIHI. The use of a neuromuscular blocking medication was associated with a decreased incidence of PIHI (OR 0.34, 95% CI 0.16–0.75).
Conclusions:
Based on our data, postintubation hypotension occurs in a significant proportion of ED patients requiring emergent airway control. Further investigation is needed to confirm the factors we found to be associated with PIHI and to determine if PIHI is associated with increased morbidity and mortality. -
July
2011
13
4
Alina Toma, Angela Stone, Robert S. Green, Sara Gray
CLINICAL QUESTION What is the role of steroids in septic shock in the emergency department?
ARTICLE CHOSEN Sprung CL, Annane D, Keh D, et al; CORTICUS Study Group. Hydrocortisone therapy for patients with septic shock. N Engl J Med 2008;358:111-24.
STUDY OBJECTIVE To assess the safety and efficacy of low-dose hydrocortisone therapy for patients with septic shock and to compare outcomes based on response to corticotropin testing. -
November
2008
10
6
Daniel Howes, David Easton, Dennis Djogovic, Edward Patterson, Jonathan S. Davidow, Peter G. Brindley, Robert S. Green, Robert Stenstrom, Sara Gray
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September
2008
10
5
Daniel Howes, David Easton, Dennis Djogovic, Edward Patterson, Jonathan S. Davidow, Peter G. Brindley, Robert S. Green, Robert Stenstrom, Sara Gray
Introduction: Optimal management of severe sepsis in the ED has evolved rapidly. The purpose of these guidelines is to review key management principles for Canadian emergency physicians, utilizing an evidence-based grading system.
Methods: Key areas in the management of septic patents were determined by members of the CAEP Critical Care Interest Group (C4). Members of C4 were assigned a question to be answered after literature review, based on the Oxford grading system. After completion, each section underwent a secondary review by another member of C4. A tertiary review was conducted by additional external experts, and modifications were determined by consensus. Grading was based on peer-reviewed publications only, and where evidence was insufficient to address an important topic, a "practice point" was provided based on group opinion.
Results: The project was initiated in 2005 and completed in December 2007. Key areas which were reviewed include the definition of sepsis, the use of invasive procedures, fluid resuscitation, vasopressor/inotrope use, the importance of culture acquisitionin the ED, antimicrobial therapy and source control. Other areas reviewed included the use of corticosteroids, activated protein C, transfusions and mechanical ventilation.
Conclusion: Early sepsis management in the ED is paramount for optimal patient outcomes. The CAEP Critical Care Interest Group Sepsis Position Statement provides a framework to improve the ED care of this patient population. -
March
2008
10
2
Joel Kennedy, Robert S. Green, Robert Stenstrom
Objective: Inducing mild hypothermia in survivors of cardiac arrest has been demonstrated to improve outcomes. Despite this, other studies have found that few resuscitation physicians have used hypothermia in clinical practice. The objective of this study was to characterize the use of induced hypothermia by Canadian emergency physicians.
Methods: An internet-based survey was distributed to all members of the Canadian Association of Emergency Physicians (CAEP). Participants were asked about their experience with, methods for and barriers to inducing hypothermia.
Results: Of the 1328 CAEP members surveyed, 247 (18.6%) responded, with the majority working in academic centres (60.3%). Ninety-five out of 202 respondents (47.0%, 95% confidence interval [CI] 40.8%-53.2%) indicated that they had induced hypothermia in clinical practice and 86 of 212 (40.6%, 95% CI 34.0%-47.2%) worked in a department that had a policy or protocol for the use of induced hypothermia. The presence of a departmental policy or protocol was strongly associated with the use of induced hypothermia (unadjusted odds ratio 10.5, 95% CI 5.3-20.8). Barriers against induced hypothermia cited by respondents included a lack of institutional policies and protocols (38.9%), and of resources (29.4%). Lack of support from consultants was relatively uncommon (8.7%) in Canadian practice.
Conclusion: Only one-half of Canadian emergency physicians report that they have used therapeutic hypothermia in practice. Emergency departments should develop policies or protocols for inducing hypothermia in cardiac arrest survivors to optimize patient outcomes.
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November
2006
8
6
Harry Henteleff, Joel Kennedy, Robert S. Green
Hockey is enjoyed by millions of people around the world and is a sport in which aggression is encouraged and injuries are common. Although body-checking is the most common cause of injury in hockey today, hockey sticks are associated with up to 14% of injuries. We report a case of chest trauma requiring surgical intervention secondary to the penetration of a composite hockey stick into a player's thoracic cavity.
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September
2006
8
5
Ka Wai Cheung, Kirk D. Magee, Robert S. Green
Objective: Several randomized controlled trials have suggested that mild induced hypothermia may improve neurologic outcome in comatose cardiac arrest survivors. This systematic review of randomized controlled trials was designed to determine if mild induced hypothermia improves neurologic outcome, decreases mortality, or is associated with an increased incidence of adverse events.
Data sources: The following databases were reviewed: Cochrane Controlled Trials Register (Issue 4, 2005), MEDLINE (January 1966 to November 2005), EMBASE (1980 to November 2005), CINAHL (1982 to November 2005) and Web of Science (1989 to November 2005). For each included study, references were reviewed and the primary author contacted to identify any additional studies.
Study selection: Studies that met inclusion criteria were randomized controlled trials of adult patients (>18 years of age) with primary cardiac arrest who remained comatose after return of spontaneous circulation. Patients had to be randomized to mild induced hypothermia (32°C-34°C) or normothermia within 24 hours of presentation. Only studies reporting pre-determined outcomes including discharge neurologic outcome, mortality or significant treatment-related adverse events were included. There were no language or publication restrictions.
Data synthesis: Four studies involving 436 patients, with 232 cooled to a core temperature of 32°C-34°C met inclusion criteria. Pooled data demonstrated that mild hypothermia decreased in-hospital mortality (relative ratio [RR] 0.75; 95% confidence interval [CI], 0.62-0.92) and reduced the incidence of poor neurologic outcome (RR 0.74; 95% CI, 0.62-0.84). Numbers needed to treat were 7 patients to save 1 life, and 5 patients to improve neurologic outcome. There was no evidence of treatment-limiting side effects.
Conclusions: Therapeutically induced mild hypothermia decreases in-hospital mortality and improves neurologic outcome in comatose cardiac arrest survivors. The possibility of treatment-limiting side effects cannot be excluded.
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January
2005
7
1
Daniel Howes, Robert S. Green
Anoxic brain injury is a common outcome after cardiac arrest. Despite substantial research into the pathophysiology and management of this injury, a beneficial treatment modality has not been previously identified. Recent studies show that induced hypothermia reduces mortality and improves neurological outcomes in patients resuscitated from ventricular fibrillation. This article reviews the literature on induced hypothermia for anoxic brain injury and summarizes a treatment algorithm proposed by the Canadian Association of Emergency Physicians Critical Care Committee for hypothermia induction in cardiac arrest survivors.
