CAEP/ACMU 2002 Scientific Abstracts: 90-104

2003 Scientific Abstracts

CJEM 2002;4(2):124-154

090 Concordance between Radiologist Reports and Emergency Physician Diagnosis of Community-Acquired Pneumonia in Patients Discharged from an Emergency Department.
Campbell SG, Patrick W, Varley-Doyle S, Els M, Murray D, Urquhart D, Maxwell D, Hawass A, McIvor RA, Hernandez P, McParland C, Haase D. Dalhousie University Department of Emergency Medicine. Halifax, NS.

INTRODUCTION: Chest x-ray (CXR) has long been considered the 'gold standard' for the diagnosis of community-acquired pneumonia (CAP), however CXR may miss up to 30% of pneumonias seen on chest CT. Recent suggestions that acute bronchitis not be treated with antibiotics have highlighted the importance of differentiating the 2 conditions. Radiologists rarely have the benefit of direct patient contact when deciding on the clinical relevance of seemingly unimportant x-ray features. Although numerous studies (using CXR as the standard) have described 'miss' rates in CAP, very little work has been done on cases where the treating physician 'overcalls' the diagnosis. OBJECTIVES: To evaluate the level of concordance between radiologist reports, (received after discharge of patients), with the diagnosis of CAP in patients discharged from an emergency department. METHODS: Three investigators conducted a retrospective chart audit of all patients identified in the ED database as having been discharged with a diagnosis of 'pneumonia' or 'possible pneumonia' during the period 3 Jan 1999-3 Jan 2001. Emergency physician (EP) and radiology report (RR) diagnoses were categorized as 'pneumonia', 'possible pneumonia', 'non-pneumonia' and 'normal', and reports for each patient were compared. RESULTS: 867 patients were identified for audit. Of these, x-rays were performed in 844 (97.3%). RR were not found in 31 cases (3.67%). Of 669 EP diagnoses of 'pneumonia', 304 (37.4%) RR's were in agreement, although in 82 (10%), the RR diagnosis was of 'possible pneumonia) of 813 EP diagnoses of 'pneumonia' or 'possible pneumonia', 426 (52.4%) of RR's were in agreement. 214 (26.3%) of RR's in the combined group were of diagnoses other than pneumonia, while 173 (21.3%) were read as 'normal'. CONCLUSION: EP's and radiologists frequently disagree on whether a patient has pneumonia or not. Perhaps it is time too revisit the 'gold standard' status of plain chest x-ray.

091 Maintaining Normocapnia Prevents Cerebral Vasoconstriction during Oxygen Therapy.
Tesler J, Rucker J, Volgyesi G, Fedorko L, Fisher J. Department of Anesthesia, University Health Network. Toronto, ON.

INTRODUCTION: O2 treatment is accompanied by cerebral vasoconstriction which offsets, or even reduces, O2 delivery to the brain. Hyperoxia also causes hypocapnia which constricts CO2-responsive vascular beds. We hypothesized that preventing hypocapnia during O2 treatment would prevent oxygen-induced cerebovascular vasoconstriction. METHODS: We exposed 5 normal subjects to >97% O2 for 3 consecutive 20 minute test periods. Normocapnia was maintained only during the second test period but subjects were unaware when normocapnia was maintained. We monitored tidal volume, respiratory rate, and middle cerebral artery blood velocity (MCABV) as an index of cerebral blood flow. RESULTS: On the initial exposure to hyperoxia, minute ventilation increased by 21% (P < 0.05), end-tidal PCO2 decreased by 3.7 mm Hg (p < 0.01, paired t test) and MCABV decreased by 11.5% (p < 0.02, paired t test). During the second test period when normocapnia was maintained, minute ventilation increased by 77% and MCABV remained at control values. During the third test period, responses were not significantly different from those during the first test period. CONCLUSIONS: Maintaining normocapnia prevents the fall in cerebral blood flow associated with O2 inhalation. Maintaining isocapnia during O2 treatment should improve O2 delivery to organs with CO2 responsive vascular beds, such as the brain, heart and kidney.

092 Factors Associated with Activation of the Pediatric Trauma Team for Severely Injured Children.

Au BL, Shephard AL, Brennan-Barnes M, Osmond MH. McMaster University. Hamilton, ON.

INTRODUCTION: Activation of the pediatric trauma team (PTT) in our tertiary-care pediatric centre is based on specific criteria (physiologic, anatomic, and mechanism). However, there are instances in which the PTT is not activated for severely injured children. OBJECTIVES: The primary objective of the study was to determine factors associated with activation of the PTT for severely injured patients. The secondary objective was to determine whether care by the PTT would decrease length of stay in the emergency department (ED). METHODS: All patients seen from July 4, 2000 to June 1, 2001 with an Injury Severity Score (ISS) >11 were included. Data were collected from a trauma registry database. Data collected included: age, gender, ISS, mechanism of injury, need for surgery, length of stay in the ED, and final disposition (ward vs PICU). RESULTS: 69 patients with an ISS >11 were seen during the study period. The PTT was activated for 20 patients, and not activated (NTT) for 49. There were no significant differences between the PTT and NTT groups (PTT vs NTT) in: mean age (years) (9.35 ± 5.21 vs 9.16 ± 5.19; p = 0.893), proportion male (13/20 vs 34/49; p = 0.466), mean ISS (23.10 ± 10.99 vs 17.88 ± 4.64; p = 0.052), or fall as mechanism of injury (3/20 vs 14/49; p = 0.358). The PTT was more likely to be activated for MVA mechanism (15/20 vs 13/49; p = 0.0003). Proportion of patients admitted to the PICU was significantly greater in the PTT group (14/20 vs 21/49; p = 0.037). Proportion of patients going to surgery was similar in both groups (3/20 vs 3/49; p = 0.346). ED length of stay (min) was significantly lower in the PTT group (177.70 ± 74.36 vs 255.96 ± 203.84; p = 0.026). CONCLUSIONS: Severely injured patients managed by the pediatric trauma team had shorter lengths of stay in the ED, were more likely have MVA mechanism, and were more likely to be admitted to the PICU.

093 Major Injury Associated with All-Terrain Vehicle use in Nova Scotia: A Five Year Review.
Sibley AK, Tallon JM. Dalhousie University. Halifax, NS.

BACKGROUND: All-terrain vehicle (ATV) riding is a popular recreational sport with approximately 1.5 million users in Canada. Despite legislation to lower ATV injury rates, ATV related incidents are still a major cause of trauma and death. This paper reviews the epidemiology of major injury associated with ATV use in Nova Scotia. METHODS: Using the Nova Scotia Provincial Trauma Registry, all adult (age >15) trauma (ISS 12) related to ATV incidents over a 5 year period were evaluated. Data were analyzed for demographic variables, temporal statistics, alcohol use, helmet use, injury characteristics and as well injury outcome variables including Injury Severity Score (ISS), Length of Stay (LOS), Glasgow Coma Score and discharge status. RESULTS: 25 patients met the inclusion criteria. The majority of trauma was incurred by males (92.0%) and by persons between the ages of 15-34 (64.0%), average age 34.4. 71.4% of all trauma occurred between 13:00 hr and 19:00 hr, 52.0% occurred on the weekend and 40.0% of all injuries occurred during the spring season. Injuries to the central nervous system comprised 39.1% of all major injuries. The average ISS was 22.1 and the average LOS 21.6 days. Alcohol was involved in up to 56.0% of all incidents and only 5 patients (20.0%) were known to be wearing a helmet at the time of injury. INTERPRETATION: ATV related incidents are a continuing source of major injury. This paper describes the epidemiology of ATV related trauma presenting to the sole tertiary care referral centre in 1 province. Information gained from this study should be used to influence ATV public education programs.

094 Prospective Evaluation of a Guideline for the Selective Elimination of Pre-Reduction Radiographs in Clinically-Obvious Anterior Shoulder Dislocation.
Shuster M, Abu-Laban RB, Boyd J, Gauthier C, Shepherd L, Turner C. Department of Emergency Medicine, Mineral Springs Hospital. Banff, AB.

INTRODUCTION: Previous research by our group demonstrated that experienced Emergency Physicians (EPs) can identify a subgroup of patients with shoulder dislocation for whom pre-reduction radiographs do not alter management. This led us to develop a treatment guideline for the selective elimination of pre-reduction radiographs in clinically-evident anterior shoulder dislocation. Our primary objective was to prospectively evaluate this guideline and determine whether it was effective in safely eliminating unnecessary radiographs. METHODS: We enrolled a convenience sample of 98 patients presenting to Mineral Springs Hospital (Banff, Canada) with possible shoulder dislocation between November/2000 and April/2001. EPs scored their clinical certainty of the diagnosis of dislocation on a 10cm visual analog scale after patient assessment and prior to pre-reduction radiographs (if obtained). EPs were aware of our treatment guideline however following it was optional. Data was collected on clinical scoring and evaluation, compliance with the guideline, and outcomes. RESULTS: EPs were certain of shoulder dislocation in 93.7% of patients with possible anterior shoulder dislocation (59/63, 95% CI: 84.5%-98.2%). Compliance with the treatment guideline was 82.5% (52/63, 95% CI: 70.9%-90.9%) and most deviations involved the elimination of post-reduction radiographs (which the guideline advises on all patients). Compared to a practice of obtaining pre-reduction radiographs for all cases of suspected shoulder dislocation, the use of our treatment guideline resulted in a statistically significant 88.9% (56/63, p < 0.0001, 95% CI: 78.4-95.4%) elimination of pre-reduction radiographs. CONCLUSIONS: Experienced EPs are frequently certain of the diagnosis of anterior shoulder dislocation on clinical grounds and can comfortably and safely manage these cases using our guideline for the selective elimination of pre-reduction radiographs in clinically-obvious shoulder dislocation. Validation of our guideline in other settings is warranted. If adopted generally, this guideline will result in both improved patient care and significant cost-savings.

095 Does CT at a Primary Hospital Delay the Transfer of Trauma Patients to a Tertiary Centre?
Onzuka J, Worster A. McMaster University. Hamilton, ON.

INTRODUCTION: We feel that delays in transfer of patients to the level 1 trauma centre are due to imaging procedures done at the primary hospital, namely the CT scan. For this reason, we set out to identify whether doing CT scans in the primary hospital would delay the transfer of trauma patients to a level 1 trauma centre and whether this affected mortality rate. METHODS: We undertook a retrospective chart review of all patients that were transferred to the Hamilton General Hospital (HGH), which services 2.2 million people and 24 hospitals over an area of 13,434 km², for management of traumatic injuries from primary hospitals in the period including April 1, 1999 to March 4, 2001. Assessments were made to whether doing a CT scan at these primary hospitals delayed the transfer of patients to the HGH and to assess whether this contributed to a higher mortality rate. RESULTS: Patients were transferred to the Hamilton General Hospital 85 mins. (95% CI - 65-108) (p < 0.00001) faster if they had not received a CT scan at the primary hopital (power = 1.00, alpha = 0.05 and n = 72). The 2 groups of patients (those that had CT and those that did not) were matched for ISS, age, gender and mode of transport to the Hamilton General Hospital. Analysis of the mortality data comparing the group who received CTs at the primary hospital vs the group that did not, revealed an OR = 0.87 (95% CI 0.37-2.05) CONCLUSIONS: Our data clearly identifies a statistically significant delay in the transport of multisystem trauma patients to a level 1 trauma centre if CT scans were performed on patients in a primary hospital. At this point, however, we have not significantly correlated this with an increase in mortality since the OR = 0.87 (95% CI 0.37-2.05) for having a CT at a primary hospital.

096 Using Electronic Clinical Practice Guidelines in Emergency Medicine.
Meurer DP, Rowe BH, Bullard MJ, Holroyd BR. Emergency Medicine Research Group, Division of Emergency Medicine, University of Alberta. Edmonton, AB.

OBJECTIVES: Previous efforts to incorporate clinical practice guideliens (CPG) into practice have met with failure, especially in the emergency department (ED). This study examines the use of an innovative CPG project as well as the characteristics of resource use recorded by a computer-based health information system. METHODS: The EM CPG is a single sign-on, intranet, desktop application for emergency department clinical decision making. This product consists of decision tools, in- and out-patient order sets, patient information and important links; all EM physician staff at 1 major teaching hospital affiliated with the University of Alberta had access. The data for the usage characteristics were derived anonymously from user logs and spanned the first 8 months this resource was available. Whenever possible, clinicians completed brief questionnaires using a 7-point Likert scale at the conclusion of their encounter. RESULTS: 24 (96%) of 26 EM physicians accessed the site and there were 322 recorded uses to the CPG program over the study period. The "helpfulness" (median = 6.0; IQR: 5, 7) and "ease of use" (median = 6.0; IQR: 5, 7) was rated as "high" by 130 users. Also, "increasing confidence with treatment" (median = 5.0; IQR: 4, 6) and "improving quality of care" (median = 5; IQR: 4, 6) received "moderately high" ratings. Most (80%) EM physicians used 1 product during an interaction. Frequently used resources were community acquired pneumonia decision rules (n = 55), swollen limb assessment sets with Well's criteria (n = 94), the IV out-patient treatment order form (n = 25), and the head injury patient information form (n = 27); specific clinic consult forms were also popular (n = 32). For 3 of the most commonly used resources, forms with pre-formatted "no" responses were used 66% of the time. Use of the CPG resources increased 43% in the second 4-month period of the study. CONCLUSIONS: An intranet CPG dedicated to the management of common emergency department problems has been well received by most staff and rated very highly for ease of use and helpfulness. Further implementation and evaluation of interventions designed to improve the use of EBM resources, such as CPGs, appear warranted.

097 Using Clinical Practice Guidelines in Emergency Medicine.
Rowe BH, Meurer DP, Bullard M, Holroyd BR. Division of Emergency Medicine, University of Alberta, Edmonton, AB.

OBJECTIVES: Previous efforts to incorporate clinical practice guidelines (CPG) into practice have met with failure, especially in the emergency department (ED). This study examines the use of an innovative CPG project as well as the characteristics of resource use recorded by a computerized system. METHODS: The EM CPG is an intranet-based desktop application for ED clinical decision making. This product consists of decision tools, order sets, patient information and important links; access was provided to all 26 EM physicians at 1 teaching hospital. The data for the usage characteristics were derived anonymously from user logs and spanned the first 8 months of use. Whenever possible, clinicians completed brief questionnaires using a 7-point Likert scale at the conclusion of their encounter. RESULTS: 24 (96%) of staff physicians accessed the site and there were 322 recorded uses to the CPG program over the study period. The overall helpfulness (median = 6.0; IQR: 5, 7) and ease of use (median = 6.0; IQR: 5, 7) were rated as high by 130 users. Most (80%) EM physicians used only 1 product during an interaction. The most highly used resources were community acquired pneumonia decision rules (n = 55), swollen limb assessment sets (n = 94), IV out-patient treatment order form (n = 25), and the head injury patient information form (n = 27); specific clinic consult forms were also popular (n = 15). For 3 of the most commonly used resources, defaulted forms (with pre-formatted The overall "helpfulness" (median = 6.0; IQR: 5, 7) and "ease of use" (median = 6.0; IQR: 5, 7) was rated as "high" by 130 users. Most (80%) EM physicians used only 1 product during an interaction. The most highly used resources were community acquired pneumonia decision rules (n = 55), swollen limb assessment sets with Well's criteria (n = 94), the IV out-patient treatment order form (n = 25), and the head injury patient information form (n = 27); specific clinic consult forms were also popular (n = 15). For 3 of the most commonly used resources, defaulted forms (with pre-formatted 'no' responses) were used 66% of the time. Use of the CPG resources increased 43% in the second 4-month period of the study. CONCLUSIONS: An intranet CPG dedicated to the management of common emergency department problems has been well-received by most staff and rated very highly for ease of use and helpfulness. Further implementation and evaluation of interventions designed to improve the use of EBM resources, such as CPGs, appear warranted.

098 Cellulitis in the ED: Factors Associated with Treatment Failure.
Murray HE, Stiell IG, Wells GA. Kingston General Hospital, Kingston, ON, and the Ottawa Hospital, Civic Campus, Ottawa, ON.

OBJECTIVE: This preliminary study identified both the expected rate of treatment failure and the historical features and clinical characteristics that are associated with treatment failure in ED patients with cellulitis. METHODS: This prospective observational cohort study was performed in a tertiary care centre with ~50,000 annual visits. Adult patients with cellulitis had a standardized physician assessment performed prior to the initiation of treatment. The primary outcomes were clinical response or treatment failure, which was defined as any 1 of the following poor outcomes: I&D of abscess, change in antibiotics (not due to allergy/intolerance) specialist consultation or admission to hospital. Comparison of the means and proportions between the 2 groups was performed with univariate associations, using parametric or non-parametric tests where appropriate. RESULTS: 80 patients with 78 episodes of infection were entered. The patients were 60% male, mean age 49 (SD 19) with 76 (95%) extremity cellulitis and 11 (14%) abscess with cellulitis. 14 episodes (17.5%) were classified as treatment failures. This can be further broken down into an oral antibiotic failure rate (6.8%) and an ED-based IV antibiotic failure rate (26.1%). Patients with treatment failure were older (mean age 59 vs. 46, p = 0.02) and more likely to have already taken oral antibiotics (50% vs. 17%, p = 0.01). Patients with olecranon bursitis were also more likely to fail treatment (29% vs. 9%, p = 0.05). CONCLUSIONS: The treatment of cellulitis with daily ED-based IV antibiotics is a relatively new phenomenon. A clinical trial of this practice is needed to determine which patients require IV therapy or admission. Patients with previous (failed) oral therapy and those with olecranon bursitis are more likely to fail ED treatment for cellulitis and should not be randomized in a clinical trial of oral vs. ED based IV antibiotics.

099 Cellulitis in the ED: Factors Affecting Treatment Decisions.
Murray HE, Stiell IG, Wells GA. Kingston General Hospital, Queen's University. Kingston, ON.

OBJECTIVES: The correct ED treatment of cellulitis is not clear. This study examined the historical and clinical characteristics that determine the severity of a cellulitis episode. METHODS: This was a prospective cohort study from a tertiary care centre with ~50,000 annual visits. Adult patients with cellulitis had a standardized MD assessment prior to initiating treatment. Relevant historical features and objective measurements including infection size were recorded on the data form. The primary outcome was a treatment-based severity classification: those treated with ED-based IV antibiotics were considered 'severe'and those with oral antibiotics 'mild.' Means and proportions were compared between the 2 groups with univariate associations (using parametric or non-parametric tests where appropriate). ROC curves were constructed for significant continuous data. RESULTS: The 64 study patients had a mean age of 45 years, 61 (95%) had extremity infections and 8 (12.5%) had abscesses with cellulitis. 27 episodes were 'mild' and 37 'severe.' Patients with severe cellulitis were more likely to report a previous history of cellulitis (32.4% vs. 7.4%, p = 0.02), fever (31.4% vs. 11.1%, p = 0.05) or systemic symptoms (38.9% vs. 3.7%, p < 0.01). There were no differences in demographics or the presence of co-morbidities. The size of infection was larger in severe infections (637.7 cm² vs. 219.9 cm², p < 0.01). The area under an ROC curve of size vs. severity was 0.78 (95% CI 0.67, 0.90). There was no size cut point with 100% sensitivity for severe infections. CONCLUSIONS:This is the first prospective study to evaluate the characteristics determining cellulitis severity. Patients with previous cellulitis, larger size of infection and systemic symptoms were more likely to be treated with IV antibiotics. However, the absence of a clear division between the groups allows ethical randomization of patients with all size infections into a proposed clinical trial comparing oral vs. IV antibiotics in cellulitis.

100 A Survey of Influenza Vaccination Rates Amongst Emergency Department Personnel.
Saluja IS, Theakston K. London Health Sciences Centre, Emergency Department. London, ON.

INTRODUCTION: During the influenza season of 1999-2000, emergency department (ED) health care workers at UWO teaching hospitals were surveyed to investigate their influenza vaccination rates, motivating factors and attitudes toward vaccination. METHODS: An anonymous 28-item survey was distributed to emergency physicians and residents, nurses, respiratory therapists (RTs), and other allied healthcare workers. Statistical analysis was done using SPSS v.10. RESULTS: 343 surveys were returned for an overall response rate of 81%. The respondents were 75% female, 87% nonsmokers, with a mean age of 38. The overall vaccination rate was 37%. The RTs had the highest vaccination rate of 46%, the allied healthcare workers the lowest at 27%, and the physician's rate was 35%. Logistic regression analysis revealed that respondents with a chronic medical condition were almost twice as likely to receive vaccination (OR 1.96, p = 0.018). With regards to perceptions and attitudes, 28% felt adverse affects were common, 51% felt vaccination was effective, 52% would support a program to improve vaccination rates, and 41% would support mandatory vaccination. Only 27% felt that patients are at an increased risk of getting influenza from ED staff, but 58% perceive that ED staff are at an increased risk of getting ill from patients. CONCLUSIONS: While there is a perception of increased risk of influenza transmission in the ED, the immunization rate amongst ED personnel was only 37%, and the majority (59%) did not support mandatory immunization. When controlled for baseline characteristics, the only significant motivator to get vaccinated that was identified was the presence of a chronic medical condition. There is good evidence that influenza immunization of the elderly and nursing home workers decreases mortality, however more work needs to be done regarding the efficacy of ED personnel influenza vaccination.

101 Pneumonia Presentations in the Emergency Department: Description and Outcome.
Spooner CH, Rowe BH, Yiannakoulias N, Bullard M, Holroyd B, Craig W, Klassen T, Johnson D, Svenson L, Rosychuk R, Schopflocher D. Division of Emergency Medicine, University of Alberta. Edmonton, AB.

OBJECTIVES: Pneumonia is a common condition that presents to the emergency department (ED) but the epidemiology of this problem is understudied. This study examines all ED pneumonia visits within a large, standardized health care region for 1 fiscal year. METHODS: All patients presenting to Alberta EDs were eligible for inclusion. Data were derived from a sample of ED patients treated in 17 health regions over 1 year (98/99) with a diagnostic code of pneumonia (486.x; but not influenza). Data were extracted from the Ambulatory Care Classification System (ACCS) database, consisting of computerized abstracts coded similarly across regions. Diagnostic categories were coded by medical record nosologists using ICD-9 codes for the primary discharge diagnosis. Descriptive statistics and crude presentation rates are reported. RESULTS: Overall, 1.49 million ED visits were recorded in the year; the number of patients with a diagnosis of pneumonia was 17,162 (1.2% ED visits). Overall, 70% were under the age of 65 years with a peak at 1-4 yrs (15.2%); male / female representation 52%/48%. Limited daily variation existed; Saturday-Monday (~15.5%), Thursday (12.8%). However, seasonal variation was noted: December-February (11.5-13.5%) numbers were highest, June-September lowest (6.2-6.5%). Most patients were discharged (63.8%); however, admission (5924; 34.5%) was higher than the ED average (9%). Few patients left prior to seeing a physician (9, <1%). The rate of pneumonia varied between regions, with an average of 3.8/1000 population across the province; urban areas had the lowest rate of presentation. More than 1 presentation for pneumonia was recorded for 16% of visits (2 or more visits: 10.3%). CONCLUSIONS: These results indicate that pneumonia is a relatively common presentation to the ED, and admission rates are high. Further evaluation of pneumonia patients in the ED is required to understand the observed variation and to evaluate interventions to improve outcome.

102 Salty Broth for Salicylate Poisoning? Misleading Overdose Management Advice in the 2001 Compendium of Pharmaceuticals and Specialties (CPS).
J Brubacher, R Purssell, D Kent. Vancouver Hospital and Health Sciences Centre, UBC, British Columbia Drug and Poison Information Centre. Vancouver, BC.

INTRODUCTION: The CPS contains monographs on medications sold in Canada and is similar to the American Physician's Desk Reference (PDR). Poison management advice in the PDR was shown to be erroneous; therefore we examined advice found in the CPS. METHODS: Using American Association of Poison Control Centers (AAPCC) data, we choose 10 classes of medications consistently responsible for fatalities. A panel of 3 toxicologists reviewed Poisindex and 3 leading toxicology textbooks and arrived at a consensus on indicated, contraindicated, and futile interventions for each of these classes of drugs. Corresponding CPS monographs were then ranked from poor to excellent on their inclusion of key interventions and exclusion of contraindicated interventions. We also considered whether the monograph would allow a reasonable clinician to manage an overdose, whether it served to refresh one's memory, or whether it was simply misleading or dangerous. RESULTS: A total of 119 monographs were reviewed. Of these 25 (21%) were adequate to allow a clinician to manage an overdose, 48 (40%) would serve to refresh the memory regarding the key management points but 62 (52%) were dangerous or misleading. In terms of listing key interventions, 63 (53%) monographs were poor, 33 (28%) were fair, 22 (18%) were good and 1 (1%) was excellent. For excluding contraindicated therapies, 57 (48%) were poor, 9 (8%) were fair, 51 (43%) were good, and 2 (2%) were excellent. CONCLUSIONS: Poison management advice in the CPS is usually inadequate and often misleading or dangerous. These sections should either be omitted or rewritten to reflect current standards of care.

103 Treatment Choices and Frequency of Emergency Visits Among Migraine Sufferers.
Epstein N. Credit Valley Hospital. Thornhill, ON.

INTRODUCTION: Patients suffering recurrent migraines, analgesic-induced migraines (rebound headaches), and narcotic seekers feigning migraines constitutes frequenct visits to emergency. Although, abortive medicines such as dopamine antagonists are considered the standard of care, a number of patients still continue to receive opiates. It is intuitively thought that giving opiates may alleviate headaches suboptimally and may precipitate more visits to the emergency. This study will look at treatment modalities of migraine headaches and compare opiates, dopamine antagonists and serotonergic receptor agonists used in the emergency and determine time intervals (frequency )between visits. METHOD: The study will be a retrospective audit of emergency charts. Entry in the study will include patients with a documented history of migraines and at least 2 visits to emergency over a 6 month period. Any patients with a known history of narcotic abuse will be excluded.The parameter measured will be time from treatment in emergency to subsequent visit for a migraine headache. RESULTS: As of writing over 200 charts will be reviewed consisting of 52 patients. The median age is 33 years old and a female ratio of 3:1. CONCLUSIONS: Audits can be effective tools illustrating aberrant practices. This audit should indicate whether using opiates for treatment of migraines is conducive to more frequent visits for emergency, and ths may be deemed unacceptable therapy.

104 A Retrospective Chart Review of Potential Organ Donors Treated in the Emergency Department.
Tenn-Lyn NA, Cass DE. St. Michael's Hospital, University of Toronto. Toronto, ON.

INTRODUCTION: Ten hospitals in Ontario provide an active Neurosurgery service. Patients from community hospitals are transferred to these neurosurgical centres for assessment. Patients who are assessed by a neurosurgeon to have non-survivable intracranial pathology are often returned to the sending facility for end-of-life care, thus depriving families of the opportunity to consider organ donation as part of the end-of-life process. PURPOSE: To determine the number of patients transferred from community hospitals to tertiary care neurosurgical centres in Ontario who fulfill criteria for potential organ donation. METHODS: At centres across Ontario, ED databases were used to identify all ED patients between April 1st, 1998 and March 31st, 1999 inclusive registered as 'Direct to Neurosurgery'. Charts were reviewed to determine the number of patients meeting inclusion criteria for evidence of (imminent) brain death in the ED, their disposition from the ED, and whether organ donation was discussed with their families. RESULTS: Of 2717 ED patients direct to Neurosurgery at 5 centres, 99 patients met the established criteria for potential organ donors. Nine patients (9.1%) were pronounced dead in the ED. Nine patients (9.1%) became organ donors with their families' consent. Charts from the remaining 81 potential organ donors (81.8%) did not have any documented evidence to suggest that the option of organ donation was offered or discussed. Twenty-one (25.9%) of these patients were transferred back to their referring institution, also representing missed potential organ donors. CONCLUSIONS: A significant number of families were denied the opportunity to consider donation as part of their end-of-life decisions for their loved ones. Further review is needed to fully quantify the extent of this deficit across Ontario. These results emphasize the need to examine ways to improve the overall quality of the organ donation process at tertiary care hospitals in Ontario.

Acknowledgements: A thank you goes out to Drs. Brian Rowe, Eric Grafstein and the many CAEP members and researchers who volunteered their time to evaluate the abstract submissions for this year's scientific presentations. A special thanks goes out to Carol Spooner (CAEP Research Consortium Research Associate) who has committed countless hours to this and other CAEP research projects.