2004 CAEP/ACMU Scientific Abstracts - Oral Abstracts (#33 to #52)

CAEP Abstracts

CJEM 2004;6(3):173-212

abstracts:  001-016 | 017-032 | 033-052 | 053-075 | 076-092 | 093-111 | 112-132

033 Addition of long-acting beta-agonists to corticosteroid therapy after discharge for acute asthma: a randomized controlled trial.

Rowe BH, Wong E, Blitz S, Diner B, Ross S, Mackey D, Tyler L, Senthilselvan A. Division of Emergency Medicine, University of Alberta, Edmonton, AB

INTRODUCTION: One regimen to reduce relapse following emergency department (ED) acute asthma includes prednisone and inhaled corticosteroid (ICS). We investigated the effect of adding a long-acting beta-agonist (LABA) to this regimen for patients discharged. METHODS: Patients aged 18-55 with acute asthma receiving < 2000 mcg of beclomethasone or equivalent ICS at 4 Canadian EDs were eligible. All 137 patients received similar ED treatment and upon discharge received oral prednisone (50 mg X 7 days) and inhaled beta-agonists. In a concealed, double blind fashion, patients were randomly assigned to receive either Advair (ADV; 1000 mcg/day fluticasone and 100 mcg salmeterol) or identical fluticasone (FLO; 1000 mcg/day) via dry powder delivery system. Patients were followed for 21 days. The main outcome was relapse to additional care; Asthma Quality of Life Questionnaire (AQLQ), beta-agonist use and compliance were also collected. RESULTS: After 21 days, 10 of 68 patients (14.7%; 95% CI: 7, 21) in the FLO group reported a relapse, compared to 7 of 69 (10.1%; 95% CI: 16, 34) in the ADV group (p = 0.46). The groups (ADV vs. FLO) reported similar impairment for total (6.4 vs. 6.2) AQLQ, and the activity (6.4 vs. 6.2), environmental (6.5 vs. 6.1), emotional (6.3 vs. 6.1), and symptom (6.3 vs. 6.2) AQLQ domains at 21 days; no differences were clinically or statistically significant (p > 0.23). For patients using ICS at the time of an exacerbation, ADV reduced the relapse from 24% to 13%. Early inhaler compliance was high; side effects were minor and similar in both the groups. CONCLUSIONS: Treatment with ICS/LABA combination therapy does not reduces relapses or improve quality of life during the first 3 weeks following discharged from the ED for acute asthma. Initial post-ED care should focus on standard treatment with prednisone and ICS; the potential role of combination agents appears to be most promising for patients already receiving ICS at the time of exacerbation.

Key words: asthma, corticosteroids, bronchodilator

034 The sensitivity of computed tomography for the diagnosis of subarachnoid hemorrhage in ED patients with acute headache.

Perry JJ, Stiell IG, Wells GA, Mortensen M, Lesiuk H, Sivilotti M, Bullard M. Department of Emergency Medicine, University of Ottawa, Ottawa, ON

INTRODUCTION: It is recommended that patients with acute headache undergo computed tomography (CT) followed by lumbar puncture (LP) to rule out subarachnoid hemorrhage (SAH). This is based on small studies with CT sensitivity for SAH varying from 90.5% to 100%. Our objective was to determine the CT sensitivity for SAH overall and when done <6 hours from headache onset in patients with normal neurological exam. METHODS: This prospective cohort study was conducted at 4 university tertiary care EDs. Patients >15 years, with normal neurological exam, GCS 15, and a complaint of a non-traumatic acute (<1hour from onset to peak) headache were enrolled over 3 years. Exclusion criteria were history of recurrent headaches, referral of confirmed SAH, papilledema, previous SAH or brain neoplasm. Physicians completed forms prior to investigations. The outcome criterion, SAH, was defined by any of: 1) SAH on CT, 2) xanthochromia in the cerebrospinal fluid (CSF), or 3) red blood cells in the final tube of CSF with positive cerebral angiography. Analysis included sensitivity, specificity with corresponding 95% confidence intervals. A priori subgroup analysis was performed for patients with CT scan <6 hours from onset of headache. RESULTS: There were 913 enrolled patients including 75 SAHs. The mean age was 44.6 years (SD 18.9) with 61.4% female. The median peak pain (0-10) was 10 (IQR 8,10) and 83.5% reported the worst headache of their life. Overall, the sensitivity of CT for SAH was 92.0% (95%CI 83%-96%) with a specificity of 100%. Of the 305 patients with CT performed <6 hours from onset of headache, 43 had SAH. The sensitivity of CT for SAH in this group was 100% (95%CI 92%-100%) with specificity of 100%. CONCLUSION: This was the largest prospective study determining the sensitivity of CT for SAH in neurologically intact patients. CT alone is highly sensitive for SAH when it is performed in <6 hours from the onset of headache and may be adequate to rule out SAH without the need for LP.

Key words: subarachnoid hemorrhage, computed tomography, diagnosis

035 Aminophylline in bradyasystolic cardiac arrest: A randomized placebo-controlled trial.

Abu-Laban RB, McIntyre CM, Christenson JM, van Beek CA, Innes GD, O'Brien R, Wanger KP, McKnight RD, Gin KG, Zed PJ, Watts J, Puskaric J, MacPhail IA, Berringer RG, Milner RA. Division of Emergency Medicine, University of British Columbia, Vancouver, BC

INTRODUCTION: Case reports and small trials have suggested that aminophylline may facilitate resuscitation from cardiac arrest. Our objective was to determine if the addition of aminophylline to standard treatment leads to an absolute increase of at least 8.8% in the proportion of prehospital adult bradyasystolic cardiac arrest patients who achieve return of spontaneous circulation (ROSC). METHODS: Patients with asystole or pulseless electrical activity at a rate less than 60/minute after endotracheal intubation, 1mg IV epinephrine, and 3mg IV atropine were eligible. Subjects were randomized to receive aminophylline (250mg IV bolus, followed by an additional 250mg IV bolus if no ROSC occurred within 90 seconds) or equivalently administered placebo, in a double-blind fashion. Standard resuscitation measures were continued for a minimum of 10 minutes after study drug administration. RESULTS: From 01/22/2001 to 09/03/2003, 1886 cardiac arrests were treated in the study area. Of 1025 eligible patients, 971 (94.7%) were enrolled (486 aminophylline, 485 placebo). Baseline characteristics and survival predictors were similar in the two treatment groups. The median time from paramedic arrival to study drug administration was 13 minutes. The proportion of patients with non-sinus tachyarrhythmias after study drug was 34.8% in the aminophylline group and 26.2% in the placebo group (p = 0.004). The proportion of patients with ROSC after study drug was 24.5% in the aminophylline group and 23.7% in the placebo group (difference 0.8%: 95% CI -4.6% to +6.2%, p = 0.778). Survival to hospital admission (6.6% vs 7.6%) and survival to hospital discharge (0.4% vs 0.6%) were not statistically different in the aminophylline and placebo groups respectively. CONCLUSIONS: Although aminophylline increases non-sinus tachyarrhythmias, we found no evidence in this sufficiently powered study that it significantly increases the proportion of adult patients who achieve ROSC in prehospital bradyasystolic cardiac arrest.

Key words: cardiac arrest, resuscitation, aminophylline, dysrhythmia

036 A clinical decision rule for the use of CT head in children with minor head injury.

Osmond MH, Klassen TP, Stiell IG, Correll R, Aronyk K, Reed M, Joubert G, Nijssen-Jordan C, Jarvis A, Pusic M, Kimoff L, Silver N, McConnell D, Bailey B, Hamilton M, Vassilyadi M, Moher D, for the CATCH Study Group. Department of Pediatrics, University of Ottawa, Ottawa, ON

INTRODUCTION: As part of the Canadian Assessment of Tomography for Childhood Head Injury (CATCH) Study, the objective was to develop a clinical decision rule for the use of CT Head in children with minor head injury. METHODS: This prospective cohort study included children (0-16 years) with documented loss of consciousness, amnesia, disorientation, persistent vomiting (>=2 times) or irritability (children < 2) and a GCS score of 13-15. Physicians in 9 Canadian pediatric teaching hospital EDs completed a 28-item assessment form prior to CT scan and in some cases a 2nd physician performed an interobserver assessment. The outcome standard, brain injury, was determined by CT and a 14-day telephone interview. Analyses included the kappa coefficient, appropriate univariate tests, and chi-square recursive partitioning. RESULTS: The 2441 patients in the study had these characteristics: mean age 9.2 (range 0-16); male 65.3%; GCS scores: 13- 2.4%, 14- 10.0%, 15- 87.6%; transfers 17.2%; mechanisms: fall 45.8%, sports 22.2%, bicycle 7.7%, MVC 7.2%; admitted 12.4%; brain injury on CT 3.9%; neurological intervention 0.5%. A rule with these 4 factors would have 100% sensitivity (95% CI 75-100%) and 68.4% specificity (95% CI 66-70%) for predicting neurological intervention: a) initial GCS score < 15, or decreases at any time, b) possible skull penetration or depressed fracture, c) lethargy, or d) irritability on exam. Adding 4 additional features would give 92.6% sensitivity (95% CI 85-96%) and 54.4% specificity (95% CI 52-56%) for predicting any brain injury on CT scan: e) signs of basilar skull fracture, f) large and boggy scalp hematoma, g) fall from a height >=3ft or >=5 stairs, or h) adverse event after assessment. CONCLUSIONS: This study has derived a highly sensitive decision rule for use of CT Head in minor head injury and this rule should be prospectively validated before clinical use.

Key words: minor head injury, computed tomography, clinical prediction rule, pediatric

037 What is the etiology of out-of-hospital pediatric cardiopulmonary arrest?

Gerein R, Osmond MH, Stiell IG, Nesbitt L, Campbell S, for the OPALS Study Group. Department of Emergency Medicine, University of Ottawa, Ottawa, ON

INTRODUCTION: Pediatric cardiopulmonary arrest (CPA) outside hospital has a very high mortality rate. In hopes of developing strategies to improve pre-hospital resuscitation we evaluated the etiology and initial compromise of pediatric CPA. METHODS: The Ontario Prehospital Advanced Life Support (OPALS) Study is a large multicenter initiative to evaluate the impact of EMS programs on 17 communities with 40,000 critically ill and injured patients. As part of this study we conducted a prospective cohort study that included all children < 19 years with prehospital CPA in a 10-year period from 1992-2002. Data were collected from ambulance reports and centralized dispatch data. We performed descriptive statistics with 95% CIs. RESULTS: There were 308 children with CPA with these characteristics: Mean age 4.1 (range 0-18); Male 55.2%; Unwitnessed arrest 68.5%; CPR first started by: bystander 19.2%, First Responder (Fire/Police) 27.9%, BLS crew 22.4%, ALS (paramedics) 9.4%. Initial rhythm: asystole 83.1%, PEA 13.9%, VF 2.4%, VT 0.6%; Overall survival to discharge was 2.1%. CPA witnessed in 27.9% of cases; bystander 77.9%, EMS 22.1%. Initial compromise of witnessed arrests was judged to be: respiratory 47.7%, trauma 23.3%, sudden collapse (presumed electrical) 14.0%, and progressive shock 2.3%. Presumed etiology was SIDS 27.3%, trauma 13.0%, drowning 10.7%, respiratory disease 9.0%, chronic disease 8.4%, strangulation 4.9%, asphyxia 4.2%, fire 4.2%, neonatal asphyxia 3.6%, and cardiac disease 3.2%. CONCLUSIONS: This is the largest prospective cohort of pediatric CPA reported to date and reveals that most pediatric arrests are unwitnessed and receive no bystander CPR. Those witnessed are most often due to respiratory arrests or trauma. SIDS, trauma and drowning are the most common etiologies. These data are vital to planning large resuscitation trials and highlights the need for better strategies for prevention, early recognition, and increasing the frequency of bystander CPR for children.

Key words: cardiac arrest, emergency medical services, pediatric

038 A randomized controlled trial of removable splinting versus casting in the management of wrist buckle fractures.

Plint AC, Perry J, Gaboury I, Correll R, Lawton L. Dept of Pediatrics, University of Ottawa, Ottawa, ON

INTRODUCTION: The objective of this study was to determine if children with wrist buckle fractures treated with a removable splint have better functioning than those treated with a cast for 3 weeks. METHODS: Children, 6-15 yrs, presenting with radial and/or ulnar buckle fractures to a pediatric ED were randomized to treatment with a short arm cast or removable splint. A validated outcome tool, ASKp was used to measure physical disability/daily functioning over a 4 week period. Primary outcome was ASKp score at 14 days. Other outcomes included change in ASKp, difficulties with grooming, sport, daily living, pain (measured by VAS), parental satisfaction, and refracture. Cast removal was at 21 days. Splinted children removed their splint as desired. RESULTS: 94 subjects were enrolled, 48 randomized to splint and 46 to cast. Study groups were similar in age, bone fractured and dominant hand injured. There were 69% and 59% males in the splint and cast groups respectively. There was no difference in overall ASKp score throughout the study, but change in ASKp from baseline revealed better functioning at day 14 in the splint group (p = 0.042). Splinted children had significantly less difficulty with bathing through the entire study (p < 0.001) and less difficulty with printing/writing (p = 0.006), grooming (p = 0.024), and drawing (p = 0.006) by day 20. More splinted children returned to their regular sports at day 20 than casted children (p = 0.013) and this persisted at day 28 (p = 0.007). There were no differences in pain between the groups. Average length of splint use was 13.8 (sd 6.1) days. 25 (54.3%) children had problems with their cast, 22 (45.8%) had problems with their splint during the study. Parental satisfaction was 100% in both groups. There were no refractures. CONCLUSIONS: Children treated with removable splinting have better physical functioning and less difficulty with most activities than those treated with casts. We recommend the use of removable splints in the treatment of this common injury.

Key words: fracture, immobilization, pediatric

039 Which children with acute injury seek care at tertiary care pediatric centers? Health service utilization for acute pediatric trauma: An expansion of the Canadian hospitals injury reporting prevention program (CHIRPP).

Osmond MH, MacKay M, Lipskie T, Mongeon S, Grant VJ, Macpherson A. Department of Pediatrics, University of Ottawa, Ottawa, ON

INTRODUCTION: CHIRPP is a surveillance system that collects data on the circumstances and nature of pediatric injuries from 10 tertiary care pediatric hospital EDs (PED ED) across Canada. Though the data is detailed it is limited by not being population-based. In order to determine how representative this PED ED sample is we aimed to compare the population of injured children seeking acute care at a PED ED to those visiting other acute care facilities in a large Canadian city (750,000 pop.). METHODS: After a 3-month run-in period, we performed a prospective cohort study where CHIRPP data were collected over a one-year period (Feb 2002-Mar 2003) on all children 0-19 years presenting with acute injuries at all acute care facilities in the city. These included one PED ED, and six additional sites (2 adult tertiary care hospital EDs (AD), 2 community non-teaching hospital EDs (COM), and 2 urgent care centres (UCC)). We performed descriptive statistics with 95% CIs. RESULTS: The 30,150 patients in the study had these characteristics: Age: 0-4 20.3%, 5-9 18.5%, 10-14 32.0%, 15-19 29.1%; Male 60.2%; Site visited: PED ED 46.3%, AD 8.3%, COM 22.4%, UCC 22.9%; The PED ED treated 69.3% of all children 0-4, 56.6% of those 5-9, 47.0% of those 10-14, and 23% of those 15-19. Of those requiring admission, 86.1% presented to the PED ED. 67.6% of admissions were < 15 years old and all presented to the PED ED. Of all children the following proportions presented to the PED ED: sprains 22.2%, superficial injury 29.2%, muscular injury 38.5%, lacerations 40.2%, fractures 52.9%, poisoning 61.5%, intracranial injury 67.4%, internal organ injury 68.2%, minor head injury 73.6%, and drowning 78.9%. CONCLUSIONS: The use of a tertiary care pediatric hospital-based injury surveillance system does not adequately reflect the true injury picture in a city and results in a greater representation of younger and more severely injured children. Users of PED ED injury surveillance data should recognize its limitations.

Key words: trauma, injury surveillance, pediatric

040 The additive value of nuclear medicine shuntograms to computed tomography for suspected cerebrospinal fluid shunt obstruction in the pediatric emergency department.

Ouellette D, Everson T, Bruder E, Lynch T, Lim R, Joubert G. Childrens Hospital of Western Ontario, LHSC, London, ON

INTRODUCTION: Traditionally, radiographic studies (shunt series) & CT have been performed to evaluate children with suspected CSF shunt obstruction. Nuclear medicine studies (CSF shuntograms) are dynamic studies that potentially can identify & localize a CSF shunt obstruction. This study was designed to measure the predictive value of nuclear medicine & radiographic studies in a cohort of children undergoing evaluation for suspected shunt obstruction in a tertiary care pediatric ED. METHODS: A retrospective chart review was conducted on patients (< 18 yrs) who presented to the Pediatric ED of CHWO & had both a CT head & a CSF shuntogram between December, 1998 & April, 2003. Nuclear medicine & radiological reports were reviewed for all patients presenting to the ED with suspected shunt obstruction. Three independent investigators interpreted these investigations as normal, inconclusive or abnormal, or inconclusive (kappa = 1). RESULTS: Of the 69 patients evaluated for suspected cerebrospinal shunt obstruction, twenty-six (37.7 %) patients required corrective surgery for suspected shunt obstruction (confirmed intra-operatively). The CT scans showed abnormalities suggestive of CSF shunt obstruction in 20 patients that required surgery (sensitivity, 77%; negative predictive value, 82%) while CSF shuntograms showed abnormalities suggestive of CSF obstruction in 24 patients that required surgery (sensitivity, 92%; negative predictive value, 93%). CT scans & shuntograms combined revealed abnormalities suggestive of CSF shunt obstruction in 25 of the 26 patients who required surgery (sensitivity, 96%; negative predictive value, 97%). CONCLUSIONS: Over one-third of pediatric ED patients evaluated with CT & CSF shuntograms required surgical management. Both sensitivity & negative predictive values were increased with CT & CSF shuntogram compared to CT alone. Prospective studies are required to assess the use of these modalities for shunt evaluation & to develop appropriate clinical decision rules for the EM physician.

Key words: shunt

041 Early analgesia in children with acute abdominal pain.

Green RS, Bulloch B, Kabani A, Hancock BJ, Tenenbein M. Department of Emergency Medicine, Dalhousie University, Halifax, NS

INTRODUCTION: Current practice in pediatric emergency medicine dictate that children do not receive analgesics when presenting to the ED with acute abdominal pain. Theoretically, analgesia may mask pain and diminish physical signs thereby confounding the diagnosis of a surgical condition. The purpose of this study was to determine whether the administration of morphine to children with acute abdominal pain would impede the diagnosis of appendicitis and to determine its efficacy in relieving the pain. METHODS: This is a double blind controlled randomized clinical trial in 5-16 year old children presenting to a tertiary care emergency department with acute abdominal pain requiring surgical consultation. Subjects were randomized to receive intravenous morphine or normal saline. Clinical data and the emergency physicians confidence with their clinical diagnosis were systematically collected using a standardized form. This was repeated 15 minutes after the administration of the study medication. Surgical assessment was completed within one hour of enrolment. Pain was assessed using a color analogue scale before and after study medication administration. Each subject was followed for two weeks after enrolment. RESULTS: One hundred and eight children were enrolled; 52 received morphine and 56 were saline controls. There were no differences between groups in demographic variables or degree of pain. There were no differences between groups in the diagnosis of appendicitis, perforated appendicitis or the number of children who were observed and the subsequently underwent laparotomy. The mean reduction in the median pain score was significantly greater in the morphine group, 2.2 vs 1.2 cm respectively (p = 0.026). Both the emergency physicians' and the surgeons' confidence with their diagnosis was not affected by the administration of morphine. CONCLUSIONS: Our data show that morphine effectively reduces the intensity of pain in children with acute abdominal pain and does not impede the diagnosis of appendicitis.

Key words: pain management, abdominal pain, pediatric

042 Prevalence and attitudes towards the use of protective equipment in skateboarding parks.

Martin C, Joubert GI. University of Western Ontario, London, ON

INTRODUCTION: Skateboarding (SB) is a popular activity for millions of children in North America (NA). SB injuries result in over 50,000 Emergency department (ED) visits/year in the US alone. SB parks (SBP), designed specifically for SB are growing in popularity in NA. Although protective equipment (PE) decreases injury risk, many children do not wear PE while SB. The objective of this study was to determine the attitudes of children/adolescents have regarding the use of PE. METHODS: Subjects ages 10 to 18 years at 5 SBP in Southwestern Ontario (SWO) were surveyed on use and attitudes towards PE. Data collected included SB experience, hours per week, frequency of use of PE (helmet, knee pads, elbow pads and wrist guards), number of injuries, visits to ED and their reasons for not wearing PE. RESULTS: 83 subjects (78 males/5 females) completed the survey with an average age of 13.8 yrs and SB 24.1 hrs per week. 55.4% reported never wearing a helmet and 27.7% reported only wearing a helmet occasionally or with "high risk tricks". 73.5% reported never wearing knee pads, 80.7% reported never wearing elbow pads and 81.9% reported never wearing wrist guards. The reasons for not using PE were: restricts movement (27.7%), uncomfortable (25.3%), and unnecessary (22.9%). The mean number of total injuries for each child was 54.2, with 1.6 of these injuries requiring a visit to ED. 94% thought they could be seriously hurt while SB. 72.3% thought that protective gear would help protect against injury. 39 children surveyed reported never wearing any PE. These subjects were older age (14.26 years) and had similar experience (2.6 yrs). They reported less total injuries (42.6) and less visits to the ED (1.4). Of the 39, 61.5% believe that they could be seriously hurt while SB and that PE prevented injury. CONCLUSIONS: This study shows that there is a very low prevalence of protective gear use in SWO SBP. Low use of PE is not due to a lack of understanding, but instead to a lack of willingness.

Key words: Injury prevention, skateboard injury

043 Reliability of ED head CT scan interpretation.

Bullard M, Lari H, Steinke D, Emery D, Colman I, Sahai V, Rowe BH. Division of Emergency Medicine, University of Alberta, Edmonton, AB

INTRODUCTION: Non-contrast CT is the modality of choice for detecting intra-cranial hemorrhage, especially to rule-out subarachnoid hemorrhage. The ability to accurately identify the presence of blood on a CT scan may vary by specialty and level of experience. This study examined the agreement in identifying hemorrhage on CT scans among different reviewers based on specialty and levels of training. METHODS: One hundred selected head CT scans of patients >15 years old who presented to the ED were evaluated. All CT scans were catalogued in a computer and independently reviewed by a "reference standard" neuro-radiologist and 20 reviewers who were blinded to any radiologist's report and clinical data. The reviewers included 5 residents each from emergency medicine (EM), Neurosciences (NSc: neurology and neurosurgery) and radiology (Rad) and 5 EM staff physicians. Pooled agreement (kappa: k; 95% confidence intervals: 95% CI) and sensitivity (SN) were calculated for the presence of hemorrhage for each rater group compared to the reference standard. RESULTS: Mean age was 49.7 years, 52% were female, and 45% were hospitalized. The presence of abnormality according to the reference neuro-radiologist was 50%; 41% demonstrated presence of hemorrhage. EM staff physicians (k: 0.87; 95% CI: 0.79, 0.96) and residents (k: 0.87; 95% CI: 0.78, 0.96) demonstrated similar agreement. Rad (k: 0.94; 95% CI: 0.85, 1.0) and NSc (k: 0.92; 95% CI: 0.83, 1.0) also demonstrated excellent agreement. Not all EM staff achieved 100% sensitivity; however, in combination with Rad or Nsc, all hemorrhages were detected. CONCLUSIONS: Agreement with a gold standard for presence of blood on CT varies minimally and is generally high; however, EM staff do miss occasional hemorrhages. If consultation with radiology or experienced NSc resident is sought, sensitivity increases to 100%. Adoption of this approach for negative head CTs may limit medical error and reduce unnecessary testing in the ED.

Key words: computed tomography, subarachnoid hemorrhage, diagnosis

044 La corrélation entre l'évaluation par des médecins et par des infirmières de la performance de médecins d'urgence.

Poitras J, Belley R, Doucet R, Lapointe J, Paquet F. Département de médecine d'urgence, Hôtel-Dieu de Lévis, Université Laval, Québec, PQ

INTRODUCTION : Nous avons démontré précédemment que l'objectivation de la performance de médecins d'urgence peut être réalisée par une évaluation rétroactive à 360 degrés. Notre objectif était de déterminer, dans le cadre d'une telle évaluation, la corrélation entre l'évaluation des médecins et celle des infirmières. METHODES : Un questionnaire sur quatre champs de compétences des médecins d'urgence a été distribué aux médecins d'un département académique de médecine d'urgence ainsi qu'à un groupe de dix infirmières œuvrant dans ce département. La corrélation entre les notes attribuées par les médecins à leur collègues et celles attribuées par les infirmières a été déterminée en utilisant le coefficient kappa. RESULTATS : Les notes moyennes (sur 5) obtenues par les médecins sont présentées au tableau 1. La corrélation entre les notes accordées par les médecins et celles accordées par les infirmières est présentée au tableau 2. CONCLUSIONS : La corrélation entre l'évaluation des infirmières et celle des médecins est bonne pour les habiletés interpersonnelles et managérielles, mais faible pour les habiletés personnelles et intellectuelles. Ceci peut reflèter une connaissance moindre de ces aspects par les infirmières. Elles ont coté généralement plus faiblement la performance des médecins que les médecins eux-mêmes. La reprise de cette évaluation devrait cibler davantage les questions adressées aux infirmières sur les habiletés personnelles et intellectuelles afin de prendre en compte les aspects avec lesquels elles sont les plus familiers. Mots clés : compétences, gestion, perceptions

045 Le centre de services ambulatoires : une alternative au recours à l'urgence hospitalière acceptable pour les patients?

Leduc N, Ricard J, Gbaya A, Farand L, Roberge D. Groupe de recherche interdisciplinaire en santé, Faculté de médecine, Université de Montréal, Montréal, PQ

INTRODUCTION : Le Centre Hospitalier Pierre-Le Gardeur, situé en banlieue de Montréal, met présentement sur pied un centre de services ambulatoires qui aura entre autres fonctions de diminuer le recours à l'urgence hospitalière, en offrant à la clientèle atteinte de problèmes non urgents ou subaigus un accès rapide à des services médicaux de 1ère et 2^e lignes. L'objectif de ce projet est d'identifier les services de santé considérés acceptables comme alternatives à l'urgence hospitalière selon la perspective des patients. MÉTHODES : L'étude a été réalisée auprès de 399 patients recevant les codes 4 ou 5 à leur arrivée à l'urgence. Les informations suivantes ont été recueillies par questionnaire auto-administré : motif de consultation, durée et nouveauté du problème, gravité perçue, douleur et limitations, trajectoires de soin avant le recours à l'urgence, source régulière de soins, habitudes d'utilisation, attitudes et préférences à l'égard des divers types de services de santé et de leurs attributs réels ou potentiels. Des estimations par intervalle, des mesures d'association et des régressions logistiques ont été effectuées. RÉSULTATS : Le médecin de famille serait le service auquel les patients recourraient volontiers plutôt qu'à l'urgence, si le temps d'attente y était moindre, s'il offrait la possibilité de consultations spécialisées dans un court délai et qu'on y avait accès plus facilement. À temps d'attente équivalent, l'urgence demeure le service de choix. Les principaux attributs recherchés sont l'accès rapide à des services spécialisés d'investigation et des médecins spécialistes et, de façon secondaire, le suivi par le même médecin. La proximité n'aurait que peu d'importance. CONCLUSION : Ces résultats montrent qu'un centre ambulatoire, branché sur le réseau de 1ère ligne et offrant des services spécialisés, aurait une forte probabilité de succès pour diminuer l'achalandage de l'urgence et accroître l'accessibilité aux services de santé. Mots clés : achalandage, centre ambulatoire, triage

046 L'autoadministration de morphine aux urgences.

Brana A, Getti R, Mezaib K, de Beauchêne M, Simon N. Dept. Accueil Urgences Hopital de Poissy, PQ

INTRODUCTION : Évaluer l'autoadministration contrôlée de morphine (PCA) en situation d'urgence. METHODS : Les patients relevant d'une analgésie par PCA étaient admis en unité d'observation. Après une titration initiale la PCA suivait un algorithme tenant compte de la dose de titration, d'une administration par bolus seuls pendant 4 h, d'un ajustement à H4 et d'une perfusion continue avec bolus ensuite. RESULTS : 23 malades d'age moyen 38 ans (18-86). Étaient inclus (12 drépanocytoses, 5 coliques néphrétiques rebelles aux AINS, 2 pancréatites aiguës; 4 autres). L'EVA initiale était à 82 mm (CI 95 : 75-89). La titration est de 20 mg de morphine (CI 95 : 16-24 ) ramenant l'EVA à 31mm (CI 95 : 18-43). Dans les 4 premières heures, les bolus reçus sont de 3,5 mg (CI 95 : 2,8-4,2) la dose administrée de 39 mg (CI 95 : 28-50); l' EVA à 16 (CI 95 : 8-24) à H4. Après la quatrième heure 14 patients ont reçus une dose continue en plus des bolus. La durée médiane totale de PCA est de 19 h (IQ 12-24) la dose totale de morphine de 60 mg (CI 95 : 40-79); L'EVA à la fin à 13 mm (CI 95 : 6-20). 22 malades ont reçu une coanalgésie (paracétamol ou AINS ou N2O). 14 sont sortis directement chez eux. Un seul patient a présenté des effets secondaires (prurit, globe vésical) sans nécessiter l'arrêt de la PCA. CONCLUSIONS : L'auto administration contrôlée de morphine par PCA a sa place aux urgences et permet une excellente analgésie durable en toute sécurité. Mots clés : douleur, analgésie, autoadministration

047 The effects of an evidence-based emergency medicine workshop on the application of pre-appraised resources in clinical practice.

Lang E, Wyer P, Guttman A, Poitras J, Colacone A, Xue X, Hayward R, Afilalo M. Emergency Department, Sir Mortimer B. Davis Jewish General Hospital, McGill University, Montreal, PQ

OBJECTIVES: Workshops in Evidence-Based Medicine (EBM) are designed to encourage participants to use online resources and incorporate EBM into clinical practice as well as academic and leadership activities. The objective of this study was to measure the effects of this type of workshop on behaviors related to EBM practice. METHODS: Participants in an EBM workshop were asked to complete an anonymous online survey of EBM activities both prior to and 6 months following the completion of the course. Five-point Likert scales, multiple choice and open response questions were employed. Pre/post comparisons with dichotomized Likert scale responses were analyzed using Chi-Square or the Fisher's exact test as appropriate. RESULTS: 28 (77%) of workshop participants completed the pre-conference survey while 24 (86%) of these completed the post-course exercise. Respondents were mostly full-time emergency physicians (81%) based in academic centers (83%); 18% of respondents were residents. Participants reported that they consulted The Cochrane Collaboration to answer clinical questions arising from practice more frequently (> or = to 1/week) after their participation in the workshop (4% vs.42%, p < 0.001). Participants also reported themselves to be better skilled (fair, good or excellent) at incorporating EBM into daily clinical practice (41% vs. 96%, p < 0.001). Workshop involvement did not clearly result in an increased use (occasionally, frequently or all the time) of structured critical appraisal during Journal Club (JC) (62% vs. 83%, p = 0.10) nor did it increase involvement in developing evidence-based guidelines within their institutions (45% vs. 58%, p = NS). CONCLUSIONS: An EBM workshop results in a sustained increase in searching of relevant online resources as well as the incorporation of EBM into practice. Improved strategies are needed to increase individual involvement in the creation of EBM guidelines at home institutions as well as the use of structured critical appraisal during JC.

 

048 Emergency department triage: Evaluating the implementation of a computerized triage tool.

Bullard MJ, Dong SL, Meurer DP, Blitz S, Colman I, Rowe BH. Division of Emergency Medicine, University of Alberta, Edmonton, AB

OBJECTIVES: Emergency department (ED) triage prioritizes patients based on urgency of care. The Canadian Triage and Acuity Scale (CTAS) is the nationally recognized standard. A web-based triage tool (eTRIAGE) based on CTAS has been developed. We describe the experience of implementing eTRIAGE in a real time environment. METHODS: This prospective study took place in a tertiary care ED in a large urban centre. The ED deployed eTRIAGE after training a cohort of its triage nurses in its use. The training sessions were two to three hours long. These nurses were to share their knowledge with untrained nurses during regular triage shifts. During the study period, patients were assessed by the triage nurse (TN) using eTRIAGE and assigned a CTAS score. A study nurse (SN), blinded to the first triage assessment, independently assessed the same patients using eTRIAGE. The SNs were trained in eTRIAGE and had extensive experience with the software from previous use. Each nurse's use of eTRIAGE was studied. Agreement between the two triage scores was reported using kappa statistics. RESULTS: Over a six week period, 569 adult patients were assessed and 540 had complete records. The mean age was 48 (range 17-95) and 51.8% were male. Twenty-five different TNs, many who were not in the initial training cohort, made the TN assessments. The percent of patients in each CTAS category (1 to 5) were 0.9, 13.2, 50.9, 30.4, and 4.6 for TN and 1.7, 22.2, 45.2, 24.1, and 6.9 for SN. Agreement between TN and SN was fair (kappa = 0.295, 95% CI 0.230, 0.359; weighted kappa = 0.431, 95% CI 0.367, 0.495). When agreement was considered to be within one triage level, agreement improved (kappa = 0.728, 95% CI 0.633, 0.823). CONCLUSIONS: Agreement between nurses using eTRIAGE may be limited by many factors. Training and experience with the software between users may affect its use. We plan on conducting a further study with a fewer number of TNs who will have had more experience with the software.

Key words: triage, Canadian triage and acuity scale, reliability

049 A randomized controlled trial comparing the efficacy of training paramedic students endotracheal intubation on a patient simulator versus human subjects.

Hall RE, Plant JR, Bands CJ, Kang J, Hall CA. Division of Emergency Medicine, University of Calgary, Calgary, AB

INTRODUCTION: Endotracheal intubation (ETI) is a crucial skill for paramedics and the optimal method of training remains controversial. Student crowding in the operating room (OR) impacts the training of medical and paramedical personnel. Also, the nature of the OR makes it a less than ideal learning environment. Patient simulators are being used to replace OR experience for training ETI despite limited data. The purpose of this study was to determine the efficacy of training paramedic students ETI using a human patient simulator. METHODS: Paramedic students were enrolled if they had no previous ETI training (N = 36). Students received identical didactic and manikin training. Students were then randomized to be trained ETI on a patient simulator (SIM group) or on human subjects in the OR (OR group). All students received a formalized test of 15 intubations in the OR. Test intubations were evaluated by the attending anesthesiologist. The primary outcome was the overall success rate of intubation. Secondary outcomes were first attempt success, complications, and success versus airway difficulty. For the overall success rate, the study was powered to detect a 10% difference between training methods (alpha error 0.05, beta error 0.2). Data was analyzed to account for repeated measures. RESULTS: The overall success rate was 87.8% in the SIM group and 84.8% in the OR group, with a difference of 3.0% (95% CI -4.2, 10.1). Success on the first attempt was 84.4% in the SIM group and 80.0% in the OR group, with a difference of 4.4% (95% CI -3.4, 12.3). The overall complication rate was 6.3% in the SIM group and 4.8% in the OR group (p = 0.44). CONCLUSIONS: When tested in the OR, paramedic students trained ETI on a patient simulator are comparable to students trained on human subjects. The results support using human patient simulators to teach ETI.

Key words: medical education, airway management

050 Use of an emergency department (ED) asthma order sheet to increase adherence to evidence-based (EB) guidelines: An interventional trial.

McGillivray DL, Chalut DS, Plotnick LH, Savdie SR, Ducharme FM. Division of Pediatric Emergency Medicine, Montreal, Quebec, PQ

INTRODUCTION: Despite the dissemination of EB pediatric asthma guidelines, adherence to guidelines remains a significant problem in many EDs. The objective of this study was to determine if the introduction of an evidence-based asthma order sheet increases adherence to EB guidelines. METHODS: All children, age 2-17 years, presenting to an urban pediatric ED for an acute asthma exacerbation during the pre and post intervention period, each lasting 8 weeks, were enrolled into the study. The asthma order sheet, developed using the EB literature, incorporated measurement of severity of disease using the PRAM (Pre-school respiratory assessment score). EB treatment goals were as follows: severity scores were to be done on all children at triage and within 1 hour of arrival, children with moderate asthma were to receive three doses of salbutamol and systemic steroids and severe asthmatics were to receive three doses of salbutamol and ipratropium plus systemic steroids. The primary outcome measure was fractile adherence (FA) for the study goals (the percentage of patients in whom the treatment goal was achieved. RESULTS:438 and 601 children were enrolled in the pre and post intervention groups, respectively. FA for measurement of severity was 67.8% (95% CI 0.63, 0.72) and 93% (0.91, 0.95) in the pre and post groups respectively, P < 0.001. FA for medications given for the pre and post groups were as follows; steroids 53.3% (42.0, 64.6) vs 78.4% (72.8, 84.0) P = <0.001, ipratropium 61.5% (35.1, 88.0) vs 76.9% (65.5, 88.4) P = 0.14. FA for receiving medications on time was not significantly different with the exception of steroids where 17.3% (8.7.25/9) vs 30.8% (24.5, 37.0) of the steroids were given on time in the pre vs post group. CONCLUSION: The use of an EB order sheet for pediatric asthma improved guideline adherence with respect to measurement of severity of disease and appropriate use of medications, especially steroids.

Key words: asthma, quality improvement

051 Clinical factors predicting fractures associated to an anterior shoulder dislocation.

Emond M, Lavoie A, Le Sage N, Rochette L. Division of Emergency Medicine, Department of Family Medicine, Laval University, Quebec City, PQ

INTRODUCTION: To identify risk factors for fractures associated with anterior shoulder dislocation treated in an emergency department (ED). METHODS: A retrospective nested case-control study reviewed consecutive medical charts of patients with an anterior shoulder dislocation over 5 years in a university-affiliated ED. Chart review identified possible predictors of fractures. Comparing profile of patients having a clinically important fracture associated to their shoulder dislocation (cases) to those sustaining a non-complicated dislocation (controls) provided the outcome measure. RESULTS: Four hundred and sixty-two (462) patients were included in the study. Ninety three had a clinically important fracture-dislocation (20.1%), the remaining three hundred and sixty nine sustained non-complicated shoulder dislocation (79.9%). Chi-Square, logistic regression and recursive partitioning analysis revealed three significant factors for presence of fracture-dislocation: 1) age over 50 years old, 2) a first episode of dislocation and 3) mechanism of injury (i.e. a fall greater than one flight of stairs, an aggression/direct blow episode or a motor vehicle crash). A multiple logistic regression model estimated the significant adjusted odds ratios (OR) [and their 95 % confidence intervals] for each of the three factors: 3.67 [2.25-6.28], 5.13 [2.44-10.77] and 4.13 [2.15-7.98] respectively. A predictive model using all three factors reached a sensitivity of 94.6% [88.0-97.7], a specificity of 36.3% [31.6-41.1], a negative predictive value of 96.4% [91.9-98.5] and a negative likelihood ratio of 0.15 [0.06-0.35]. CONCLUSIONS: Three risk factors predict clinically important fractures associated with shoulder dislocation: age, first episode and mechanism of dislocation. A prospective validation should lead to clear clinical guidelines.

Key words: fracture, dislocation, x-ray

052 Evaluation of a dedicated teaching shift involving direct bedside observation of trainees by attending staff.

Alam N, Lang E, Ross J, Turner J, Serero D, Colacone A, Xue X, Afilalo M. Emergency Department, Sir Mortimer B. Davis Jewish General Hospital, McGill University, Montreal, PQ

OBJECTIVES: In many institutions, Emergency Department crowding has resulted in the erosion of bedside teaching. A dedicated teaching shift involving direct one on one observation of trainees while they assess and manage patients has been proposed to improve the quality of bedside teaching. The objective of this study was to determine the educational value of this shift as perceived by trainees and supervisors. METHODS: A practice-plan sponsored teaching shift was instituted during 4 academic periods (months) in 2003 on 4 mornings per week. Supervisors and trainees completed surveys (anonymous for trainees) after each encounter providing feedback on each others' performance as clinicians and teachers respectively. Five-point Likert scales with descriptors from not at all (1) to very good (5), multiple choice and open response questions were used. RESULTS: Information was gathered from 61 one-hour encounters between trainees (mostly PGY1) and 11 supervisors. Trainees who completed surveys (N = 38) indicated that staff were very good at identifying areas for improvement (mean + sd) 4.57 ± 0.60 and provided useful guidance 4.50 ± 0.80. According to trainees, the teaching encounters identified the following areas for improvement: history taking (55.3%), differential diagnosis (52.6%), physical exam (47.4%), communication (23.7%), decision making (15.8%), case presentation (5.3%) and test interpretation (5.3%). Intimidation was rated low 2.03 ± 0.97 and educational value high 4.47 ± 0.80. Trainees perceived these sessions to have better educational value than routinely reviewed cases 4.47 ± 0.60. They also perceived the feedback received as accurate (100%) and constructive (97%). Supervisors felt the teaching session was useful 3.84 ± 0.63 and that they had had a positive impact 3.80 ± 0.62. CONCLUSIONS: A dedicated teaching shift involving direct bedside observation of trainees by clinical supervisors is perceived as having superior educational value by both students and teachers.