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.

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.

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.

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 inhospital 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.

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.

Measurement of the serum B-type natriuretic peptide (BNP) level and more recently its precursor, N-terminal proBNP (NT-proBNP), has been advocated to facilitate the diagnosis of heart failure in the emergency department (ED). We sought to determine the potential impact of adding NT-proBNP testing to the routine evaluation of emergency patients with acute dyspnea.

This prospective cohort study enrolled a convenience sample of acutely dyspneic patients at a tertiary care ED. We excluded trauma patients and those under 30 years of age. Patients underwent standard evaluation, including radiography when indicated. At the point of final diagnosis and blinded to the NT-proBNP result, physicians documented the likelihood that heart failure accounted for the patient's acute dyspnea on a 7-point Likert scale, the data from which was subsequently collapsed to 3 categories for analysis purposes. The primary outcome was the agreement between clinical impression and the NT-proBNP assay classified using manufacturer-recommended, age-specific cut-offs. Newly proposed cut-offs from a recent study were also evaluated.

One hundred and twenty-nine patients making 139 ED visits were enrolled (median age 76 years; 59% admitted). The serum NT-proBNP assay was positive in 119 (86%, 95% confidence interval [CI] 80%–91%) cases, including 75% (43/57, 95% CI 62%–86%) of the cases that the treating physician felt were not caused by heart failure, and 86% (25/29, 95% CI 68%–96%) where the treating physician was unsure. The median NT-proBNP concentration was higher in patients clinically believed to have heart failure rather than pneumonia or chronic obstructive pulmonary disease; however, the ranges of these values overlapped extensively (median 4361 pg/mL; interquartile range [IQR] 2386–10877 v. 1651 pg/mL; IQR 370–4745, respectively).

There is high discordance between the clinical impression of treating physicians and NT-proBNP concentrations, notably in patients who are believed not to have heart failure. Although the reference standard of ED diagnosis is imperfect, the broad overlap in NT-proBNP concentrations suggests poor specificity in this target patient population. The introduction of routine ED NT-proBNP testing using the current cut-offs would be expected to result in substantial indirect costs from further diagnostic testing. It remains unclear whether the introduction of this diagnostic test would have a positive impact on clinically relevant patient outcomes.

Autoregulation is dysfunctional in the injured brain. Increases in intracranial and arterial pressure may therefore result in extension of the primary injury. Rapid sequence intubation (RSI) is a well-known cause of surges in both arterial pressure and intracranial pressure. Neuroprotective agents, namely lidocaine and fentanyl, have the potential to minimize the pressure surges implicated in secondary brain injury. The purpose of this study was to determine the frequency with which neuroprotective agents were used for neuroprotective RSI in the emergency department.

We conducted a retrospective chart review of all 139 patients intubated in the emergency department of Vancouver General Hospital between March and October 2003. Patients were eligible if there was an indication for neuroprotective agents defined as presumed intracranial pathology and a mean arterial pressure (MAP) > 85 mm Hg. Contraindications to fentanyl included MAP < 85 mm Hg or allergy to fentanyl.

Seventy-seven patients were intubated for primary neurological indications. Indication for intubation included non-traumatic causes (n = 37) (including cerebrovascular accident or intracranial hemorrhage) and closed head injury (n = 40). The mean age (± standard deviation) was 52.3 ± 20.4 years, and 31.4% were female. Fifty-seven (74.0%) patients had indications for neuroprotective agents, without contraindications. When neuroprotective agents were indicated, lidocaine was used in 84.2% (95% confidence interval [CI] 72.6%–91.5%) of patients while fentanyl was used in 33.3% (95%CI 22.4%–46.3%) of patients. Eleven percent of the intubations were performed with a fentanyl dose of Δ 2 mcg/kg, which is the lower limit considered effective.

Despite the potential benefit of using lidocaine and fentanyl in appropriate patients undergoing neuroprotective RSI in the emergency department, our study identified a significant underutilization of optimal premedication. The identification of barriers to use and the implementation of strategies to optimize use are necessary.

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.

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.

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 (Sao2 ≤ 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.

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.

Inadequate hospital stocking and the unavailability of essential antidotes is a worldwide problem with potentially disastrous repercussions for poisoned patients. Research indicates minimal progress has been made in the resolution of this issue in both urban and rural hospitals. In response to this issue the British Columbia Drug and Poison Information Centre developed provincial antidote stocking guidelines in 2003. We sought to determine the compliance with antidote stocking in BC hospitals and any factors associated with inadequate supply.

A 2-part survey, consisting of hospital demographics and antidote stocking information, was distributed in 2005 to all acute care hospital pharmacy directors in BC. The 32 antidotes examined (21 deemed essential) and the definitions of adequacy were based on the 2003 BC guidelines. Availability was reported as number of antidotes stocked per hospital and proportion of hospitals stocking each antidote. For secondary purposes, we assessed factors potentially associated with inadequate stocking.

Surveys were completed for all 79 (100%) hospitals. A mean of 15.6 ± 4.9 antidotes were adequately stocked per hospital. Over 90% of hospitals had adequate stocks of N-acetylcysteine, activated charcoal, naloxone, calcium salts, flumazenil and vitamin K; 71%–90% had adequate dextrose 50% in water (D50W), ethyl alcohol or fomepizole, polyethylene glycol electrolyte solution, protamine sulfate, and cyanide antidotes; 51%–70% had adequate folic acid, glucagon, methylene blue, atropine, pralidoxime, leucovorin, pyridoxine, and deferoxamine; and <50% had adequate isoproterenol and digoxin immune Fab. Only 7 (8.9%) hospitals sufficiently stocked all 21 essential antidotes. Factors predicting poor stocking included small hospital size (p < 0.0001), isolation (p = 0.01) and rural location (p < 0.0001).

Although antidote stocking has improved since the implementation of the 2003 guidelines, essential antidotes are absent in many BC hospitals. Future research should focus on determining the reasons for this situation and the effects of corrective interventions.

The trend toward operating Canadian hospitals at full capacity necessitates in some settings the transfer of patients from one hospital's emergency department (ED) to another hospital for admission, due to lack of bed availability at the first hospital. Our objectives were to determine how many and which patients are transported, to measure how much time is spent in the peri-transport process and to document any morbidity or mortality associated with these periods of transitional care.

In this retrospective, observational health records review, we obtained health records during February, June and October 2002 for patients evaluated in any 1 of 3 adult EDs from a single Canadian city and subsequently transferred for admission to 1 of the other 2 hospitals. Data included the reason for transport, admitting service, transport process times and administration of key medications (asthma, cardiac, diabetes, analgesic or antibiotics).

Five hundred and thirteen records of transported patients were reviewed, and 507 were evaluated. Of those, 372 (73.4%) transfers were capacity-related and 135 (26.6%) were transferred for specialty services. Of the capacity transports, 219 (58.9%) were admissions for psychiatry and 123 (33.1%) for medicine. Median wait time at the first hospital was 6.7 hours, being longest for psychiatric patients. Thirty patients (8.1%) missed 1 or more doses of a key medication in the peri-transport process, and 8 (2.2%) missed 2 or more.

Overcrowding of hospitals is a significant problem in many Canadian EDs, resulting in measurable increases in lengths of stay. Transfers arranged to other facilities for admission further prolong lengths of stay. Increased boarding times can result in missed medications, which may increase patient morbidity. Further study is needed to assess the need for capacity transfers and the possible risk to patients associated with periods of transitional care.

To determine the effectiveness and safety of procedural sedation and analgesia (PSA) in a Canadian community emergency department (ED) staffed primarily by family physicians and to assess the role of capnometry monitoring in PSA.

One hundred and sixty (160) consecutive procedural sedation cases were reviewed from the ED of a rural hospital in Huntsville, Ont. The ED is mainly staffed by family physicians who have received in-house training in PSA. Safety and effectiveness measures were extrapolated from a standardized PSA form by a blinded research assistant.

The mean age of the patient population was 33.6 years (standard deviation = 23.6). Fifty-four percent of the patients were male, and 33% of the cases were pediatric. PSA medications included propofol (84%), fentanyl (51%) and midazolam (15%), and the procedural success rate was 95.6%. The adverse event (AE) rate was 18% and included apnea (10%), inadequate sedation (3%), bradycardia (2%), desaturation (1%), hypotension (1%) and bag-valve-mask use (1%). In those aged ≥65 years there was a greater incidence of apnea. There were no episodes of emesis and there were no intubations. A modified jaw thrust manoeuvre was used in 23% of the cases. In the 64% of cases where capnometry was used, there was no association between its use and any AE measures.

Procedural sedation was safe and effective in our environment. Capnometry recording did not appear to alter outcomes, although the data are incomplete.

Relatively little is known about the ability of Canadian emergency departments (EDs) and the federal, provincial and territorial governments to quantify ED activity. The objectives of this study were to determine the use of electronic patient data in Canadian EDs, the accessibility of provincial data on ED visits, and to identify the data elements and current methods of ED information system (EDIS) data collection nationally.

Surveys were conducted of the following 3 groups: 1) all ED directors of Canadian hospitals located in communities of >10 000 people, 2) all electronic EDIS vendors, and 3) representatives from the ministries of health from 13 provincial and territorial jurisdictions who had knowledge of ED data collection.

Of the 243 ED directors contacted, 158 completed the survey (65% response rate) and 39% of those reported using an electronic EDIS. All 11 EDIS vendor representatives responded. Most of the vendors provide a similar package of basic EDIS options, with add-on features. All 13 provincial or territorial government representatives completed the survey. Nine (69%) provinces and territories collect ED data, however the source of this information varies. Five provinces and territories collect triage data, and 3 have a comprehensive, jurisdiction-wide, population-based ED database. Thirty-nine percent of EDs in larger Canadian communities track patients using electronic methods. A variety of EDIS vendor options are available and used in Canada.

The wide variation in methods and in data collected presents serious barriers to meaningful comparison of ED services across the country. It is little wonder that the majority of information regarding ED overcrowding in Canada is anecdotal, when the collection of this critical health information is so variable. There is an urgent need to place the collection of ED information on the provincial and national agenda and to ensure that the collection of this information consistent, comprehensive and mandatory.

To clarify the benefits, risks and timing of glucose control and intensive insulin therapy in several groups, specifically the neurologic, cardiac and septic populations of patients, commonly seen in the emergency department.

Electronic search of MEDLINE (1966–2005; once with PubMed and once with Ovid) and Embase (1980–2005) using the terms insulin and glucose combined with emergency medicine, intensive care, cardiology and emergency department.

There is considerable controversy in the literature surrounding the use of strict glucose control in cardiac, neurologic and septic patients. Much of this literature is non-randomized, and the timing of therapy is poorly investigated.

Hyperglycemia is associated with adverse outcomes in acutely ill neurologic, cardiac and septic patients, but it remains unclear whether this is a causative association. Glucose control and intensive insulin therapy may be useful in some patient subgroups; however, controlled trials of aggressive glycemic control have provided insufficient evidence to justify subjecting patients to the real risks of iatrogenic hypoglycemia. We recommend a cautious approach to the control of glucose levels in acutely ill emergency department patients, with a target glucose of below 8 to 9 mmol/L.

Demography affects emergency department (ED) utilization and influences the health care needs of patients, yet the demographics of the caregivers who accompany children to pediatric EDs are not well described. The objective of this study was to provide a demographic description of this population. The hypothesis was that single parent status, annual income less than $20 000, and education no greater than high school constitute a social triad that might reduce the ability to provide health care for a sick child.

Over a 1-month period, a convenience survey of caregivers who brought children to a pediatric ED was conducted. Twelve hundred surveys were distributed to 1733 eligible subjects. Social and economic determinants were captured, including age, gender, visible minority status, income group, employment, single parent status and education level.

In total, 1018 (85%) of 1200 surveys were returned — a population response rate of 59%. Single parent status, income less than $20 000/yr, and education no greater than high school were found to be risk factors for altered delivery of health care. Overall, 40.9% of caregivers had at least one risk factor, including 43.2% of women, 63.4% of those under 30 years of age, 65.1% of those with visible minority status, and 71.6% of women who were from a visible minority. In addition, 41.7% of single parents had no more than a high school education, and 75.7% of single parent families had incomes of less than $40 000 per year.

It was found that a high level of educational, social and financial disadvantage in our population. These factors may adversely affect parental capability to provide health care at home for their child. The extent of this problem in other regions is not well defined and should be a focus of future research. It is recommended that inquiry into parental income, education and single parent status be a routine part of the history in pediatric emergency populations.