The Emergency Severity Index (ESI©) is an initial measure of patient assessment in the emergency department (ED). It rates patients based on acuity and predicted resource intensity from Level 1 (most ill) to Level 5 (least resource intensive). Already implemented and evaluated in several US hospitals, ESI has yet to be evaluated in a Canadian setting or compared with the fivelevel Canadian Emergency Department Triage and Acuity Scale (CTAS).

To compare the inter-observer reliability of 2 five-level triage and acuity scales.

Ten triage nurses, who had all been trained in the use of CTAS, from 4 urban, academic Canadian EDs were randomly assigned either to training in ESI version 3 (ESI v.3) or to refresher training in CTAS. They independently assigned triage scores to 200 emergency cases, unaware of the rating by the other nurses.

Number of years of nursing practice was the only significant demographic difference found between the 2 groups (p = 0.014). A quadratically weighted kappa to measure the inter-observer reliability of the CTAS group was 0.91 (0.90, 0.99) and not significantly different from that of the ESI group 0.89 (0.88, 0.99). An inter-test generalizability (G) study performed on the variance components derived from an analysis of variance (ANOVA) revealed G(5) = 0.90 (0.82, 0.99). Conclusions: After 3 hours of training, experienced triage nurses were able to perform triage assessments using ESI v.3 with the same inter-observer reliability as those with experience and refresher training in using the CTAS.

It may be appropriate for nurse practitioners (NPs) to provide care for a subset of emergency department (ED) patients with non-urgent problems. Our objective was to determine the attitude of ED patients with minor problems to being treated by an NP.

Consecutive adults who presented to this tertiary ED on weekdays between 8 am and 4 pm were eligible for the study if they had 1 of the following 18 complaints: minor abrasions or lacerations, minor bites, minor burns, minor extremity trauma, cast check, earache, superficial foreign body, lice or pinworms, morning-after pill request, needlestick injury or body-fluid exposure, prescription refill, puncture wound, sore throat, subconjunctival hemorrhage, suture removal or wound check, tetanus immunization request, toothache, or urinary tract infection (women). Unless pain or a language barrier precluded study involvement, a triage nurse gave each patient a brief survey to be completed prior to physician assessment.

Of 728 eligible patients during the study period, 246 (34%) were invited to participate and 213 (87%) were enrolled. The mean age was 34.5 years, and 58% were men. When asked about their willingness to be treated by an NP, 72.5% said “yes” (95% confidence interval [CI], 65.8%–78.4%), 15.5% were “uncertain” (95% CI, 10.8%–21.1%) and 12.1% said “no” (95% CI, 8.0%–17.3%). Of those who said “yes,” 21% expected to also see an emergency physician during their ED visit and 67% did not. Willingness to be treated by an NP was independent of age, gender or educational status.

A majority of ED patients with minor problems accepted being treated by an NP, often without additional physician assessment. Several factors, including impact on ED staffing and patient flow, logistics, cost and quality of care should be evaluated before implementing such strategies.

To systematically review the efficacy and safety of N-acetylcysteine (NAC) for the prevention of radiocontrast-induced nephropathy (RIN), and to discuss its potential role in the emergency department.

We conducted a search of MEDLINE (from 1966 to December 2003), PubMed (1966 to December 2003) and EMBASE (1988 to December 2003) for English-language, prospective, randomized, controlled trials in humans using the search terms N-acetylcysteine, acetylcysteine, radiopharmaceuticals, contrast media, and kidney failure (acute).

Five trials support and 4 trials refute the hypothesis that NAC helps prevent RIN. In 7 of 9 trials, oral NAC was administered twice daily for 2 days, on the day before and on the day of the radiocontrast study — a regime not feasible for emergent situations. More recent trials suggest that adequate hydration and lower volumes of radiocontrast, rather than NAC, are more effective ways to prevent RIN.

Although further study may be indicated, current evidence does not suggest that NAC has a role in the emergency prevention of RIN.

Obtaining prompt vascular access in young children presenting to the emergency department (ED) is frequently both necessary and technically challenging. The objective of our study was to describe our experience using intramuscular (IM) ketamine to facilitate the placement of central venous catheters in children presenting to our ED needing vascular access in a timely fashion.

We performed a retrospective medical record review of all pediatric patients <18 years of age who presented to our tertiary care pediatric ED between May 1, 1998, and August 7, 2003, and underwent the placement of a central venous catheter facilitated by the use of IM ketamine.

Eleven children met our inclusion criteria. Most of the children were young and medically complicated. The children ranged in age from 6 months to 8 years. The only complication identified was vomiting experienced by an 8-year-old boy. Emergency physicians successfully obtained central venous access in all subjects in the case series.

The use of IM ketamine to facilitate the placement of central venous catheters in children who do not have peripheral venous access appears to be helpful. Emergency physicians may find it useful to be familiar with this use of IM ketamine.

To determine survival rates in adult trauma patients requiring cardiopulmonary resuscitation (CPR).

We used 1992–2002 trauma registry data to identify all adult trauma patients over the age of 16 who required CPR in the pre-hospital setting or within 24 hours of arriving at the hospital. Demographic information, mechanism of injury, injury severity score (ISS), vital signs at the scene and in the hospital, and mortality were obtained from patient charts. Patients were stratified into 2 groups: those with absent vital signs in the field who required prehospital CPR, and those who lost vital signs within 24 hours of arriving at the trauma suite.

Of 50 eligible patients, 28 (58%) were male and 46 (92%) sustained blunt trauma. Mean age was 44.8 ± 20 years and mean ISS was 38 ± 18. Overall mortality was 96% (48/50), and all patients who required prehospital CPR died. The only 2 survivors were patients who arrived with vital signs and developed pulseless electrical activity while in the trauma suite.

In this consecutive series of trauma victims with cardiopulmonary arrest there were no survivors among those who lost vital signs and required CPR prior to arriving at the hospital.