This study’s objective was to measure the criterion validity of the BIG score (a new pediatric trauma score composed of the initial base deficit [BD], international normalized ratio [INR], and Glasgow Coma Scale [GCS]) to predict in-hospital mortality among children admitted to the emergency department with blunt trauma requiring an admission to the intensive care unit, knowing that a score <16 identifies children with a high probability of survival.

This was a retrospective cohort study performed in a single tertiary care pediatric hospital between 2008 and 2016. Participants were all children admitted to the emergency department for a blunt trauma requiring intensive care unit admission or who died in the emergency department. The primary analysis was the association between a BIG score ≥16 and in-hospital mortality.

Twenty-eight children died among the 336 who met the inclusion criteria. Two hundred eighty-four children had information on the three components of the BIG score, and they were included in the primary analysis. A BIG score ≥16 demonstrated a sensitivity of 0.93 (95% confidence interval [CI]: 0.76-0.98) and specificity of 0.83 (95% CI: 0.78-0.87) to identify mortality. Using receiver operating characteristic curves, the area under the curve was higher for the BIG score (0.97; 95% IC: 0.95-0.99) in comparison to the Injury Severity Score (0.78; 95% IC: 0.71-0.85).

In this retrospective cohort, the BIG score was an excellent predictor of survival for children admitted to the emergency department following a blunt trauma.

Physician variation in the use of computed tomography (CT) is concerning due to the risks of ionizing radiation, cost, and downstream effects of unnecessary testing. The objectives of this study were to describe variation in CT-ordering rates among emergency physicians (EPs), to measure correlation between perceived and actual CT-ordering rates, to assess attitudes that influence decisions to order imaging tests, and to identify EP attitudes associated with higher CT utilization.

This study was a retrospective review of imaging and administrative billing records at two emergency department sites of a tertiary care adult teaching hospital. The study also included a cross-sectional survey of EPs at this hospital. We asked physicians about their perceived ordering behaviour, and what factors influenced their decision to order a CT. We examined correlations between perceived and actual CT-ordering rates. We adjusted ordering rates for shift distribution using a logistic regression model and identified outlier physicians whose ordering rate was significantly lower or higher than expected. We used multivariable regression analysis to determine which survey responses predicted higher CT utilization.

During the study period, 59 EPs saw 45,854 patients, and ordered 6,609 CTs — a mean ordering rate of 14.4% (standard deviation (SD)=4.3%). The ordering rate for individual physicians ranged from 5.9% to 25.9%. Of the 59 EPs, 13 EPs were low-ordering outliers; 12 were high-ordering outliers. Forty-five EPs (76.3%) completed the survey. Mean perceived ordering rate was 12.6%, and was weakly correlated with actual ordering (r=0.19, p=0.21). 42 EPs (93.3%) believed they ordered “about the same” or “fewer” CTs than their peers. Of the 17 EPs in the two highest ordering quintiles, only 3 (18%) knew they were high orderers. In the multivariable analysis, higher ordering was associated with increasing strength of response to the following predictors: medico-legal risk (relative risk [RR]=1.18, 95% CI: 1.03–1.21), risk of contrast (RR=1.14, 95% CI: 1.07–1.22), what colleagues would do (RR=1.09, 95% CI: 0.99–1.19), risk of missing a diagnosis (RR=1.08, 95% CI: 0.98–1.21), and patient wishes (RR=1.07, 95% CI: 0.97–1.17).

There is large variation in CT ordering among EPs. Physicians’ self-reported ordering rate correlates poorly with actual ordering. High CT orderers were rarely aware that they ordered more than their colleagues. Higher rates of ordering were observed among physicians who reported increased concern with 1) risk of missing a diagnosis, 2) medico-legal risk, 3) risk of contrast, 4) patient wishes, and 5) what colleagues would do.

In patients taking antiplatelet therapy, does a platelet transfusion after acute spontaneous primary intracerebral hemorrhage reduce the risk of death or dependence?

Baharoglu MI, Cordonnier C, Al-Shahi Salman R, et al. Platelet transfusion versus standard care after acute stroke due to spontaneous cerebral hemorrhage associated with antiplatelet therapy (PATCH): a randomized, open-label, phase 3 trial. Lancet 2016;387(10038):2605-13.

The primary objective of this study was to investigate whether a platelet transfusion with standard care, compared with standard care alone, reduced death or dependence after intracerebral hemorrhage associated with antiplatelet therapy use.

Should I use apneic oxygenation when intubating patients in the emergency department to increase peri-intubation oxygen saturation and first-pass success?

Oliveira JE, Silva L, Cabrera D, Barrionuevo P, et al. Effectiveness of apneic oxygenation during intubation: a systematic review and meta-analysis. Ann Emerg Med 2017;70(4):483-94.

The purpose of this study was to synthesize and appraise the apneic oxygenation literature for its effect on peri-intubation outcomes.

To make pragmatic recommendations on best practices for the engagement of patients in emergency medicine (EM) research.

We created a panel of expert Canadian EM researchers, physicians, and a patient partner to develop our recommendations. We used mixed methods consisting of 1) a literature review; 2) a survey of Canadian EM researchers; 3) qualitative interviews with key informants; and 4) feedback during the 2017 Canadian Association of Emergency Physicians (CAEP) Academic Symposium.

We synthesized our literature review into categories including identification and engagement, patients’ roles, perceived benefits, harms, and barriers to patient engagement; 40/75 (53% response rate) invited researchers completed our survey. Among respondents, 58% had engaged patients in research, and 83% intended to engage patients in future research. However, 95% stated that they need further guidance to engage patients. Our qualitative interviews revealed barriers to patient engagement, including the need for training and patient partner recruitment.

Our panel recommends 1) an overarching positive recommendation to support patient engagement in EM research; 2) seven policy-level recommendations for CAEP to support the creation of a national patient council, to develop, adopt and adapt training material, guidelines, and tools for patient engagement, and to support increased patient engagement in EM research; and 3) nine pragmatic recommendations about engaging patients in the preparatory, execution, and translational phases of EM research.

Patient engagement can improve EM research by helping researchers select meaningful outcomes, increase social acceptability of studies, and design knowledge translation strategies that target patients’ needs.

Collecting patient-reported follow-up data for prospective studies in the emergency department (ED) is challenging in this minimal continuity setting. The objective of this study was to determine whether text messaging study participants involved in an ongoing randomized trial resulted in a lower rate of attrition as compared to conventional telephone follow-up.

This was a nested cohort analysis of research participants enrolled in a randomized controlled trial assessing head injury discharge instructions. During the first 4 months of study follow-up, participants were contacted by a conventional telephone call. For the final 3 months, participants were contacted by text messaging following the first failed telephone attempt.

A total of 118 patients were enrolled in the study (78 underwent conventional follow-up, and 40 received text messages). During the period of conventional follow-up, 3 participants withdrew from the study. Of the remaining 75 participants, 24 (32.0%) at 2 weeks and 32 (42.7%) at 4 weeks were unable to be contacted. Of the 40 participants receiving a reminder text message, 4 (10.0%) at 2 weeks and 10 (25.0%) at 4 weeks were unable to be contacted. Overall, text messaging study participants decreased attrition by 22% (95% CI: 5.9%, 34.7%) and 17.7% (95% CI: -0.8%, 33.3%) at 2- and 4-week follow-ups, respectively.

In this ED cohort participating in a randomized trial, text message reminders of upcoming telephone follow-up interviews decreased the rate of attrition. Text messaging is a viable, low-cost communication strategy that can improve follow-up participation in prospective research studies.

Rapid exposure of a trauma patient is an essential component of the primary survey. No gold standard exists regarding the best technique to remove clothing from a trauma patient. The purpose of this study is to compare two techniques of clothing removal versus usual practice using standard trauma shears.

Advanced Care Paramedic (ACP) students were randomized to either the Cut and Rip (CAR) or Cut Alone (CAL) techniques to remove clothing from a standardized trauma mannequin. Practicing paramedics were recruited to remove clothing from the mannequin using Usual Practice (UP). Total time and time for removal of individual pieces of clothing was recorded.

Twenty-four participants (8 per group) were recruited to participate. The student groups (CAR, CAL) were similar in mean age (29, 27), years of practice (1 student >5 years) and male gender (63, 43%). The UP group was older (mean 34), more experienced (63% practice >5 years), and had a higher level of training (63% ACP) but a similar percentage of males (63%). Removal time was significantly less in the CAR group compared to the CAL group (mean 104 seconds, 95% CI 88–120 vs. mean 136 seconds, 95% CI 119–154, p=0.02). Removal times in the UP group were not significantly different from the other groups (mean 124 seconds, 95% CI 108–140, p>0.05).

The CAR technique is faster than both CAL and UP groups to remove clothing from a standard trauma mannequin.

The objective of this panel was to generate recommendations to promote the engagement of front-line emergency department (ED) clinicians in clinical and implementation research.

Panel members conducted semi-structured interviews with 37 Canadian adult and pediatric emergency medicine researchers to elicit barriers and facilitators to clinician engagement in research activities, and to glean strategies for promoting clinician engagement.

Responses were organized by themes, and, based on these responses, recommendations were developed and refined in an iterative fashion by panel members.

We offer eight recommendations to promote front-line clinician engagement in clinical research activities. Recommendations to promote clinician engagement specifically address the creation of a research-friendly culture in the ED, minimizing the burden of data collection on clinical staff through the careful design of data collection tools and the use of research staff, and communication between researchers and clinical staff to promote adherence to study protocols.

Does the addition of topical tranexamic acid to anterior nasal packing decrease bleeding in patients with epistaxis who are taking antiplatelet medications?

Zahed R, Jayazeri M, Naderi A, et al. Topical tranexamic acid compared with anterior nasal packing for treatment of epistaxis in patients taking antiplatelet drugs: randomized controlled trial. Acad Emerg Med 2018;25(3):261-6.

The primary outcome of this randomized controlled trial was the percentage of patients whose epistaxis had stopped at 10 minutes from the time of intervention. Secondary outcomes included the frequency of epistaxis recurrence at both 24 hours and 7 days, emergency department length of stay, and patient satisfaction.

Education scholarship can be conducted using a variety of methods, from quantitative experiments to qualitative studies. Qualitative methods are less commonly used in emergency medicine (EM) education research but are well-suited to explore complex educational problems and generate hypotheses. We aimed to review the literature to provide resources to guide educators who wish to conduct qualitative research in EM education.

We conducted a scoping review to outline: 1) a list of journals that regularly publish qualitative educational papers; 2) an aggregate set of quality markers for qualitative educational research and scholarship; and 3) a list of quality checklists for qualitative educational research and scholarship.

We found nine journals that have published more than one qualitative educational research paper in EM. From the literature, we identified 39 quality markers that were grouped into 10 themes: Initial Grounding Work (preparation, background); Goals, Problem Statement, or Question; Methods (general considerations); Sampling Techniques; Data Collection Techniques; Data Interpretation and Theory Generation; Measures to Optimize Rigour and Trustworthiness; Relevance to the Field; Evidence of Reflective Practice; Dissemination and Reporting. Lastly, five quality checklists were found for guiding educators in reporting their qualitative work.

Many problems that EM educators face are well-suited to exploration using qualitative methods. The results of our scoping review provide publication venues, quality indicators, and checklists that may be useful to EM educators embarking on qualitative projects.

Mentorship is perceived to be an important component of residency education. However, evidence of the impact of mentorship on professional development in Emergency Medicine (EM) is lacking.

Online survey distributed to attending physician members of the Canadian Association of Emergency Physicians (CAEP), using a modified Dillman method. Survey contained questions about mentorship during residency training, and perceptions of the impact of mentorship on career development.

The response rate was 23.5% (309/1314). 63.6% reported having at least one mentor during residency. The proportion of participants with a formal mentorship component during residency was higher among those with mentors (44.5%) compared to those without any formal mentorship component during residency (8.0%, p<0.001). The most common topics discussed with mentors were career planning and work-life balance. The least common topics included research and finances. While many participants consulted their mentor regarding their first job (56.5%), fewer consulted their mentor regarding subspecialty training (45.1%) and research (41.1%). 71.8% chose to work in a similar centre as their mentor, but few completed the same subspecialty (24.8%), or performed similar research (30.4%). 94.1% stated that mentorship was important to success during residency. Participants in a formal mentorship program did not rate their experience of mentorship higher than those without a formal program.

Among academic EM physicians with an interest in mentorship, mentorship during EM residency may have a greater association with location of practice than academic scholarship or subspecialty choice. Formal mentorship programs increase the likelihood of obtaining a mentor, but do not appear to improve reported mentorship experiences.

Trauma code activation is initiated by emergency physicians using physiological and anatomical criteria, mechanism of injury, and patient demographic factors. Our objective was to identify factors associated with delayed trauma team activation.

We assessed consecutive cases from a regional trauma database from January 2008 to March 2014. We defined a delay in trauma code activation as a time greater than 30 minutes from the time of arrival. We conducted univariate analysis for factors potentially influencing trauma team activation, and we subsequently used multiple logistic regression analysis models for delayed activation in relation to mortality, length of stay, and time to operative management.

Patients totalling 846 were included for our analysis; 4.1% (35/846) of trauma codes were activated after 30 minutes. Mean age was 40.8 years in the early group versus 49.2 in the delayed group (p=0.01). Patients were over age 70 years in 7.6% in the early activation group versus 17.1% in the delayed group (p=0.04). There was no significant difference in sex, type of injury, injury severity, or time from injury between the two groups. There was no significant difference in mortality, median length of stay, or median time to operative management.

Delayed activation is linked with increasing age with no clear link to increased mortality. Given the severe injuries in the delayed cohort that required activation of the trauma team, further emphasis on the older trauma patient and interventions to recognize this vulnerable population should be made.