A 64-year-old male with lung cancer presents to the emergency department with one week of cough and increasing shortness of breath. At triage, his temperature is 37.3° Celsius, heart rate 106 beats per minute, blood pressure 136/80, and oxygen saturation 87% on room air, which improves to 94% with 3 L of oxygen via nasal prongs. He has a chest X-ray that demonstrates bilateral patchy infiltrates. He is treated for pneumonia with antibiotics. His respiratory status worsens, with an increasing oxygen requirement. Additional history reveals that the patient recently finished treatment for lung cancer with an immune checkpoint inhibitor.

Introduction: The emergency department (ED) is often the first point of health care contact for patients with mild traumatic brain injury (MTBI). Spontaneous resolution occurs in most patients within 7 days, yet 15-30% will develop post-concussion syndrome (PCS). Given the paucity of effective management strategies to prevent PCS and emerging evidence supporting exercise, the objective of this study was to evaluate the impact of prescribed early light exercise compared to standard discharge instructions for acute MTBI patients in the ED. Methods: This was a randomized controlled trial conducted in three Canadian EDs. Consecutive, adult (18-64 years) ED patients with a MTBI sustained within the preceding 48 hours were eligible for enrollment. The intervention group received discharge instructions prescribing 30 minutes of daily light exercise (e.g., walking), and the control group was given standard MTBI instructions advising gradual return to exercise following symptom resolution. Participants documented their daily physical activities and completed follow-up questionnaires at 7, 14, and 30 days. The primary outcome was the proportion of patients with PCS at 30 days, defined as the presence of ≥ 3 symptoms on the Rivermead Post-concussion Symptoms Questionnaire (RPQ) at 30 days. Results: 367 patients were enrolled (control n = 184; intervention n = 183). Median age was 32 years and 201 (57.6%) were female. There was no difference in the proportion of patients with PCS at 30 days (control 13.4 vs intervention 14.6; Δ1.2, 95% CI: -6.2 to 8.5). There were no differences in median change of RPQ scores (control 14 vs intervention 13; Δ1, 95% CI: -1 to 4), median number of return health care provider visits (control 1 vs intervention 1; Δ0, 95% CI: 0 to 0), or median number of missed school or work days (control 2 vs intervention 2; Δ0, 95% CI: 0 to 1) at 30 days. There was a nonsignificant difference in unplanned return ED visits within 30 days (control 9.9% vs intervention 5.6%; Δ1, 95% CI: -1.4 to 10.3). Participants in the control group reported fewer minutes of light exercise at 7 days (30 vs 35; Δ5, 95% CI: 2 to 15). Conclusion: To our knowledge, this is the first randomized trial of prescribed early light exercise for adults with acute MTBI. There were no differences in recovery or healthcare utilization outcomes. Results suggest prescribed early light exercise should be encouraged as tolerated at ED discharge following MTBI, but exercise prescription alone is not sufficient to prevent PCS.

Introduction: Vaginal bleeding in early pregnancy is a common emergency department (ED) presentation, with many of these episodes resulting in poor obstetrical outcome. These outcomes have been extensively studied, but there have been few evaluations of what variables are associated predictors. This study aimed to identify predictors of less than optimal obstetrical outcomes for women who present to the ED with early pregnancy bleeding. Methods: A regional centre health records review included pregnant females who presented to the ED with vaginal bleeding at <20 weeks gestation. This study investigated differences in presenting features between groups with subsequent optimal outcomes (OO; defined as a full-term live birth >37 weeks) and less than optimal outcomes (LOO; defined as a miscarriage, stillbirth or pre-term live birth). Predictor variables included: maternal age, gestational age at presentation, number of return ED visits, socioeconomic status (SES), gravida-para-abortus status, Rh status, Hgb level and presence of cramping. Rates and results of point of care ultrasound (PoCUS) and ultrasound (US) by radiology were also considered. Results: Records for 422 patients from Jan 2017 to Nov 2018 were screened and 180 patients were included. Overall, 58.3% of study participants had a LOO. The only strong predictor of outcome was seeing an Intra-Uterine Pregnancy (IUP) with Fetal Heart Beat (FHB) on US; OO rate 74.3% (95% CI 59.8-88.7; p < 0.01). Cramping (with bleeding) trended towards a higher rate of LOO (62.7%, 95% CI 54.2-71.1; p = 0.07). SES was not a reliable predictor of LOO, with similar clinical outcome rates above and below the poverty line (57.5% [95% CI 46.7-68.3] vs 59% [95% CI 49.3-68.6] LOO). For anemic patients, the non-live birth rate was 100%, but the number with this variable was small (n = 5). Return visits (58.3%, 95% CI 42.2-74.4), previous abortion (58.8%, 95% CI 49.7-67.8), no living children (60.2%, 95% CI 50.7-69.6) and past pregnancy (55.9%, 95% CI 46.6-65.1) were not associated with higher rates of LOO. Conclusion: Identification of a live IUP, anemia, and cramping have potential as predictors of obstetrical outcome in early pregnancy bleeding. This information may provide better guidance for clinical practice and investigations in the emergency department and the predictive value of these variables support more appropriate counseling to this patient population.

A 65-year-old male with a history of hypertension presents to the emergency department (ED) with new onset of non-traumatic back pain. The patient is investigated for life-threatening diagnoses and screened for “red flag symptoms,” including fever, neurologic abnormalities, bowel/bladder symptoms, and a history of injectiondrug use (IVDU). The patient is treated symptomatically and discharged home but represents to the ED three additional times, each time with new and progressive symptoms. At the time of admission, he is unable to ambulate, has perineal anesthesia, and 500 cc of urinary retention. Whole spine magnetic resonance imaging (MRI) confirms a thoracic spinal epidural abscess. This case, and many like it, prompts the questions: when should emergency physicians consider the diagnosis of a spinal epidural abscess, and what is the appropriate evaluation of these patients in the ED? (Figure 1).

A 67-year-old male presents to the emergency department (ED) with a 10-minute history of right upper extremity and right facial weakness, which came on suddenly. His symptoms spontaneously remitted. He has never experienced symptoms like this before. He has a past medical history of coronary artery disease, type 2 diabetes mellitus, dyslipidemia, and is a lifelong smoker. The patient states that he now feels completely well and back to his baseline. On examination, the patient is afebrile. Blood pressure is 160/87, heart rate is 89 in sinus rhythm, and respiratory rate is 16. His oxygen saturation on room air is 94%. Glucose is 5.6 mmol/L. Cranial nerve and peripheral neurological examination are completely unremarkable. Reflexes, coordination, and gait are all within normal limits. Cardiac and respiratory examination are also unremarkable. His electrocardiogram shows normal sinus rhythm.

Soft tissue abscess used to be an easy emergency department (ED) presentation: perform an incision and drainage (I + D) and discharge your patient. Times have changed. Methicillin-resistant Staphylococcus aureus (MRSA) is now a major cause of soft tissue abscess in ED patients. MRSA is, by definition, resistant to cloxacillin and cephalosporins. Almost all Canadian strains are susceptible to vancomycin and linezolid. MRSA strains are variably susceptible to trimethoprim-sulfamethoxazole (TMP-SMX), tetra/doxycycline, and clindamycin, with pooled Canadian clindamycin resistance just over 40%.

A 21-year-old male with known type 1 diabetes mellitus presented to the emergency department (ED) with two days of vomiting, polyuria, and polydipsia after several days of viral upper respiratory tract infection symptoms. Since his symptom onset, his home capillary blood glucose readings have been higher than usual. On the day of presentation, his glucometer read “high,” and he could not tolerate oral fluids. On examination, his pulse was 110 beats/minute, and his respiratory rate was 24 breaths/minute. He was afebrile, and the remaining vital signs were normal. Other than dry mucous membranes, his cardiopulmonary, abdominal, and neurologic exams were unremarkable. Venous blood gas demonstrated a pH of 7.25 mm Hg, pCO2 of 31 mm Hg, HCO3 of 13 mm Hg, anion gap of 18 mmol/L, and laboratory blood glucose of 40 mmol/L, as well as serum ketones measuring “large.”

A 16-month-old presents to the emergency department (ED) after a fall while running at home. Her mother noted some blood in the child's mouth and believed there was a tear in the skin above the front teeth.

A 23-year-old female presents with right lower quadrant pain that has been intermittent for the past several days. The pain suddenly worsened 1 hour ago. She denies vaginal bleeding or discharge, dysuria, fever, and back pain, but she has had several episodes of nausea with nonbloody, nonbilious vomiting. On examination, she is tender in the right lower quadrant, but her abdomen is not rigid.

Introduction: Intubation is one of the highest-risk procedures performed in the emergency department (ED) on a regular basis. The British Columbia Airway Registry for Emergencies (BCARE) Network collects data from every ED intubation at two tertiary care centres and one community centre and serves as a valuable quality improvement tool. We compared intubation techniques, success, and complication rates between emergency medicine physicians and trainees. Methods: We completed an observational study of all patients intubated in the ED by resident trainees or attending physicians over a period of 28 months from July 2017 to November 2019. Respiratory therapists (RTs) completed a standardized data collection form after every intubation and the data was used to analyze techniques, success, and complication rates. Form completion compliance was periodically reviewed by cross-referencing patient names in the BCARE network with the radiology database for chest x-rays that were performed after intubation in the hospital. Results: 642 intubations were performed by EM physicians: 66 by PGY1-2 residents,141 by PGY3-5 residents, and 435 by staff physicians. Airway assessment prior to intubation was completed by PGY1-2 in 78.1% of cases, PGY3-5 in 67.9%, and staff in 62.6%. Direct laryngoscopy (DL) was chosen as first-choice technique 24.2% by PGY1-2, 24.8% by PGY3-5, and 30.1% by attending physicians. Bougie was used 2.7% of cases for all groups. First-pass success was 78.8% for PGY1-2, 86.5% for PGY3-5, and 85.7% for staff. Mean number of attempts were similar at 1.24, 1.18, and 1.20 for R1-2, R3-5, and staff, respectively. There were similar complication rates between all groups, on average 16.9%, with the most common being hypoxemia prior to induction, and desaturation following induction. There was a higher rate of staff performing second intubation attempts following junior residents (50.0%) than senior residents (26.3%). Conclusion: Trainees have a stronger preference to use video laryngoscopy (VL) than staff physicians as their first-line technique. Success rates were similar between senior residents and attending physicians, but significantly lower in junior residents, despite number of attempts being similar between the three groups. Complication rates were similar among all 3 groups. This data may suggest that a stronger emphasis for DL use among trainees is important.

The role of air medical and land-based critical care transport services is not always clear amongst traditional emergency medical service providers or hospital-based health care practitioners. Some of this is historical, when air medical services were in their infancy and their role within the broader health care system was limited. Despite their evolution within the regionalized health care system, some myths remain regarding air medical services in Canada. The goal is to clarify several commonly held but erroneous beliefs regarding the role, impact, and practices in air medical transport.