Cerebral air embolism (CAE) is a common, often lethal, complication in blunt and penetrating chest trauma. The factors affecting the outcome of CAE patients are poorly understood, and there is no generally accepted treatment algorithm. In this report, we present the case of a 28-year-old male motorcyclist with a massive CAE, including bilateral internal carotid artery air on computed tomographic examination following blunt chest trauma. With prehospital intubation, oxygen, transfusion, and open laparotomy but without any specific treatment regarding the CAE, a follow-up computed tomography (CT) scan approximately 6 hours later showed resolution of the cerebrovascular air. Recovery was unremarkable, and the patient was discharged neurologically intact after 22 days.

Over the past few decades, point-of-care ultrasound (PoCUS) has come to play a major role in the practice of emergency medicine. Despite its numerous benefits, there has been a slow uptake of PoCUS use in rural emergency departments. Surveys conducted across Canada and the United States have identified a lack of equipment, training, funding, quality assurance, and an inability to maintain skills as major barriers to PoCUS use. Potential solutions include expanding residency training in ultrasound skills, extending funding for PoCUS training to rural physicians in practice, moving PoCUS training courses to rural sites, and creating telesonography training for rural physicians. With these barriers identified and solutions proposed, corrective measures must be taken so that the benefits of PoCUS are extended to patients in rural Canada where, arguably, it has the greatest potential for benefit when access to advanced imaging is not readily available.

Precise therapeutic decision-making is vital in managing out-of-hospital cardiac arrest. We present an interesting approach where suspected pulmonary embolism could be confirmed by early computed tomography in cardiac arrest. Chest compressions were performed automatically by mechanical devices also during the acquisition of computed tomography data and subsequent thrombolysis.

Introduction: Low back pain (LBP) may be having a significant impact on emergency departments (ED) around the world. Two analyses conducted in the USA and Australia suggest that LBP is one of the leading causes of emergency department visits. However, in the peer-reviewed literature, there has been limited focus on the prevalence and management of back pain in the ED setting. Furthermore, the applicability of the available research to our local ED setting is unclear. Methods: This project includes two studies to investigate the prevalence of LBP in the ED: 1. a comprehensive systematic review of the published literature to gather a comprehensive and global perspective about the prevalence of LBP in the ED setting, and 2. a retrospective cross sectional analysis using six years of data from our local ED, the Charles V. Keating Emergency and Trauma Centre, Halifax, Nova Scotia. Results: Searches from multiple databases including PubMed (392 citations), resulted in 3024 citations, of which 20 studies were found to have prevalence data for LBP. Studies were reported between 2001–2015 and used mixed methods of data collection, including electronic databases, surveys and patient charts. Ranges for prevalence estimates were 1.9% to 17% of patient visits. Results indicated there are many gaps in the literature, for example research in rural EDs and in Canada. In our primary study, we have identified a sample of 10 000 patients presenting with LBP to our local ED. Analysis of this data will be completed prior to the CAEP conference. Conclusion: This project is the first systematic review; comprehensive search strategy to examine the prevalence of LBP in the ED. It is also the first project to assess the prevalence of LBP in a Canadian ED. Results from this study will inform healthcare providers, as well as administrative and policy decision-makers, of the global and local impact of LBP in the ED, and will identify opportunities for further research to enhance care pathways of patients suffering from LBP.

Introduction: Patients with acute exacerbations of heart failure (HF) or chronic obstructive pulmonary disease (COPD) may be at high risk for preventable adverse events (AEs). Preventable AEs are ED care-associated complications due to medical error. Our objective was to identify and characterize preventable AEs among ED patients over 50 presenting with dyspnea from an acute exacerbation of HF or COPD; who were subsequently admitted or discharged. Methods: We conducted a multicentre health records review from six academic centers in Ontario and Alberta. We analysed health records for all prospectively enrolled patients who experienced flagged outcomes: relapse to ED within 14 days requiring admission; admission to a monitored unit (AMU), cardiac care unit(CCU), or intensive care unit(ICU); intubation(ETI); non-invasive ventilation(NIV); diagnosis of acute myocardial infarction(AMI); or death within 30 days. Using a validated approach, an ED physician analyzed case summaries for flagged outcomes that were associated with ED care, designated as AEs. Preventable AEs had contributing errors in diagnosis, management, procedure, medications or unsafe disposition decisions. We analyzed these data using thematic coding and descriptive statistics. Results: Of 2,515 patients enrolled (1,100 HF and 1,415 COPD), 210 patients experienced flagged outcomes, 47.1% of which were female, 64.3% had HF and the remaining COPD. The majority (86.2%) of flagged outcomes were related to underlying disease, but 13.8% of cases met criteria for AE and all were deemed preventable. Of the identified AEs, 72.4% returned to the ED and required admission to hospital; 17.2% were admitted to ICU, CCU, or AMU; 6.9% of patients died; 3.4% were intubated; 3.4% had a diagnosis of AMI and 0% required NIV. We found 75.8% of preventable AEs resulted from a management error (eg. not prescribing steroids on discharge for moderate COPD exacerbation); 31.0% from an unsafe disposition decision and 10.3% of AEs resulted from diagnostic error. Conclusion: Patients with acute exacerbations of HF and COPD are at high risk of preventable AEs directly related to care provided in the ED. Management and disposition decisions were a concerning source of error and should compel and focus future quality improvement efforts.

There is evidence to suggest that point-of-care ultrasound assessment of the lungs has a higher sensitivity and specificity than chest radiography for the diagnosis of pneumonia. It is unknown if the same is true for pneumonia complications. We present and discuss the case of a 61-year-old woman who presented to the emergency department with confusion, decreased level of consciousness, and signs of sepsis. A chest x-ray revealed a right sided infiltrate. An ultrasound of the patient’s lungs was performed, and revealed a complex loculated fluid collection consistent with an empyema. A chest CT confirmed the diagnosis, and immediate percutaneous drainage was performed.

Despite its relatively protected position, the liver is the most frequently injured solid intra-abdominal organ.1 Most liver injuries can be managed conservatively, but about 5% to 10% require urgent laparotomy, usually when the mechanism of injury involves a vehicle accident and hemodynamic instability persists, in spite of 40 mL/kg of blood transfusion.2,3 In particular, grades IV and V liver injuries may pose a challenge to the surgeon trying to control hemorrhage, the leading cause of mortality.4 Traumatic injuries to the portal vein are rare but devastating. The mortality rate for portal vein injury ranges from 50% to 70%. A recent study of portal triad injuries has highighted the higher mortality rates associated with combination injuries involving multiple portal triad components, especially those that include portal vein injury.5 This case study describes a unique case of relatively minor trauma in a child resulting in portal triad injury, sudden demise, and surgical repair.

Marijuana is the most commonly used illicit drug in Canada, with 10% of the general population admitting to its use in the past year. This high prevalence increases risk of accidental ingestion in young children.

We report four pediatric cases of accidental marijuana ingestion who presented to our local emergency department with altered mental status. Three patients had extensive testing, including one patient who underwent lumbar puncture and empirical treatment for meningitis. To our knowledge, this is the first Canadian case series since McNabb et al., published over 2 decades ago.

The case series aims to highlight the importance of considering acute marijuana intoxication in the differential diagnosis when assessing young children with altered level of consciousness.

Wernicke’s encephalopathy (WE) is a serious neurologic condition resulting from thiamine deficiency. The majority of cases involve alcoholism; however, nonalcohol-associated WE does occur and is under-recognized. We discuss a case of a 22-year-old man with a history of Crohn’s disease who presented to our emergency department with multiple neurologic complaints related to WE.

Introduction: While a majority of patients presenting to the emergency department (ED) are discharged home without need for inpatient hospitalization, many require outpatient follow-up. Currently, outpatient referrals from our ED are made via a complex and error-prone series of manual steps which have the potential to be unreliable and negatively impact quality of care. We sought to perform a current state analysis of our outpatient referral processes across the hospital’s specialties. Methods: We conducted a retrospective health records review at a tertiary academic centre (>160,000 ED visits/year) from January 1 to January 7, 2015. All consecutive outpatient consultation requests triggered by an ED physician were identified and included for chart review. All cases were subsequently followed up to 11 months. A single reviewer extracted data on demographics, actual referral attendance rates, incomplete referrals, return ED visits, and time intervals. The top 3 and bottom 3 performing services were identified for further analysis of their outpatient referral mechanisms and processes. We present descriptive statistics. Results: A total of 251 outpatient referrals to a broad range of specialty services were identified during the study period. 216 (86.1%) of patients attended the intended appointment, while 35 (13.9%) of referrals were incomplete at 11 months post index ED visit. The overall median time to successful outpatient follow-up appointments was 8.5 days [IQR=3.8-24.2]. 8 (3.2%) patients had a return ED visit for a related complaint prior to being seen at their outpatient appointment. The top 3 performers were Ophthalmology [Median=1.0 day, IQR=0.0-1.0, Incomplete=2.8%], Plastic Surgery [Median=5.0 days, IQR=2.8-6.0, Incomplete=7.7%], and Orthopedics [Median=8.0 days, IQR=7.0-10.0, Incomplete=0.0%]. The bottom 3 performers were Dermatology [Median=52days, IQR=41.5-92.5, Incomplete=25.0%], Neurology [Median=40.0 days, IQR= 2.5-43.5, Incomplete=56.3%], and Urology [Median=14.0 days, IQR=10.5-48.0, Incomplete=33.3%]. Conclusion: We found a tremendous range of variability in both the waiting times and actual reliability of outpatient referral processes from the ED. Future phases of this project will focus on examining specific processes of the top and bottom performing specialties in order to improve and standardize all outpatient referrals.

Cardiopulmonary resuscitation (CPR) is an inherently traumatic procedure. Successful resuscitations are often complicated by iatrogenic injuries to structures of the neck, thorax, or abdomen. Rib and sternal fractures are the most frequently induced injuries. However, rare and life-threatening trauma to vital organs such as the heart may also occur during CPR. We describe a novel case of CPR-associated right ventricular rupture in a woman with acute-on-chronic pulmonary embolism and no known pre-existing cardiac disease. We propose that chest compressions in the setting of elevated right ventricular pressure resulted in cardiac rupture, in this case.