Can J Emerg Med
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Review Case Reports
Conservative management of laryngeal perforation in a rural setting: case report and review of the literature on penetrating neck injuries.
Penetrating neck injuries (PNIs) are infrequent but can result in significant morbidity and mortality. Although surgical management of unstable patients with penetrating neck trauma is the standard of care, management of stable patients remains controversial owing to the possibility of occult injuries. Recent studies suggest that physical examination and ancillary imaging may be sufficiently accurate to diagnose or rule out surgically significant injuries in PNI. We report a patient with a laryngeal perforation who was managed conservatively in a rural hospital without complications and review the literature pertinent to cases of this nature.
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During the past 7 years, considerable new evidence has accumulated supporting the use of prophylactic hypothermia for traumatic brain injury (TBI). Studies can be divided into 2 broad categories: studies with protocols for cooling for a short, predetermined period (e.g., 24-48 h), and those that cool for longer periods and/or terminate based on the normalization of intracranial pressure (ICP). There have been no systematic reviews of hypothermia for TBI that include this recent new evidence. ⋯ The best available evidence to date supports the use of early prophylactic mild-to-moderate hypothermia in patients with severe TBI (Glasgow Coma Scale score < or = 8) to decrease mortality and improve rates of good neurologic recovery. This treatment should be commenced as soon as possible after injury (e.g., in the emergency department after computed tomography) regardless of initial ICP, or before ICP is measured. Most studies report using a temperature of 32 degrees -34 degrees C. The maximal benefit occurred with a long-term or goal-directed cooling protocol, in which cooling was continued for at least 72 hours and/or until stable normalization of intracranial pressure for at least 24 hours was achieved. There is large potential for further research on this therapy in prehospital and emergency department settings.
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This systematic review included controlled clinical trials comparing tracheal intubation (TI) with alternative airway techniques (AAT) (bag mask ventilation and use of extraglottic devices) performed by paramedics in the prehospital setting. A priori outcomes to be assessed were survival, neurologic outcome, airway management success rates and complications. We identified trials using EMBASE, MEDLINE, CINAHL, The Cochrane Library, Web of Science, author contacts and hand searching. ⋯ Because of study heterogeneity, we did not pool the data. This is the most comprehensive review to date on paramedic trials. Owing to the heterogeneity of prehospital systems, administrators of each system must individually consider their airway management protocols.
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Review Meta Analysis
Prehospital triage and direct transport of patients with ST-elevation myocardial infarction to primary percutaneous coronary intervention centres: a systematic review and meta-analysis.
Percutaneous coronary intervention (PCI) appears to be superior to in-hospital fibrinolysis for most patients with ST-elevation myocardial infarction (STEMI). However, few hospitals have PCI capability. The optimal prehospital strategy for facilitating rapid coronary reperfusion in STEMI patients is unclear. We sought to determine whether direct transport of adult STEMI patients by emergency medical services to primary PCI centres improves 30-day all-cause mortality when compared with a strategy of transportation to the closest hospital. ⋯ There is insufficient evidence to support the effectiveness of direct transport of patients with STEMI for primary PCI when compared with transportation to the closest hospital.
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Emergency department targeted ultrasonography (EDTU) offers the possibility of rapid exclusion of ectopic pregnancy in patients with first-trimester pelvic pain or bleeding. We sought to systematically review the evidence describing the diagnostic accuracy and clinical utility of EDTU in the first trimester of pregnancy, and to generate a pooled estimate of the sensitivity and specificity of EDTU for the detection of intrauterine pregnancy (IUP). ⋯ EDTU is highly specific for the identification of IUP. Patients who have an IUP identified with EDTU may be safely discharged from the ED with outpatient follow-up. The specificity of EDTU for IUP, along with the potential improvements in patient care that EDTU affords, justifies its adoption as routine ED care in evaluating first-trimester pain or bleeding.