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Acute atrial fibrillation is the most common arrythmia treated in the emergency department. Our primary aim was to compare conversion to sinus rhythm between pharmacological cardioversion followed by electrical cardioversion (drug–shock), and electrical cardioversion alone (shock-only). Our secondary aim was to compare the effectiveness of two pad positions for electrical cardioversion. We did a partial factorial trial of two protocols for patients with acute atrial fibrillation at 11 academic hospital emergency departments in Canada. We enrolled adult patients with acute atrial fibrillation. Protocol 1 was a randomised, blinded, placebo-controlled comparison of attempted pharmacological cardioversion with intravenous procainamide (15 mg/kg over 30 min) followed by electrical cardioversion if necessary (up to three shocks, each of ≥200 J), and placebo infusion followed by electrical cardioversion. For patients having electrical cardioversion, we used Protocol 2, a randomised, open-label, nested comparison of anteroposterior versus anterolateral pad positions. Patients were randomly assigned (1:1, stratified by study site) for Protocol 1 by on-site research personnel using an online electronic data capture system. Randomisation for Protocol 2 occurred 30 min after drug infusion for patients who had not converted and was stratified by site and Protocol 1 allocation. Patients and all research and emergency department staff were masked to treatment allocation for Protocol 1. The primary outcome was conversion to normal sinus rhythm for at least 30 min at any time after randomisation and up to a point immediately after three shocks. Protocol 1 was analysed by intention to treat and Protocol 2 excluded patients who did not receive electrical cardioversion. This study is registered at ClinicalTrials.gov, number NCT01891058. Between July 18, 2013, and Oct 17, 2018, we enrolled 396 patients, and none were lost to follow-up. In the drug–shock group (n=204), conversion to sinus rhythm occurred in 196 (96%) patients and in the shock-only group (n=192), conversion occurred in 176 (92%) patients (absolute difference 4%; 95% CI 0–9; p=0·07). The proportion of patients discharged home was 97% (n=198) versus 95% (n=183; p=0·60). 106 (52%) patients in the drug–shock group converted after drug infusion only. No patients had serious adverse events in follow-up. The different pad positions in Protocol 2 (n=244), had similar conversions to sinus rhythm (119 [94%] of 127 in anterolateral group vs 108 [92%] of 117 in anteroposterior group; p=0·68). Both the drug–shock and shock-only strategies were highly effective, rapid, and safe in restoring sinus rhythm for patients in the emergency department with acute atrial fibrillation, avoiding the need for return to hospital. The drug infusion worked for about half of patients and avoided the resource intensive procedural sedation required for electrical cardioversion. We also found no significant difference between the anterolateral and anteroposterior pad positions for electrical cardioversion. Immediate rhythm control for patients in the emergency department with acute atrial fibrillation leads to excellent outcomes. Heart and Stroke Foundation of Canada and the Canadian Institutes of Health Research.

We examined emergency physician disposition decisions and computed tomography (CT) ordering as markers of decision fatigue over an eight-hour shift. Administrative database analysis of patients presenting to an academic, tertiary care, emergency department (ED) over two years. Patients were grouped by the hour of the shift that they were initially assessed by an emergency physician. For each hour, we evaluated the proportions of patients who had CT head, chest, or abdomen, consultations, and consultations not resulting in admission. For patients discharged without consultation, we evaluated return visits within 72 h and ED length-of-stay (LOS). Statistical significance was assessed using random effects regression accounting for clustering by physician. We analyzed 87,752 patients and there were no important differences in consultations, consultations not resulting in admission, or return visits in relation to the hour of shift the patient was seen. Rates of CT head and abdomen and ED LOS decreased as the shift progressed. From the first to the last hour, CT head ordering decreased from 15.8% to 12.2% (OR 0.73, 95% CI 0.66–0.80, p < 0.0001), CT abdomen ordering decreased from 9.6% to 7.6% (OR 0.72, 95% CI 0.64–0.80, p < 0.0001), and ED LOS decreased from 5.5 h to 4.9 h (relative difference 0.83, 95% CI 0.81–0.85, p < 0.0001). Emergency physician decisions about patient disposition did not change throughout the shift. The rates of CT head and abdomen and ED LOS decreased as the shift progressed. We did not find evidence of decision fatigue among emergency physicians over an eight-hour shift.

Bariatric surgery is becoming increasingly common and postoperative patients often present to the emergency department (ED) with complications. We sought to describe the presenting complaints, management, and outcomes of postoperative bariatric surgery patients seen in the ED. We conducted a health records review of 300 consecutive postoperative Roux-en-Y bypass surgery patients who presented to two tertiary care EDs of a major bariatric surgery center within one year of surgery. Cases were identified using a data analytic tool, and two evaluators abstracted clinical variables, imaging, treatments, and outcomes using the electronic health record. Attending emergency physicians verified the data and an experienced bariatric surgeon interpreted the computed tomography (CT) results and surgical procedures. We included 300 patients with mean age 43.0 years, 89.7% female. Of these, 70.0% presented within 30 days of surgery and 41.7% were admitted to hospital. ED treatments included intravenous fluids (67.0%), antiemetics (53.3%), and analgesia (61.9%). Patients presenting within 30 days of surgery were more likely to undergo a CT (74.3% vs 63.3%; p = 0.06) and to have clinically important CT findings (31.9% vs 6.6%; p ≤0.001). More of the ≤30-day patients were admitted to hospital (46.2% vs 31.1%; p = 0.02). While a higher proportion of patients presenting after 30 days underwent a procedure, a large number of those were not directly related to bariatric surgery, such as appendectomy and cholecystectomy. Of the 34 patients undergoing a procedure, the majority presented with abdominal pain (76.5%). This is the first detailed health records review of postoperative bariatric patients seen in the ED in the emergency medicine literature. Those presenting with abdominal pain were more likely to undergo CT abdomen and a surgical procedure. Similarly, those presenting within 30 days of surgery were more likely to have significant CT findings and require hospital admission. Others presenting with primarily nausea and vomiting may improve with ED symptom management and be discharged home with bariatric team follow-up.

AbstractObjectiveTo conduct a randomised, open label comparison of the effectiveness and safety of intravenous vernakalant and intravenous procainamide for the management of acute atrial fibrillation in the emergency department.DesignRandomised clinical trial (RAFF4 trial).Setting12 tertiary care emergency departments in Canada.ParticipantsPatients with acute atrial fibrillation for whom acute rhythm control was a safe option.InterventionsPatients were randomised (1:1) to an intravenous infusion of vernakalant or procainamide; when rapid conversion did not occur, patients were offered electrical cardioversion.Main outcomes and measuresThe primary outcome was conversion to sinus rhythm within 30 minutes of drug infusion completion. Secondary outcomes included time to conversion to sinus rhythm and whether the patient required electrical cardioversion.ResultsOf the 350 enrolled eligible patients, baseline characteristics were similar in the procainamide (n=172) and vernakalant (n=178) groups. For the primary outcome of conversion success, vernakalant was more effective (62.4% v 48.3%; adjusted absolute difference 15.0%, 95% confidence interval 4.6% to 25.0%, P=0.005; adjusted odds ratio 1.87, 95% confidence interval 1.2 to 2.9, P=0.006). With vernakalant, time to conversion was faster (21.8 v 44.7 minutes; mean difference −22.9, 95% confidence interval −29.9 to −16.0, P<0.001), and fewer patients underwent attempted electrical cardioversion (33.7% v 44.2%; odds ratio 0.62, 95% confidence interval 0.39 to 0.96, P=0.033). Adverse events were similar in both groups, were generally mild and brief, and most patients were discharged home. Subgroup analysis strongly favoured vernakalant for conversion in patients younger than 70 years (73.3% v 47.2%; adjusted odds ratio 3.1, 95% confidence interval 1.7 to 5.5, P=0.001, interaction P=0.005).ConclusionsIn this head-to-head comparison, vernakalant was superior to procainamide for patients with higher conversion rates and faster times to conversion. Therefore, vernakalant is a safe and highly effective intravenous alternative for the rapid cardioversion and discharge home of patients with acute atrial fibrillation.Trial registrationClinicalTrials.gov NCT04485195

AbstractObjectiveTo validate the previously derived Canadian TIA Score to stratify subsequent stroke risk in a new cohort of emergency department patients with transient ischaemic attack.DesignProspective cohort study.Setting13 Canadian emergency departments over five years.Participants7607 consecutively enrolled adult patients attending the emergency department with transient ischaemic attack or minor stroke.Main outcome measuresThe primary outcome was subsequent stroke or carotid endarterectomy/carotid artery stenting within seven days. The secondary outcome was subsequent stroke within seven days (with or without carotid endarterectomy/carotid artery stenting). Telephone follow-up used the validated Questionnaire for Verifying Stroke Free Status at seven and 90 days. All outcomes were adjudicated by panels of three stroke experts, blinded to the index emergency department visit.ResultsOf the 7607 patients, 108 (1.4%) had a subsequent stroke within seven days, 83 (1.1%) had carotid endarterectomy/carotid artery stenting within seven days, and nine had both. The Canadian TIA Score stratified the risk of stroke, carotid endarterectomy/carotid artery stenting, or both within seven days as low (risk ≤0.5%; interval likelihood ratio 0.20, 95% confidence interval 0.09 to 0.44), medium (risk 2.3%; interval likelihood ratio 0.94, 0.85 to 1.04), and high (risk 5.9% interval likelihood ratio 2.56, 2.02 to 3.25) more accurately (area under the curve 0.70, 95% confidence interval 0.66 to 0.73) than did the ABCD2 (0.60, 0.55 to 0.64) or ABCD2i (0.64, 0.59 to 0.68). Results were similar for subsequent stroke regardless of carotid endarterectomy/carotid artery stenting within seven days.ConclusionThe Canadian TIA Score stratifies patients’ seven day risk for stroke, with or without carotid endarterectomy/carotid artery stenting, and is now ready for clinical use. Incorporating this validated risk estimate into management plans should improve early decision making at the index emergency visit regarding benefits of hospital admission, timing of investigations, and prioritisation of specialist referral.

Acute heart failure and chronic obstructive pulmonary disease (COPD) are sometimes difficult to differentiate in the emergency department (ED). We sought to determine the clinical impact of point-of-care ultrasonography (POCUS) in ED patients with suspected acute heart failure or COPD. We conducted a prospectively collected cohort study with health records review with frequency matching at The Ottawa Hospital between March and September 2017. We included patients aged 50 and older with shortness of breath or cough from suspected acute heart failure or COPD. Our primary outcome was ED length of stay. Secondary outcomes were time to disposition decision, time to appropriate treatment, and the incidence of adverse events. We analyzed time-to-event outcomes using Kaplan-Meier analysis and Cox regression analysis with POCUS analyzed as a time-dependent variable, and the incidence of adverse events using logistic regression analyses. There were 81 patients evaluated with lung POCUS and 243 matched patients who were not. Lung POCUS was not significantly associated with ED length of stay and time to disposition decision; however, patients evaluated with lung POCUS received disease-specific treatment faster compared with the non-POCUS group (adjusted hazard ratio, 1.50 [95% confidence interval, 1.05-2.15], a median time difference of 31 minutes). We found no significant differences in the incidence of adverse events. In this study, use of lung POCUS resulted in no difference in ED length of stay and time to disposition decision, but was associated with faster administration of disease-specific treatments for elderly patients with suspected acute heart failure or COPD.

Background Traumatic hemorrhage is a significant cause of morbidity and mortality. There is considerable interest in risk stratification tools to aid with early activation of intervention pathways for bleeding patients. In this study, we refine the Canadian Bleeding (CAN-BLEED) score for the prediction of major interventions in bleeding trauma patients. Methods We conducted a mixed retrospective-prospective cohort study. We included a retrospective cohort from the CAN-BLEED derivation study, from September 2014 to September 2017. We also conducted a prospective cohort from May 2019 to August 2021 and included both datasets for refinement of the CAN-BLEED score. The primary outcome was major intervention, defined by a composite of massive transfusion, embolization, or surgery for hemostasis. Predictors were pre-specified based on previous validation work. We used a stepdown procedure and regression coefficients to create a clinical risk stratification score. We used bootstrap internal validation to assess optimism-corrected performance. Results We included 1368 patients in the overall cohort. Incidence of penetrating injury was 23% and median injury severity score was 17. The overall incidence of the need for major intervention was 17%. The revised score included 8 variables: systolic blood pressure, heart rate, lactate, penetrating mechanism, pelvic instability, Focused Abdominal Sonography for Trauma positive for free fluid, computed tomography positive for free fluid, or contrast extravasation. The C-statistic for the simplified score is 0.89. A score cut-off of less than 2 points yielded a 97% (94–98%) sensitivity in ruling out the need for major intervention. Conclusion The revised CAN-BLEED score offers a clinically intuitive and internally validated tool with excellent performance in identifying patients requiring major intervention for traumatic bleeding. Further efforts are required to evaluate its performance with an external validation.

BackgroundPublished risk tools do not provide possible management options for syncope in the emergency department (ED). Using the 30-day observed risk estimates based on the Canadian Syncope Risk Score (CSRS), we developed personalised risk prediction to guide management decisions.MethodsWe pooled previously reported data from two large cohort studies, the CSRS derivation and validation cohorts, that prospectively enrolled adults (≥16 years) with syncope at 11 Canadian EDs between 2010 and 2018. Using this larger cohort, we calculated the CSRS calibration and discrimination, and determined with greater precision than in previous studies the 30-day risk of adjudicated serious outcomes not identified during the index ED evaluation depending on the CSRS and the risk category. Based on these findings, we developed an on-line calculator and pictorial decision aids.Results8233 patients were included of whom 295 (3.6%, 95% CI 3.2% to 4.0%) experienced 30-day serious outcomes. The calibration slope was 1.0, and the area under the curve was 0.88 (95% CI 0.87 to 0.91). The observed risk increased from 0.3% (95% CI 0.2% to 0.5%) in the very-low-risk group (CSRS −3 to –2) to 42.7% (95% CI 35.0% to 50.7%), in the very-high-risk (CSRS≥+6) group (Cochrane-Armitage trend test p<0.001). Among the very-low and low-risk patients (score −3 to 0), ≤1.0% had any serious outcome, there was one death due to sepsis and none suffered a ventricular arrhythmia. Among the medium-risk patients (score +1 to+3), 7.8% had serious outcomes, with <1% death, and a serious outcome was present in >20% of high/very-high-risk patients (score +4 to+11) including 4%–6% deaths. The online calculator and the pictorial aids can be found at: https://teamvenk.com/csrs Conclusions30-day observed risk estimates from a large cohort of patients can be obtained for management decision-making. Our work suggests very-low-risk and low-risk patients may be discharged, discussion with patients regarding investigations and disposition are needed for medium-risk patients, and high-risk patients should be hospitalised. The online calculator, accompanied by pictorial decision aids for the CSRS, may assist in discussion with patients.

The benefit of hospital admission after emergency department evaluation for syncope is unclear. We sought to determine the association between hospital admission and detection of serious adverse events, and whether this varied according to the Canadian Syncope Risk Score (CSRS). We conducted a secondary analysis of a multicentre prospective cohort of patients assessed in the emergency department for syncope. We compared patients admitted to hospital and discharged patients, using propensity scores to match 1:1 for risk of a serious adverse event. The primary outcome was detection of a serious adverse event in hospital for admitted patients or within 30 days after emergency department disposition for discharged patients. We included 8183 patients, of whom 743 (9.1%) were admitted; 658/743 (88.6%) were matched. Admitted patients had higher odds of detection of a serious adverse event (odds ratio [OR] 5.0, 95% confidence interval [CI] 3.3–7.4), nonfatal arrhythmia (OR 5.1, 95% CI 2.9–8.8) and nonarrhythmic serious adverse event (OR 6.3, 95% CI 2.9–13.5). There were no significant differences between the 2 groups in death (OR 1.0, 95% CI 0.4–2.7) or detection of ventricular arrhythmia (OR 2.0, 95% CI 0.7–6.0). Differences between admitted and discharged patients in detection of serious adverse events were greater for those with a CSRS indicating medium to high risk (p = 0.04). Patients with syncope were more likely to have serious adverse events identified within 30 days if they were admitted to hospital rather than discharged from the emergency department. However, the benefit of hospital admission is low for patients at low risk of a serious adverse event.

Serial conventional cardiac troponin (cTn) measurements 6-9 hours apart are recommended for non-ST-elevation MI (NSTEMI) diagnosis. We sought to develop a pathway with 3-hour changes for major adverse cardiac event (MACE) identification and assess the added value of the HEART [History, Electrocardiogram (ECG), Age, Risk factors, Troponin] score to the pathway. We prospectively enrolled adults with NSTEMI symptoms at two-large emergency departments (EDs) over 32-months. Patients with STEMI, unstable angina and one cTn were excluded. We collected baseline characteristics, Siemens Vista conventional cTnI at 0, 3 or 6-hours after ED presentation; HEART score predictors; disposition and ED length of stay (LOS). Adjudicated primary outcome was 15-day MACE (acute MI, revascularization, or death due to cardiac ischemia/unknown cause). We analyzed multiples of 99th percentile cut-off cTnI values (45, 100 and 250ng/L). 1,683 patients (mean age 64.7 years; 55.3% female; median LOS 7-hours; 88 patients with 15-day MACE) were included. 1,346 (80.0%) patients with both cTnI≤45 ng/L; and 155 (9.2%) of the 213 patients with one value≥100ng/L but both<250ng/L or ≤20% change did not suffer MACE. Among 124 patients (7.4%) with one of the two values>45ng/L but<100ng/L based on 3 or 6-hour cTnI, one patient with absolute change<10ng/L and 6 of the 19 patients with≥20ng/L were diagnosed with NSTEMI (patients with Δ10-19ng/L between first and second cTnI had third one at 6-hours). Based on the results, we developed the Ottawa Troponin Pathway (OTP) with a 98.9% sensitivity (95% CI 93.8-100%) and 94.6% specificity (95% CI 93.3-95.6%). Addition of the HEART score improved the sensitivity to 100% (95% CI 95.9-100%) and decreased the specificity to 26.5% (95% CI 24.3-28.7%). The OTP with conventional cTnI 3-hours apart, should lead to better NSTEMI identification particularly those with values >99th percentile, standardize management and reduce the ED LOS.