BACKGROUND: This prospective, randomized trial was undertaken to evaluate the utility of adding end-tidal capnometry (ETC) to pulse oximetry (PO) in patients undergoing procedural sedation and analgesia (PSA) in the emergency department (ED). METHODS:The patients were randomized to monitoring with or without ETC in addition to the current standard of care. Primary endpoints included respiratory adverse events, with secondary endpoints of level of sedation, hypotension, other PSA-related adverse events and patient satisfaction. RESULTS:Of 986 patients, 501 were randomized to usual care and 485 to additional ETC monitoring. In this series, 48% of the patients were female, with a mean age of 46 years. Orthopedic manipulations (71%), cardioversion (12%) and abscess incision and drainage (12%) were the most common procedures, and propofol and fentanyl were the sedative/analgesic combination used for most patients. There was no difference in patients experiencing de-saturation (SaO 2 <90%) between the two groups; however, patients in the ETC group were more likely to require airway repositioning (12.9% vs. 9.3%, P=0.003). Hypotension (SBP<100 mmHg or <85 mmHg if baseline <100 mmHg) was observed in 16 (3.3%) patients in the ETC group and 7 (1.4%) in the control group (P=0.048). CONCLUSIONS:The addition of ETC does not appear to change any clinically significant outcomes. We found an increased incidence of the use of airway repositioning maneuvers and hypotension in cases where ETC was used. We do not believe that ETC should be recommended as a standard of care for the monitoring of patients undergoing PSA.

Introduction Procedural sedation and analgesia (PSA) is accepted as a standard of care in emergency departments (ED). PSA requires careful monitoring of a patient‟s cardio-respiratory status, and an ability to act immediately and appropriately in the event of any untoward event. The knowledge and skills necessary for this are a natural extension of the expertise of Advanced Care Paramedics (ACP). We report a series of PSA‟s conducted by ACPs over a 19 month period at a busy teaching hospital. Methods This is a retrospective descriptive study presenting data from a registry recording details of all cases of ACP-facilitated PSA conducted in our ED between August 1, 2004 and February 28, 2006. Baseline characteristics, indication for the procedure, medications used and adverse events are reported. Results 1334 ACP-facilitated PSAs were conducted during the period. According to definitions used by this study, „desaturation‟- a SaO2 of < 90% at any time during the procedure in patients with an initial SaO2 of > 95% occurred in only 11 (0.9%) patients, and „hypotension‟ – systolic blood pressure (SBP) < 85 mm Hg in patients with an initial SBP > 100 mm Hg occurred in 0.6% of patients. One significant adverse event was recorded, that of pulmonary aspiration. Medications used for PSA included fentanyl (94.1%of cases), propofol (65.5%), midazolam (36.7%) and ketamine (2.2%). Conclusion PSA conducted in the ED by specifically trained ACPs is not associated with a significant number of adverse effects. This role should be recognized and subjected to further study.

Background:The impact of the age of stored red blood cells on mortality in patients sustaining traumatic injuries requiring transfusion of blood products is unknown. The objective of this systematic review was to identify and describe the available literature on the use of older versus newer blood in trauma patient populations. Methods:We searched PubMed, Embase, Lilac and the Cochrane Database for published studies comparing the transfusion of newer versus older red blood cells in adult patients sustaining traumatic injuries. Studies included for review reported on trauma patients receiving transfusions of packed red blood cells, identified the age of stored blood that was transfused and reported patient mortality as an end point. We extracted data using a standardized form and assessed study quality using the Newcastle-Ottawa Scale.Results: Seven studies were identified (6780 patients) from 3936 initial search results. Four studies reported that transfusion of older blood was independently associated with increased mortality in trauma patients, while 3 studies did not observe any increase in patient mortality with the use of older versus newer blood. Three studies associated the transfusion of older blood with adverse patient outcomes, including longer stay in the intensive care unit, complicated sepsis, pneumonia and renal dys function. Studies varied considerably in design, volumes of blood transfused and def initions applied for old and new blood. Conclusion:The impact of the age of stored packed red blood cells on mortality in trauma patients is inconclusive. Future investigations are warranted.Contexte : On ne connaît pas l'incidence de la durée de stockage des globules rouges sur la mortalité des patients atteints de lésions traumatiques qui ont besoin de transfu sions de produits sanguins. L'objectif de cette revue systématique était de trouver et d'analyser la documentation scientifique qui compare les transfusions de sang chez les patients adultes victimes de trauma en fonction de la durée de stockage du sang.Méthodes : Nous avons effectué des recherches sur PubMed, Embase et Lilac et dans la Cochrane Database of Systematic Reviews. Les études retenues portaient sur des transfusions de concentré de globules rouges chez les patients atteints de lésions traumatiques, tenaient compte de la durée de stockage du sang transfusé et faisaient état des décès de patients. Nous avons extrait les données à l'aide d'un formulaire nor malisé et évalué la qualité des études selon l'échelle Newcastle-Ottawa.Résultats : Nous avons sélectionné 7 études (totalisant 6780 patients) parmi les 3936 ré sultats de la recherche initiale. D'un côté, 4 études rapportaient que la transfu sion de sang dont la durée de stockage était longue était indépendamment associée à l'augmentation de la mortalité chez les patients atteints de lésions traumatiques; de l'autre, 3 études ne faisaient état d'aucune augmentation de la mortalité en fonction de la durée de stockage du sang transfusé. Trois études associaient la transfusion de sang s...

We describe an emergency department process using Advanced Care Paramedics in the management of patients identified as ambulatory and low acuity, or those able to be managed without an emergency nurse. Patients streamed in this way had shorter stays than other emergency patients, without affecting the care of the latter. The process was associated with improved patient flow indicators in spite of an increased patient burden.

MEG-evoked responses to the ANT reveal neurophysiological evidence of attentional dysfunction within days of injury. A pattern of improvement was also observed over the course of three months for the P300m, while behavioural performance did not change significantly. Further development of this method may yield a useful adjunct to neurological examination for concussion diagnosis and monitoring.