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Background: Transdermal glyceryl trinitrate (GTN) has potential beneficial properties in acute stroke including intracerebral hemorrhage (ICH) and possible clinical benefits suggested in ultra‐early stroke (≤6 h). Our meta‐analysis updated the evidence on its safety and benefits in acute stroke. Methods: We searched major electronic databases for randomized trials comparing transdermal GTN versus placebo/control in acute stroke. Primary outcomes were mortality, 90‐day modified Rankin Scale (mRS), and blood pressure (BP) effects. Secondary outcomes included early, late, resource utilization, and surrogate outcomes. Safety outcomes were adverse events. Reviewers identified studies, extracted data, and assessed risk of bias (RoB) using a modified Cochrane RoB instrument and quality of evidence (QoE) using GRADE. We also performed a priori subgroup and trial sequential analyses (TSA) on primary outcomes. These subgroup analyses were ICH versus ischemic stroke, minor (NIHSS ≤5) versus major (NIHSS >5) ischemic stroke, ischemic stroke with versus without thrombolysis, prehospital versus non prehospital settings, time from stroke to randomization ≤6 h versus >6 h, and high versus low overall RoB studies. Results: Seven eligible primary trials enrolled 5363 patients. GTN reduced BP (mean difference [MD] = –4.74 mm Hg, 95% confidence interval [CI] = –6.03 to –3.45 mm Hg] and diastolic BP (MD = –2.94 mm Hg, 95% CI = –3.74 to −2.13 mm Hg) 24 h posttreatment but did not affect 4‐ to 10‐day mortality (relative risk [RR] = 1.11, 95% CI = 0.82 to 1.49), 90‐day mortality (RR = 0.96, 95% CI = 0.77 to 1.19), and 90‐day mRS >2 (RR = 0.98, 95% CI = 0.93 to 1.03) compared to control/placebo. The QoE was high for primary outcomes with no subgroup effects detected. GTN did not affect secondary outcomes and increased risk of headache and hypotension. TSA generally supported our conclusions regarding primary outcomes. Conclusions: Transdermal GTN reduces BP in acute stroke but does not alter clinical outcomes even in ultra‐early stroke (≤6 h). [ABSTRACT FROM AUTHOR]

Introduction: Hyperoxemia in acute exacerbation of chronic obstructive pulmonary disease (AECOPD) leads to adverse outcomes. It remains prevalent in the pre‐hospital Emergency Medical Services (EMS) and Emergency Department (ED). Objective: To determine the key predictors for hyperoxemia in AECOPD in EMS and ED. Methods: This was a prospective observational study of AECOPD patients in EMS and two EDs. Hyperoxemia was defined as PaO2 > 65 mm Hg (corresponds to SpO2 > 92%). We determined apriori candidate factors in Patient, Organization and Staff domains. Primary outcomes were the key predictors for hyperoxemia. Secondary outcomes were in‐hospital mortality and mechanical ventilation rates in hyperoxemic versus non‐hyperoxemic groups. We generated a logistic regression model for each domain. We reported the adjusted odds ratios (AORs), 95% CIs and p values. We selected the output factors using AOR ≥2.0 and ≥2.5 for modifiable and non‐modifiable factors, respectively. These selected factors were fed into a final model with eventual factors selected based on: threshold AORs as stated above and/or 95% CIs including these AORs. Results: Three hundred and twenty‐six patients were analysed; 60.7% had hyperoxemia. We found three eventual modifiable factors; first, ED SpO2 > 95% [AOR 2.62 (95% CIs: 1.61‐4.33); P < 0.001], EMS non‐rebreathing mask [AOR 2.01 (95% CIs: 1.06‐3.97); P = 0.04]; and ED nasal cannula [AOR 1.69 (95% CIs: 1.05‐2.72); P = 0.03]. Secondary outcomes did not differ between groups. Conclusion: We identified three key modifiable predictors. We intend to conduct an interventional study using them to reduce hyperoxemia rate in AECOPD. [ABSTRACT FROM AUTHOR]

Introduction: Traumatic diaphragmatic injuries (TDIs) are clinically challenging. We aimed to review TDIs treated at a tertiary trauma centre over a 12-year period.Methods: This was a single-centre retrospective review of adult patients with TDIs treated between 1 January 2003 and 31 December 2014. Primary outcomes were mortality rates and Injury Severity Scores (ISS) associated with each TDI subtype. Secondary outcomes included proportions of TDIs diagnosed radiologically, operatively or during autopsy. We compared the TDI subtypes with respect to mechanism of injury, mortality rates and median ISS. Data was analysed using descriptive statistics.Results: Among 46 patients studied, the TDI subtypes noted were acute diaphragmatic herniation (n = 14, 30.4%), tears (n = 22, 47.8%) and contusions (n = 10, 21.7%). Patients with these TDI subtypes had a mortality rate of 35.7%-100%, while the ISS ranges for survivors and deaths were 22.0-34.0 (interquartile range [IQR] 6.5-23.0) and 53.5-66.0 (IQR 16.0-28.5), respectively. TDIs were identified via chest radiography (n = 2/33, 6.1%) and computed tomography (n = 6/13, 46.2%). All survivors (n = 21) and deaths (n = 25) underwent open surgery or autopsy, respectively, which confirmed TDIs. Blunt traumas and penetrating traumas were more frequently associated with acute herniation/contusions and tears, respectively. There were statistically significant differences among the TDI subtypes in their mechanism of injury, mortality rate and median ISS of survivors.Conclusion: TDIs showed varying injury patterns with blunt versus penetrating mechanisms of injury, and were associated with significant mortality rates. Preoperative imaging had limited diagnostic use. [ABSTRACT FROM AUTHOR]

Objectives: We investigated delayed outcomes of patients with minor head injury, warfarin, and a normal initial head computer tomographic (CT) scan finding.Methods: We conducted a single-center, retrospective study on such patients who were admitted. A second CT was not mandatory. International normalized ratios were classified into subtherapeutic, therapeutic, and supratherapeutic ranges. We traced them 2 weeks after discharge for delayed intracranial hemorrhage (ICH). Primary outcomes were proportions with ICH on second CT, fresh-frozen plasma (FFP) and/or vitamin K administration, and neurosurgical intervention. Secondary outcomes were hospital length of stay and the proportion with ICH 2 weeks after discharge. We explored differences in proportions of ICH during hospital stay among different strata (age ≥65 years, antiplatelet therapy, supratherapeutic international normalized ratio ranges, and FFP administration). Data were analyzed using descriptive statistics. P values less than .05 were considered statistically significant.Results: We recruited 298 patients. Of admissions (N = 295), 11 (3.7%) had a second CT, with one (0.3%) abnormality. There were 7 (2.4%) and 8 (2.7%) patients who received FFP and vitamin K, respectively. One patient (0.3%) required neurosurgical intervention. The median hospital length of stay was 3 (interquartile range, 2) days. No patients reattended 2 weeks after discharge. There were no statistically significant differences in the proportions of ICH during hospital stay among the 4 strata.Conclusions: Delayed ICH was rare with no predictive factors. Clinical monitoring before deciding on second CT was safe. The optimal period and mode of observation had yet to be determined. [ABSTRACT FROM AUTHOR]

Objectives: Butyrophenones have been reported to provide effective migraine relief in the emergency department (ED). We conducted a systematic review of the evidence for their use in the ED. Data source: We searched the Cochrane, Medline, Embase, and CINAHL databases. Study selection: Included studies were randomized trials of a parenteral butyrophenone (droperidol, haloperidol) versus placebo or a comparator in migraine or benign headache with results available in English. Study quality was determined using the Jadad score. Six articles were included. Data extraction: Primary outcomes were subjective or objective headache relief (> 50% improvement in visual analogue scale scores). Secondary outcomes included side effects. We reported pooled odds ratios (ORs) with their 95% confidence intervals (CIs) for subjective or objective headache relief for butyrophenones versus placebo or comparator agents. Data synthesis: Three studies reported subjective headache relief with a butyrophenone versus placebo or meperidine in migraine. Two studies reported objective headache relief with droperidol versus prochlorperazine, whereas one study compared droperidol versus olanzapine in benign headache. The pooled OR for subjective headache relief was 8.08 (95% CI 1.54-42.30) for a butyrophenone versus placebo, whereas it was 1.50 (95% CI 0.33-6.77) for droperidol versus meperidine in migraine. The pooled OR for objective headache relief was 2.96 (95% CI 1.36-6.43) for droperidol versus prochlorperazine in benign headache. Rates of side effects were 10 to 45%; akathesia and sedation were the most common. Conclusions: Butyrophenones are effective for the relief of migraine or benign headache. However, adverse effects make it difficult to recommend butyrophenones above agents with similar effectiveness and fewer problems. [ABSTRACT FROM AUTHOR]

Peri-mortem caesarean section (PMCS) is a very rare procedure performed to improve the chances of survival for both mother and fetus following cardiorespiratory arrest. Non-obstetricians including Emergency Physicians (EPs) are often called upon to perform this procedure under challenging and suboptimal circumstances. We reported a case of PMCS performed timely after traumatic cardiorespiratory arrest that resulted in fetal survival. A 25-year-old primigravida female and six-month pregnant presented to the Emergency Department (ED) of an adult tertiary hospital. She experienced traumatic cardiorespiratory arrest for nearly 27 min following a high-speed motor vehicle crash. Upon ED arrival, she was in pulseless electrical activity. She was immediately intubated with continuation of cardiopulmonary resuscitation. She received bilateral tube thoracostomies as well as intravenous (IV) transfusion of blood products, adrenaline and tranexamic acid. Her fundal height was two centimeters above the umbilicus on palpation. The EP performed a PMCS via a midline laparotomy 3-4 min upon ED arrival. The baby was bradycardic and cyanosed with no spontaneous respiration at birth and was resuscitated by a second EP. She was intubated and the EP gained IV access using a cannula introduced into the umbilical vein. Neonatal hypothermia was avoided using cling wrap. The baby was transported to a nearby neonatal intensive unit. She survived and is currently one year old. The mother, however, did not respond to our resuscitation and succumbed to her multiple injuries. We reviewed the limited literature regarding this potentially life-saving emergency procedure and highlighted the challenges facing our resuscitation team. [ABSTRACT FROM AUTHOR]

Abstract: Background: Chlorate poisoning as a cause of methemoglobinemia is regarded in current literature to be resistant to treatment by methylene blue due to the oxidizing and denaturing properties of the chlorate anion, and often leads to severe renal and hematological complications with a high mortality rate. Recent case studies suggest practitioners have eschewed the use of methylene blue in such situations. Objectives: This report describes a case of chlorate poisoning presenting as severe methemoglobinemia successfully treated with methylene blue alone, believed to be a first in reported literature. Case Report: A 34-year-old male construction worker presented 4 h after accidental ingestion of an industrial chemical, with giddiness and breathlessness. Physical examination did not reveal any abnormal cardiorespiratory findings, although arterial blood gas analysis and pulse oximetry revealed an “oxygen saturation gap.” Methemoglobin levels were found to be severely elevated at 66.8% 6 h after ingestion, and the patient was promptly treated with methylene blue. Clinical examination and laboratory tests suggested the absence of hemolysis at the time of treatment. The patient was discharged after a brief and uneventful hospital stay. Subsequent tests revealed the chemical ingested to be sodium chlorate. Conclusion: The successful outcome in our case suggests that a window of opportunity as long as 6 h may exist during which treatment of chlorate poisoning with methylene blue may be of clinical value. We postulate that the absence of significant hemolysis and hematological alterations at the time of antidote administration may be a necessary prerequisite for treatment success. [Copyright &y& Elsevier]