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Anaphylaxis is an acute systemic and potentially fatal allergic reaction. In this study, we evaluated trends in yearly rates of anaphylaxis in a pediatric Emergency Department (ED) in Montreal, Canada.A prospective and retrospective recruitment process was used to find families of children who had presented with anaphylaxis at the Montreal Children's Hospital between April 2011 and April 2021. Using a uniform recruitment form, data were collected. Anaphylaxis patterns were compared to clinical triggers using descriptive analysis.Among 830,382 ED visits during the study period, 2726 (26% recruited prospectively) presented with anaphylaxis. The median age was 6 years (IQR: 0.2, 12.00), and 58.7% were males. The relative frequency of anaphylaxis cases doubled between 2011-2015, from 0.22% (95% CI, 0.19, 0.26) to 0.42 March 2020, the total absolute number of anaphylaxis cases and relative frequency declined by 24 cases per month (p0.05) and by 0.5% of ED visits (p0.05).The rate of anaphylaxis has changed over the years, representing modifications in food introduction strategies or lifestyle changes. The observed decrease in the frequency of anaphylaxis presenting to the ED during the COVID pandemic may reflect decreased accidental exposures with reduced social gatherings, the school closed, and reluctance to present to ED.

Prompt epinephrine autoinjector (EAI) use is the primary treatment for anaphylaxis. However, limited Canadian data exist on the impact of reaction location on EAI use for food-induced anaphylaxis (FIA).We sought to investigate the setting, management, and severity of pediatric FIA.We recruited children presenting with FIA from 11 Canadian emergency departments. Patient demographics and the setting, management, and symptoms of FIA were collected by standardized questionnaire. Factors associated with prehospital EAI use and reaction severity were determined by logistic regression.We recruited 3,604 children; 60.2% were male and the median age was 5.0 years (interquartile range 1.8-11.0). Among cases with a known location of FIA (85.0%), home was the most common setting (68.1%), followed by school/daycare (12.8%), other locations (11.4%; eg, park, car), and restaurants (7.4%). In the prehospital setting, EAI was administered in 36.7% of reactions at home, 66.7% in school/daycare, 40.2% in other locations, and 44.5% in restaurants. Relative to reactions occurring at school/daycare, prehospital EAI use was less likely at home (adjusted odds ratio [aOR] 0.80; 95% CI 0.76-0.84), in restaurants (aOR 0.81; 95% CI 0.75-0.87), and in other settings (aOR 0.77; 95% CI 0.73-0.83), when data were adjusted for reaction severity, sex, age, comorbidities, and province. The FIA setting was not associated with reaction severity or hospitalization.Prehospital EAI use was higher at school/daycare than in other settings, potentially owing to the presence of policies and training on FIA. Setting-specific interventions including educational programs and policies/laws mandating training and stocking an EAI may improve anaphylaxis recognition and treatment.

Data are sparse regarding tree nut-induced anaphylaxis (TNA).To characterize rate, clinical characteristics, and management of TNA in children (0-17 years old) across Canada and evaluate factors associated with severe reactions and epinephrine use.Between April 2011 and May 2020, data were collected on children presenting to 5 emergency departments in Canada. Multivariate logistic analysis was used to evaluate factors associated with severe reactions (stridor, cyanosis, circulatory collapse, or hypoxia) and epinephrine use.Among 3096 cases of anaphylaxis, 540 (17%) were induced by tree nut. The median age was 5.2 (interquartile range, 2.5-9.5) years and 65.4% were of male sex. Among all reactions, 7.0% were severe. The major tree nuts accounting for anaphylaxis were cashew (32.8%), hazelnut (20.0%), and walnut (11.5%). Cashew-induced anaphylaxis was more common in British Columbia (14.0% difference [95% confidence interval (CI), 1.6-27.6]) vs Ontario and Quebec, whereas pistachio-induced anaphylaxis was more common in Ontario and Quebec (6.3% difference [95% CI, 0.5-12.2]). Prehospital and emergency department intramuscular epinephrine administration was documented in only 35.2% and 52.4% of cases, respectively. Severe reactions were more likely among of male sex (adjusted odds ratio [aOR], 1.05 [95% CI, 1.01-1.10]), older children (aOR, 1.00 [95% CI, 1.00-1.01]), and in reactions triggered by macadamia (aOR, 1.27 [95% CI, 1.03-1.57]).Different TNA patterns in Canada may be because of differences in lifestyle (higher prevalence of Asian ethnicity in British Columbia vs Arabic ethnicity in Ontario and Quebec). Intramuscular epinephrine underutilization urges for epinephrine autoinjector stocking in schools and restaurants, patient education, and consistent policies across Canada.

Sesame can cause severe allergic reactions and is a priority allergen in Canada.To assess clinical characteristics and management of pediatric sesame-induced anaphylaxis and identify factors associated with epinephrine treatment.Between 2011 and 2021, children with sesame-induced anaphylaxis presenting to 7 emergency departments (ED) in 4 Canadian provinces and 1 regional emergency medical service were enrolled in the Cross-Canada Anaphylaxis Registry. Standardized recruitment forms provided data on symptoms, severity, triggers, and management. Multivariate logistic regression evaluated associations with epinephrine treatment pre-ED and multiple epinephrine dosages.Of all food-induced anaphylactic reactions (n = 3279 children), sesame accounted for 4.0% (n = 130 children), of which 61.5% were boys, and the average (SD) age was 5.0 (4.9) years. Hummus containing sesame paste triggered 58.8% of reactions. In the pre-ED setting, 32.3% received epinephrine, and it was more likely to be used in boys (adjusted odds ratio [aOR], 1.27; 95% confidence interval [CI], 1.08-1.50) and those with a known food allergy (aOR, 1.36; 95% CI, 1.11-1.68]). In the ED, 47.7% of cases received epinephrine, with older children more likely to receive multiple epinephrine doses (aOR, 1.00; 95% CI, 1.00-1.02).In Canada, hummus is the major trigger of sesame-induced anaphylaxis. Knowledge translation focused on prompt epinephrine use and product-labeling policies are required to limit sesame reactions in communities.

Access of intraosseous (IO) compartments is a commonly used technique that is an invaluable asset in emergency resuscitation. Prehospital IO success rates using semi-automatic insertion devices vary between 70 and 100% of pediatric patients. There are limited data on time to insertion and duration of IO function in the prehospital setting. Recent studies limited to the pediatric emergency department (PED) setting have also suggested that IOs may be less successful in the infant population. We explored the use of IO access for pediatric resuscitation, encompassing the prehospital and pediatric emergency department (PED) settings.This is a retrospective review of emergency medical services (EMS) patient care reports and PED data of patients aged 0-17 years old and transported by regional ground EMS agencies in Southwestern Ontario, Canada from 2012 to 2019. Mean and median time to first insertion and IO function (from insertion to IO failure, IV access, transfer to ICU, or death) were calculated.Successful prehospital IO access was achieved in 83.7% of patients. The median time required to achieve IO access was 4 min (IQR 3-7) and mean duration of IO function was 27.6 min (SD: 14.8). Patients less than 1 year old had fewer functional IOs (25.9% vs. 75.0%), more insertion attempts (2 vs. 1), and shorter duration of IO function (18.8 vs. 32.2 mins) than the older age group (This is the first study to provide time to IO access and IO duration in the prehospital setting, and the first prehospital evidence to suggest inferior IO function in infants1 year old, compared to other ages. This highlights unique challenges for infants that have implications for the PED, interfacility transport, and critical care settings.

As part of the COVID-19 pandemic response, the Ontario Ministry of Health funded a virtual care pilot program intended to support emergency department (ED) diversion of patients with low acuity complaints and reduce the need for face-to-face contact. The objective was to describe the demographic characteristics, outcomes and experience of patients using the provincial pilot program.This was a prospective cohort study of patients using virtual care services provided by 14 ED-led pilot sites from December 2020 to September 2021. Patients who completed a virtual visit were invited by email to complete a standardized, 25-item online survey, which included questions related to satisfaction and patient-reported outcome measures.There were 22,278 virtual visits. When patients were asked why they contacted virtual urgent care, of the 82.7% patients who had a primary care provider, 31.0% said they could not make a timely appointment with their family physician. Rash, fever, abdominal pain, and COVID-19 vaccine queries represented 30% of the presenting complaints. Of 19,613 patients with a known disposition, 12,910 (65.8%) were discharged home and 3,179 (16.2%) were referred to the ED. Of the 2,177 survey responses, 94% rated their overall experience as 8/10 or greater. More than 80% said they had answers to all the questions they had related to their health concern, believed they were able to manage the issue, had a plan they could follow, and knew what to do if the issue got worse or came back.Many presenting complaints were low acuity, and most patients had a primary care provider, but timely access was not available. Future work should focus on health equity to ensure virtual care is accessible to underserved populations. We question if virtual urgent care can be safely and more economically provided by non-emergency physicians.RéSUMé: INTRODUCTION: Dans le cadre de la réponse à la pandémie de COVID-19, le ministère de la Santé de l'Ontario a financé un programme pilote de soins virtuels visant à soutenir la réorientation vers les services d'urgence des patients présentant des problèmes de faible acuité et à réduire le besoin de contact en personne. L'objectif était de décrire les caractéristiques démographiques, les résultats et l'expérience des patients utilisant le programme pilote provincial. MéTHODES: Il s'agissait d'une étude de cohorte prospective de patients utilisant des services de soins virtuels fournis par 14 sites pilotes dirigés par des services d'urgence, de décembre 2020 à septembre 2021. Les patients qui ont effectué une visite virtuelle ont été invités par courriel à répondre à une enquête en ligne standardisée de 25 questions, qui comprenait des questions relatives à la satisfaction et aux résultats rapportés par les patients. RéSULTATS: Il y a eu 22 278 visites virtuelles. Lorsqu'on a demandé aux patients pourquoi ils avaient contacté les soins urgents virtuels, sur les 82,7 % de patients qui avaient un prestataire de soins primaires, 31,0 % ont répondu qu'ils n'avaient pas pu obtenir un rendez-vous en temps voulu avec leur médecin de famille. Les éruptions cutanées, la fièvre, les douleurs abdominales et les interrogations sur le vaccin COVID-19 représentaient 30 % des plaintes présentées. Sur les 19 613 patients dont la disposition était connue, 12 910 (65,8 %) ont été renvoyés chez eux et 3 179 (16,2 %) ont été orientés vers les urgences. Sur les 2 177 réponses à l'enquête, 94 % ont attribué une note de 8/10 ou plus à leur expérience globale. Plus de 80 % d'entre eux ont déclaré avoir obtenu des réponses à toutes les questions qu'ils se posaient sur leur problème de santé, se croire capables de le gérer, avoir un plan qu'ils pouvaient suivre et savoir quoi faire si le problème s'aggravait ou revenait. CONCLUSIONS: De nombreuses plaintes présentées étaient de faible acuité, et la plupart des patients avaient un fournisseur de soins primaires, mais l'accès en temps opportun n'était pas disponible. Les travaux futurs devraient se concentrer sur l'équité en matière de santé pour s'assurer que les soins virtuels sont accessibles aux populations mal desservies et nous nous demandons si ces services peuvent être fournis en toute sécurité et de manière plus économique par des médecins non urgentistes.

Objective The risk of adverse health events is expected to increase with hotter temperatures, particularly among the most vulnerable groups such as elderly persons and children. The objective of this study was to assess the association between extreme heat and daily emergency department visits among children (0 to 17 years) in Southwestern Ontario. Methods We examined the average maximum temperature, relative humidity, and daily paediatric emergency department visits in June through August of 2002 to 2019. We reviewed emergency department visits from two academic hospitals. Daily meteorological data from the local weather station were obtained from Environment and Climate Change Canada. Results Extreme heat, defined as the 99th percentile of the maximum temperature distribution, occurred at 33.1°C and was associated with an overall 22% increase in emergency department visits, compared to the reference temperature of 21°C. This association was mostly found between the second and fifth day after the exposure, suggesting a slightly delayed effect. The results of the sub-group analysis indicate that the risk of an emergency department visit due to infectious disease increases by 35% and the most pronounced association was noted in children aged 1 to 12 years. Conclusions Extreme heat is associated with an increased incidence of emergency department visits in children. As temperatures continue to increase, strategies to mitigate heat-related health risks among children should be developed.

IntroductionEmergency medicine (EM) is a high-risk specialty for burnout. COVID-19 has had and will continue to have important consequences on wellness and burnout for EM physicians in Canada. Baseline data are crucial to monitor the health of EM physicians in Canada, and evaluate any interventions designed to help during and after COVID-19.ObjectivesTo describe the rates of burnout, depression, and suicidality in practicing EM physicians in Canada, just before the COVID-19 pandemic.MethodsA modified snowball method was used for survey distribution. Participants completed the Maslach Burnout Inventory – Health Services Tool (MBI-HSS), a screening measure for depression (PHQ-9), and a question regarding if the physician had ever or in the past 12 months contemplated suicide.ResultsA total of 384 respondent surveys were included in the final analysis: 86.1% (329/382) met at least one of the criteria for burnout, 58% (217/374) scored minimal to none on the PHQ-9 screening tool for depression, 14.3% (53/371) had contemplated suicide during their staff career in EM, and of those, 5.9% (22/371) had actively considered suicide in the past year.ConclusionCanadian EM physicians just before the COVID-19 pandemic had an alarming number of respondents meet the threshold for burnout, confirming EM as a high-risk specialty. This important baseline information can be used to monitor the physical and mental risks to EM physicians during and after COVID-19, and evaluate support for mental health and wellness, which is urgently needed now and post pandemic.

ObjectivesWe sought to conduct a major objective of the Canadian Association of Emergency Physicians (CAEP) Wellness Committee, an environmental scan of the academic emergency medicine programs across the 17 Canadian medical schools.MethodsAn 89-question questionnaire was distributed to academic heads or wellness leads. The responses were verified by the lead author to ensure that the questions were answered completely and consistently.ResultsWhile formal wellness programs may exist in varying degrees across the 17 universities, most were found to exist only at local, divisional, or departmental levels. A broad variability of established leadership positions exists. Shift practices varied greatly. In day to day practice, availability for food and debriefing were high and childcare, sleep rooms, and follow-up following critical incidents were low. Sabbaticals existed in the majority of centers. Roughly 50% of departments have gender equity program and annual retreats. Centers report programs for the initiation of leaves (82%), onboarding (64%), and reorientation (94%). Support of health benefits (76%) and pensions (76%) depended on type of appointment and relationship to the university. Fiscal transparency was reported in 53% of programs.ConclusionWellness and burnout are critical issues for emergency medicine in Canada. This comprehensive review of wellness programs identifies areas of strength, but also allows identification of areas of improvement for future work. Individual centers can identify common options when developing or expanding their wellness programs.

Background and Objective Bronchiolitis is the most common reason for admission to hospital in the first year of life, with increasing hospitalization rates in Canada. Respiratory support with high-flow nasal cannula (HFNC) is being routinely used in paediatric centres, though the evidence of efficacy is continuing to be evaluated. We examined the impact of HFNC on intubation rates, hospital and paediatric critical care unit (PCCU) length of stay (LOS), and PCCU admission rates in paediatric tertiary centres in Canada. Methods We conducted a multicentre, interrupted time series analysis to examine intubation rates pre- to postimplementation of HFNC for bronchiolitis. Data were obtained from the Canadian Institute for Health Information database. Paediatric tertiary centres that introduced HFNC between 2009 and 2014 were included, and data were collected from April 2005 to March 2017. Results A total of 17,643 patients met inclusion criteria. There was no significant change in intubation rates after the introduction of HFNC. There was a significant increase in PCCU admission, with a decrease in the PCCU LOS following the introduction of HFNC. There was no significant change in average hospital LOS after HFNC was introduced. Conclusions This study adds to the evolving evidence showing that overall disease course is not modified by the use of HFNC. The initiation of HFNC in Canadian paediatric centres resulted in no significant change in intubation rates or average LOS in hospital, but had an increase in PCCU admissions. Careful monitoring of new technologies on their clinical impact as well as health care resource utilization is warranted.

Objectives: The CAEP 2021 2SLGBTQIA +i panel sought whether a gap exists within Canadian emergency medicine training pertaining to sexual and gender minority communities. This panel aimed to generate practical recommendations on improving emergency medicine education about sexual and gender minorities, thereby improving access to equitable healthcare. Methods: From August 2020 to June 2021, a panel of emergency medicine practitioners, residents, students, and community representatives met monthly via videoconference. A literature review was undertaken, and three mixed methods surveys were distributed to the CAEP member list, CAEP Resident Section, College of Family Physicians of Canada (CFPC)iii Emergency Medicine Members Interest Group, and to emergency medicine residency program directors and their residents. Informed by the review and surveys, recommendations were drafted and refined by panel members before presentation at the 2021 CAEP Academic Symposium. A plenary was presented to symposium attendees composed of national emergency medicine community members, which reported the survey results and literature review. All attendees were divided into small groups to develop an action plan for each recommendation. Conclusions: The panel outlines eight recommendations for closing the curricular gap. It identifies three perceived or real barriers to the inclusion of sexual and gender minority content in emergency medicine residency curricula. It acknowledges three enabling recommendations that are beyond the scope of individual emergency medicine programs or emergency departments (EDs), that if enacted would enable the implementation of the recommendations. Each recommendation is accompanied by two action items as a guide to implementation. Each of the three barriers is accompanied by two action items that offer specific solutions to overcome these obstacles. Each enabling recommendation suggests an action that would shift emergency medicine towards sociocultural competence nationally. These recommendations set the primary steps towards closing the educational gap.

The objective of this study is to quantitatively evaluate the well-being of residents doing casino shifts compared with those doing standard overnight shifts while working in an academic pediatric emergency department.A randomized prospective survey study was performed over a period of 1 year on all residents who were scheduled to complete a 28-day block. Each block (28-day period) within the year was designated as either a "standard" or "casino" block. The standard overnight shifts were scheduled from midnight to 0800 hours, and casino shifts occurred from either 2000 to 0400 hours (casino A) and 0400 to 1200 hours (casino B). Participating residents were asked to complete both a preblock and postblock survey. The primary outcome was defined as differences in resident well-being as assessed by the brief resident wellness profile (BRWP). A mood faces graphical rating item to assess overall mood was used as a secondary outcome measures as well as a 10-item survey based on World Health Organization domains for quality of life and adapted to reflect completion of shiftwork.A total of 124 (90%) of 138 residents completed the study and were included in the analysis. No significant difference in resident well-being measured by BRWP between those in the standard and casino shift groups (17 ± 2.5 for preblock standard and 16.9 ± 2.8 for casino, P = 0.904; 17.1 ± 2.7 for postblock standard and 17.2 ± 3.1 for casino, P = 0.817), or in the relative change of the BRWP preblock and postblock between the 2 groups (standard, 0.35 ± 2.7; casino, 0.29 ± 3.0; P = 0.926). No significant difference in the mood faces rating scale scores or the 10-item postblock survey was found.In the first study examining the effects of casino shifts on trainees, we found no effect of standard overnight versus casino shifts on their well-being. This counters the benefits previously seen in emergency department consultant staff and highlights the need for more studies specifically in trainees.

Background Data are sparse regarding the clinical characteristics and management of fruit-induced anaphylaxis. Objective To assess clinical characteristics and management of patients with fruit-induced anaphylaxis and determine factors associated with severe reactions and epinephrine use. Methods Over 9 years, children and adults presenting with anaphylaxis to seven emergency departments in four Canadian provinces and patients requiring emergency medical services in Outaouais, Quebec were recruited as part of the Cross-Canada Anaphylaxis Registry. A standardized form documenting symptoms, triggers, and management was collected. Multivariate logistic regression was used to identify factors associated with severe reactions and epinephrine treatment in the pre-hospital setting. Results We recruited 250 patients with fruit-induced anaphylaxis, median age 10.2 years (interquartile range, 3.6-23.4 years); 48.8% were male. The most common fruit triggers were kiwi (15.6%), banana (10.8%), and mango (9.2%). Twenty-three patients reported having eczema (9.3%). Epinephrine use was low in both the pre-hospital setting and the emergency department (28.4% and 40.8%, respectively). Severe reactions to fruit were more likely to occur in spring and among those with eczema (adjusted odds ratio [aOR] = 1.12, 95% confidence interval [CI], 1.03-1.23; and 1.17, 95% CI, 1.03-1.34, respectively). Patients with moderate and severe reactions (aOR = 1.23; 95% CI, 1.06-1.43) and those with a known food allergy (aOR = 1.38; 95% CI, 1.24-1.54) were more likely to be treated with epinephrine in the pre-hospital setting. Conclusions Severe anaphylaxis to fruit is more frequent in spring. Cross-reactivity to pollens is a potential explanation that should be evaluated further.

Objective We compared pain and degree of disability in patients with acute ankle sprains receiving regular scheduled ibuprofen versus pro re nata (PRN). Methods This study is a randomized single-blinded controlled trial of children aged 7 to 17 years presenting with acute ankle sprain to an emergency department. Patients were randomized to receive 10 mg/kg of ibuprofen per dose (maximum 600 mg) every 6 hours regular scheduled versus PRN. Outcome measures included a 100-mm visual analog scale pain and degree of disability at day 4. A sample size of 72 children had a power of 80% to detect a clinically meaningful difference of 20 mm between the regular and PRN group. Results We randomly assigned 99 patients to receive regular scheduled (n = 50) or PRN (n = 49) ibuprofen. Pain scores and degree of disability at day 4 showed no significant differences between groups. The rate of reported adverse effects was higher in the regular scheduled group (11.4% vs 9.5%) versus the PRN group. Conclusions Our study suggests that there is little benefit from routinely using a regular scheduled ibuprofen regimen for acute pediatric ankle sprains.

In recent years, there has been growing interest in the field of physician wellness and burnout. The prevalence of burnout is non-uniform between medical specialties and is most prevalent amongst emergency medicine physicians. Importantly, burnout can be observed amongst individuals early in their medical careers, including medical students and residents. Despite ample studies in other populations, there is no national perspective of burnout amongst Canadian Royal College of Physicians and Surgeons of Canada (RCPSC)Emergency Medicine (EM) residents.Our study surveyed Canadian residents undergoing EM training though the RCPSC via local program directors using an anonymous electronic form. Basic demographic characteristics and residents' contemplation of suicide were surveyed. The Maslach Burnout Inventory - Human Services Survey (MBI-HSS) for medical personnel was used to assess burnout on three dimensions (emotional exhaustion, depersonalization and personal accomplishment).A total of 65 valid responses were collected from eight of 14 eligible institutions (response rate = 30%). Respondents are primarily male (58%) and in their postgraduate year (PGY) 1-3 (71%). Overall, 62% of residents met the threshold for burnout according to a widely cited definition of burnout using the MBI-HSS. Additionally, 14% contemplated suicide during their training. There was no statistical significance in burnout rates between male and female responders or between residents in different stages of training.Our results suggest significant burnout amongst Canadian EM residents. These results point to an important opportunity to better support EM residents during their training to improve wellness and reduce burnout.Ces dernières années, le bien-être et l’épuisement professionnel des médecins suscitent de plus en plus d’intérêt. La prévalence de l’épuisement professionnel n’est pas uniforme ente les spécialités médicales et est plus marquée chez les urgentologues. On peut observer l’épuisement professionnel tôt en carrière , incluant chez les étudiants en médecine et résidents. Malgré les études approfondies menées auprès d’autres populations, il n’existe aucune perspective nationale de l’épuisement professionnel chez les résidents en médecine d’urgence du Collège royal des médecins et chirurgiens du Canada (CRMCC).À l’aide d’un formulaire électronique anonyme, nous avons sondé les résidents canadiens des programmes du CRMCC enen médecine d’urgence par le biais des directeurs de programme. Le sondage a examiné les caractéristiques démographiques de base et les idées suicidaires chez les résidents. Nous nous sommes servis de Maslach Burnout Inventory – Human Services Survey (MBI-HSS) (MBI-HSS) à l’intention du personnel médical pour évaluer l’épuisement professionnel sur trois plans (épuisement émotionnel, dépersonnalisation et réalisation personnelle).Nous avons recueilli 65 réponses valides de huit des 14 établissements admissibles (taux de réponse = 30%). Les répondants sont majoritairement des hommes (58%) qui font des études postdoctorales (R1 àR3 (71%). En général, 62% des résidents ont atteint le seuil d’épuisement selon une définition de l’épuisement couramment utilisée dans le MBI-HSS. De plus, 14% ont envisagé de se suicider durant leur formation. Les taux d’épuisement des hommes et ceux des femmes sondées ne présentaient pas de différence statistiquement significative, tout comme ceux entre les résidents à diverses étapes de leur formation.Nos résultats indiquent que l’épuisement professionnel est important chez les résidents en médecine d’urgence canadiens. Par conséquent, ils fournissent un excellent point de départ pour mieux soutenir ces résidents au cours de leur formation afin d’améliorer leur mieux-être et réduire leur épuisement professionnel.

BACKGROUND: It is not established whether the risk of anaphylaxis induced by peanuts or tree nuts in children increases at specific times of the year. We aimed to evaluate the risk of peanut-and tree-nut–induced anaphylaxis during certain cultural holidays in Canadian children. METHODS: We collected data on confirmed pediatric cases of anaphylaxis presenting to emergency departments in 4 Canadian provinces as part of the Cross-Canada Anaphylaxis Registry. We assessed the mean number of cases per day and incidence rate ratio (IRR) of anaphylaxis induced by unknown nuts, peanuts and tree nuts presenting during each of 6 holidays (Halloween, Christmas, Easter, Diwali, Chinese New Year and Eid al-Adha) versus the rest of the year. We estimated IRRs and 95% confidence intervals (CIs) using Poisson regression. RESULTS: Data were collected for 1390 pediatric cases of anaphylaxis between 2011 and 2020. Their median age was 5.4 years, and 864 (62.2%) of the children were boys. During Halloween and Easter, there were higher rates of anaphylaxis to unknown nuts (IRR 1.66, 95% CI 1.13–2.43 and IRR 1.71, 95% CI 1.21–2.42, respectively) and peanuts (IRR 1.86, 95% CI 1.12–3.11 and IRR 1.57, 95% CI 0.94–2.63, respectively) compared to the rest of the year. No increased risk of peanut- or tree-nut–induced anaphylaxis was observed during Christmas, Diwali, Chinese New Year or Eid al-Adha. Anaphylaxis induced by unknown nuts, peanuts and tree nuts was more likely in children aged 6 years or older than in younger children. INTERPRETATION: We found an increased risk of anaphylaxis induced by unknown nuts and peanuts during Halloween and Easter among Canadian children. Educational tools are needed to increase awareness and vigilance in order to decrease the risk of anaphylaxis induced by peanuts and tree nuts in children during these holidays.

Cecal volvulus is a rare cause of bowel obstruction in adults and an extremely rare presentation in children. One form known as a cecal bascule has only previously been reported in children with neurodevelopmental issues or with severe chronic constipation. We present the case of a 10-year-old boy who presented with an acute history of left lower quadrant abdominal pain, who upon investigation was found to have a cecal bascule.

Point-of-care ultrasound (POCUS) is the bedside assessment by ultrasound to quickly assess patients for both procedural and diagnostic purposes. Pediatric emergency physicians are finding more applications for it in patients, making it a necessary adjunct to physical examinations. Being aware of its current use and limitations is important to all members of the health-care team. This article will review common POCUS indications for pediatric patients in the emergency department in the areas of abdominal and pulmonary emergencies, musculoskeletal injuries, and urgent vascular access.

Background Traumatic Brain Injury is a major cause of morbidity and mortality in the pediatric population affecting millions of people yearly. It is important that practitioners have the knowledge and skills to care for these complicated patients, as the initial care can significantly affect the course of the injury. We discuss the initial management of traumatic brain injury based on mild, moderate and severe presentations. Result and conclusion Management strategies to address Intracranial Pressure and Cerebral perfusion pressure, the use of oxygenation and ventilation strategies, temperature, correction of metabolic abnormalities and seizure care are discussed.

The objective of this study was to explore Canadian emergency physicians' experiences, concerns, and perspectives during the first wave of the coronavirus disease (COVID-19) pandemic.This cross-sectional survey of physician members of Pediatric Emergency Research Canada and the Canadian Association of Emergency Physicians explored: personal safety/responsibility to care; patient interactions; ethical issues in pandemic care; institutional dynamics and communication practices. Data analysis was descriptive: categorical data were summarised with frequency distributions, continuous data [100 mm visual analog scales (VAS)] were analysed using measures of central tendency. Short open-ended items were coded to identify frequencies of responses.From June 29 to July 29, 2020, 187 respondents (13% response rate) completed the survey: 39% were from Ontario and 20% from Quebec, trained in general (50%) or pediatric (37%) emergency medicine. Respondents reported a high moral obligation to care for patients (97/100, IQR: 85-100, on 100 mm VAS). Fear of contracting COVID-19 changed how 82% of respondents reported interacting with patients, while 97% reported PPE negatively impacted patient care. Despite reporting a high proportion of negative emotions (84%), respondents (59%) were not/slightly concerned about their mental health. Top concerns included a potential second wave, Canada's financial situation, worldwide solidarity, and youth mental health. Facilitators to provide emergency care included: teamwork, leadership, clear communications strategies.Canadian emergency physicians felt a strong sense of responsibility to care, while dealing with several ethical dilemmas. Clear communication strategies, measures to ensure safety, and appropriate emergency department setups facilitate pandemic care. Emergency physicians were not concerned about their own mental health, requiring further exploration.RéSUMé: CONTEXTE: L'objectif de cette étude était d'explorer les expériences, les préoccupations et les perspectives des médecins urgentistes canadiens pendant la première vague de la pandémie de coronavirus (COVID-19). MéTHODES: Cette enquête transversale auprès des médecins membres de Pediatric Emergency Research Canada et de l'Association canadienne des médecins d'urgence a permis d'explorer les aspects suivants : sécurité personnelle/responsabilité de soigner ; interactions avec les patients ; enjeux éthiques liés au soin en temps de pandémie ; dynamique institutionnelle et pratiques de communication. L'analyse des données était descriptive : les données catégorielles ont été résumées par des distributions de fréquence, les données continues [échelles visuelles analogiques (EVA) de 100 mm] ont été analysées à l'aide des indicateurs de tendance centrale. Les réponses ouvertes courtes ont été codées pour déterminer la fréquence des réponses. RéSULTATS: Du 29 juin au 29 juillet 2020, 187 répondants (taux de réponse de 13 %) ont répondu à l'enquête : 39 % provenaient de l'Ontario et 20 % du Québec, fet étaient formés en médecine d'urgence générale (50 %) ou pédiatrique (37 %). Les répondants ont rapporté une obligation morale élevée de s'occuper des patients (97/100, IQR : 85-100, sur une EVA de 100 mm). Quatre-vingt deux pourcent des répondants ont déclaré que la peur de contracter le COVID-19 avait modifié leurs intéractions avec les patients, tandis que, 97 % ont déclaré que l'EPI avait un impact négatif sur les soins aux patients. Bien qu’ils aient rapporté une forte proportion d’émotions négatives (84 %), les répondants (59 %) n’étaient pas/légèrement préoccupés par leur santé mentale. Parmi les principales préoccupations figuraient la possibilité d’une deuxième vague, la situation financière du Canada, la solidarité mondiale et la santé mentale des jeunes. Les facilitateurs chargés de fournir des soins d’urgence comprenaient : le travail d’équipe, le leadership et des stratégies de communication claires. CONCLUSION: Les médecins urgentistes canadiens ont ressenti un fort sentiment de responsabilité envers les soins, tout en faisant face à plusieurs dilemmes éthiques. Des stratégies de communication claires, des mesures visant à assurer la sécurité des professionnels d'urgence et une organisation appropriée des services d'urgence facilitent les soins en cas de pandémie. Les médecins urgentistes n'étaient pas préoccupés par leur propre santé mentale, ce qui mériterait une étude une étude plus approfondie.

OBJECTIVES: Early identification of children at risk for adverse outcomes is important. Serum bicarbonate is easily collected and widely available. We described the relationship between bicarbonate and adverse outcomes in children presenting to the emergency department (ED). METHODS: We conducted a retrospective cohort study of children aged 0 to 17 years from January 1, 2007, to December 31, 2011, who had a serum bicarbonate measured in the ED. Primary outcome was the predictive ability of bicarbonate for the individual components of the composite outcome that included at least one of the following: intensive care unit admission, assisted ventilation, inotropic support, cardiopulmonary resuscitation, or death. Secondary outcome was the relationship between bicarbonate level of greater and less than 13 mEq/L and the composite outcome. RESULTS: We reviewed 16,989 charts, of which 432 had an adverse outcome. Receiver operating characteristic curve analysis showed that a bicarbonate level of less than 18.5 mEq/L predicted inotropic support with an area under the curve of 0.69 (95% confidence interval [CI], 0.60-0.77; P < 0.001) and death with an area under the curve of 0.75 (CI, 0.66-0.85; P < 0.001). Significantly more patients with bicarbonate level of less than 13 mEq/L had at least 1 adverse outcome compared with those with bicarbonate level of greater than 13 mEq/L (4.4% vs 2.5%, P = 0.001), odds ratio 1.96 (95% CI, 1.3-2.97). CONCLUSIONS: Among children presenting to the ED, bicarbonate level of 18.5 mEq/L had fair specificity in predicting inotropic support and death. Negative outcomes are significantly associated with bicarbonate level of less than 13 mEq/L. Bicarbonate should routinely be measured in children at risk of clinical deterioration.

Introduction: Previous literature suggests that emergency medicine physicians experience high levels of work-related burnout. However, these results are drawn primarily from physicians working in large urban emergency departments. The aim of this study was to compare physician wellness between emergency medicine physicians working in urban versus rural settings. Methods: Emergency medicine physicians were recruited to complete a wellness survey from both urban and rural emergency medicine departments in Southwestern Ontario. The primary outcome measure of interest was physician burnout as measured by the Maslach Burnout Inventory-Human Services Survey (MBI-HSS). This survey tool measures physician burnout in the three domains of emotional exhaustion, depersonalization, and personal accomplishment. Descriptive statistics, paired t-tests and Mann-Whitney U tests were used to analyze parametric and non-parametric burnout domain data respectively. Results: Surveys were completed by 67/99 (68%) and 22/66 (33%) of urban and rural emergency medicine physicians, respectively. An emotional exhaustion score ≥27 OR a depersonalization sub-score ≥10 was considered the threshold for burnout and was found in 71.4% (40/56) of urban physicians surveyed and 85.7% (18/21) (P = 0.20) of rural physicians. No statistically significant difference in mean emotional exhaustion, depersonalization, or personal accomplishment was noted between groups. Conclusion: High levels of burnout were noted amongst both urban and rural emergency medicine physicians. No statistically significant differences were noted between groups when compared on the Maslach Burnout Inventory survey tool. Despite many factors differentiating urban from rural practice, rural emergency doctors suffer similar rates of burnout. Thematic qualitative interviews exploring specific burnout factors may offer further insight into the drivers of physician burnout.

OBJECTIVE The EZ-IO intraosseous (IO) needle is available in 2 needle sizes for children based on the patient weight. To date, there is no published evidence validating the use of weight-based scaling in children. We hypothesized that pretibial subcutaneous tissue thickness (PSTT) does not correspond with patient weight but rather with age and body mass index (BMI). Our objective was to describe the relationship of a patient's PSTT to their weight, age, and BMI in children less than 40 kg. METHOD One hundred patients who weighed less than 40 kg were recruited prospectively from October 2013 to April 2015 at a tertiary care pediatric emergency department. All sonographic assessments were performed by 1 of 2 emergency physicians certified in point-of-care ultrasound. A single sonographic image was taken over the proximal tibia corresponding to the site of IO insertion. In patients where both sonographers performed independent measurements, a Pearson correlation coefficient was determined. Univariate linear regression was performed to determine the relationship between age, weight, and BMI with PSTT. RESULTS One hundred participants were recruited and ranged in age from 10 days to 14 years (mean [SD], 5.01 [3.14] years). Fifty-seven percent of participants were male. Patients' weights ranged from 3.5 to 39.3 kg (mean [SD], 21.42 [9.12] kg), and BMI ranged from 12.1 to 45.0 kg/m (mean [SD], 17.31 [4.00]). The mean (SD) PSTT across participants was 0.68 (0.2) cm. The intraclass correlation coefficient for agreement between the 2 sonographers was moderate (intraclass correlation coefficient, 0.602 [confidence interval, 0.385-0.757]). There were significant positive correlations between BMI and PSTT (r = 0.562, P =

Foreign body aspirations are commonly seen in emergency departments (EDs) worldwide, presenting with cough, dyspnea, wheeze, and decreased air entry. Chest radiographs are commonly utilized diagnostic tools to confirm foreign object aspiration. The following is a case report of a child who presented in the ED with a carinal push-pin aspiration and a lack of respiratory symptoms; an extremely rare ED presentation of foreign body aspirations masquerading as a foreign body ingestion. This attests to the importance of conducting a lateral chest radiograph for diagnostic purposes to accurately interpret an esophageal or tracheal foreign body placement.

Objective: To implement a University Faculty mentorship program in the Division of Emergency Medicine. Methods: A program based on a unique Schulich faculty mentorship policy was implemented with the help of a Provider Value Officer. The process involved creating a training program which defined the roles of the mentors and mentees and established the principles of an effective mentor-mentee relationship. Faculty received training on how to participate effectively in a Schulich faculty mentorship committee. Each committee consisted of a mentee, and two mentors at the associate professor level (one internal and one external) . Thirteen distinct external divisions were represented. They were instructed to meet twice per year, as arranged by the mentee. The mentee created mentor minutes using a template, and then submitted the minutes to the members of the mentorship committee and the Chair/Chief of Emergency medicine. The Chair/Chief used the minutes during the annual Continuing Professional Development meeting.Results: In less than a year, the division has successfully transformed its mentorship program. Using the above-mentioned process, 31 of 34 (91%) eligible assistant professors have functioning mentorship committees. Collaboration and participation between the different faculties has increased. Follow-up meetings with the Chair/Chief and the Provider Value Officer revealed the theme that, universally, participants have perceived Schulich Faculty Mentorship committees as beneficial and are happy with the "fit" of their mentorship committees. Conclusion: Through careful planning and training, a successful Faculty Mentorship program can be initiated in an academic division in less than a year with the help of a local champion given protected time.

Elucidating a medical history and gaining patient consent and buy-in are difficult in any teenager presenting to a North American pediatric emergency department, but especially so when they present with limited English fluency. Translators can make this process easier, but both limited availability and impreciseness in translation can reduce their utility. We describe 2 teenage females who presented to our pediatric emergency department within 48 hours with similar presentations but no obvious organic cause or examination findings to suggest a specific diagnosis. We demonstrate how complex language translation issues in these adolescents contributed to prolonged diagnoses and advocate for independent interpreters to be available on first presentation to hospital.