Ian G Stiell

University of Ottawa, Ottawa, Ontario, Canada

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Publications (378)2859.37 Total impact

  • [Show abstract] [Hide abstract]
    ABSTRACT: Objectives To characterize the current state of Canadian emergency medicine (EM) resident research and develop recommendations to promote excellence in this area. Methods We performed a systematic review of MEDLINE, Embase, and ERIC using search terms relevant to EM resident research. We conducted an online survey of EM residency program directors from the Royal College of Physicians and Surgeons of Canada (RCPSC) and College of Family Physicians of Canada (CFPC). An expert panel reviewed these data, presented recommendations at the Canadian Association of Emergency Physicians 2014 Academic Symposium, and refined them based on feedback received. Results Of 654 potentially relevant citations, 35 articles were included. These were categorized into four themes: 1) expectations and requirements, 2) training and assessment, 3) infrastructure and support, and 4) dissemination. We received 31 responses from all 31 RCPSC-EM and CFPC-EM programs. The majority of EM programs reported requiring a resident scholarly project; however, we found wide-ranging expectations for the type of resident research performed and how results were disseminated, as well as the degree of completion expected. Although 93% of RCPSC-EM programs reported providing formal training on how to conduct research, only 53% of CFPC-EM programs reported doing so. Almost all programs (94%) reported having infrastructure in place to support resident research, but the nature of support was highly variable. Finally, there was marked variability regarding the number of resident-published abstracts and manuscripts. Conclusions Based on the literature, our national survey, and discussions with stakeholders, we offer 14 recommendations encompassing goals, expectations, training, assessment, infrastructure, and dissemination in order to improve Canadian EM resident research.
    Canadian Journal of Emergency Medicine 08/2015; 17(5):591-9. · 0.66 Impact Factor
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    European Heart Journal 08/2015; DOI:10.1093/eurheartj/ehv378 · 14.72 Impact Factor
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    ABSTRACT: Introduction Five percent of transient ischemic attack (TIA) patients have a subsequent stroke within 7 days. The Canadian TIA Score uses clinical findings to calculate the subsequent stroke risk within 7 days. Our objectives were to assess 1) anticipated use; 2) component face validity; 3) risk strata for stroke within 7 days; and 4) actions required, for a given risk for subsequent stroke. After a rigorous development process, a survey questionnaire was administered to a random sample of 300 emergency physicians selected from those registered in a national medical directory. The surveys were distributed using a modified Dillman technique. From a total of 271 eligible surveys, we received 131 (48.3%) completed surveys; 96.2% of emergency physicians would use a validated Canadian TIA Score; 8 of 13 components comprising the Canadian TIA Score were rated as Very Important or Important by survey respondents. Risk categories for subsequent stroke were defined as minimal-risk: 10% risk of subsequent stroke within 7 days. A validated Canadian TIA Score will likely be used by emergency physicians. Most components of the TIA Score have high face validity. Risk strata are definable, which may allow physicians to determine immediate actions, based on subsequent stroke risk, in the emergency department.
    Canadian Journal of Emergency Medicine 07/2015; DOI:10.1017/cem.2015.57 · 0.66 Impact Factor
  • Resuscitation 07/2015; DOI:10.1016/j.resuscitation.2015.07.003 · 3.96 Impact Factor
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    ABSTRACT: We sought to gather a comprehensive list of funding strategies and opportunities for emergency medicine (EM) centres across Canada, and make recommendations on how to successfully fund all levels of research activity, including research projects, staff salaries, infrastructure, and researcher stipends. We formed an expert panel consisting of volunteers recognized nationally for their scholarly work in EM. First, we conducted interviews with academic leaders and researchers to obtain a description of their local funding strategies using a standardized open-ended questionnaire. Panelists then identified emerging funding models. Second, we listed funding opportunities and initiatives at the provincial, national, and international levels. Finally, we used an iterative consensus-based approach to derive pragmatic recommendations after incorporating comments and suggestions from participants at an academic symposium. Our review of funding strategies identified four funding models: 1) investigator dependent model, 2) practice plan, 3) generous benefactor, and 4) mixed funding. Recommendations in this document include approaches for research contributors and producers (seven recommendations), for local academic leaders (five recommendations), and for national organizations, such as the Canadian Association of Emergency Physicians (CAEP) (three recommendations). Funding for research in EM varies across Canada and is largely insecure. We offer recommendations to help facilitate funding for large and small projects, for salary support, and for local and national leaders to advance EM research. We believe that these recommendations will increase funding for all levels of EM research activity, including research projects, staff salaries, infrastructure, and researcher stipends.
    Canadian Journal of Emergency Medicine 07/2015; 17(4):453-61. DOI:10.1017/cem.2015.58 · 0.66 Impact Factor
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    ABSTRACT: Assessment of cellulitis severity in the emergency department (ED) setting is problematic. Given the lack of research performed to describe the epidemiology and management of cellulitis, it is unsurprising that heterogeneous antibiotic prescribing and poor adherence to guidelines is common. It has been shown that up to 20.5% of ED patients with cellulitis require either a change in route or dose of the initially prescribed antibiotic regimen. The current treatment failure rate for empirically prescribed oral antibiotic therapy in Irish EDs is unknown. The association of patient risk factors with treatment failure has not been described in our setting. Lower prevalence of community-acquired methicillin-resistant Staphylococcus aureus-associated infection, differing antibiotic prescribing preferences and varying availability of outpatient intravenous therapy programmes may result in different rates of empiric antibiotic treatment failure from those previously described. Consecutive ED patients with cellulitis will be enrolled on a 24/7 basis from 3 Irish EDs. A prespecified set of clinical variables will be measured on each patient discharged on empiric oral antibiotic therapy. A second independent study recruiter will assess at least 10% of cases for each of the predictor variables. Follow-up by telephone call will occur at 14 days for all discharged patients where measurement of the primary outcome will occur. Our primary outcome is treatment failure, defined as a change in route of antibiotic administration from oral to intravenous antibiotic. Our secondary outcome is change in dose or type of prescribed antibiotic. A cohort of approximately 152 patients is required to estimate the proportion of patients failing oral antibiotic treatment with a margin of error of 0.05 around the estimate. Full ethics approval has been granted. An integrated dissemination plan, involving diverse clinical specialties and enrolled patients, is described. NCT 02230813. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.
    BMJ Open 06/2015; 5(6):e008150. DOI:10.1136/bmjopen-2015-008150 · 2.06 Impact Factor
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    ABSTRACT: Epidemiologic data regarding biphasic reactions in children with anaphylaxis are sparse. To investigate the incidence and clinical predictors of biphasic reactions in children presenting to the emergency department (ED) with anaphylaxis. A health records review of ED visits at 2 large Canadian academic pediatric EDs was conducted. All visits that satisfied anaphylaxis diagnostic criteria of the National Institute of Allergy and Infectious Diseases and the Food Allergy and Anaphylaxis Network were included. Predictors of biphasic reaction were analyzed using univariate and multiple logistic regression analyses. Of 1,749 ED records reviewed, 484 visits met the study inclusion criteria. Seventy-one patients (14.7%) developed biphasic reactions. The median age was 6 years (interquartile range 2.7-10.1) and 51 (71.8%) were boys. Forty-nine of the 71 (69%) delayed reactions involved respiratory and/or cardiovascular manifestations and 35 (49%) were treated with epinephrine. Five independent predictors for biphasic reactions were found: age 6 to 9 years (odds ratio [OR] 3.60, 95% confidence interval [CI] 1.5-8.58), delay in presentation to the ED longer than 90 minutes after the onset of the initial reaction (OR 2.58, 95% CI 1.47-4.53), wide pulse pressure at triage (OR 2.92, 95% CI 1.69-5.04), treatment of the initial reaction with more than 1 dose of epinephrine (OR 2.7, 95% CI 1.12-6.55), and administration of inhaled β-agonists in the ED (OR 2.39, 95% CI 1.24-4.62). Biphasic reactions seem to be associated with the severity of the initial anaphylactic reactions. We identified clinical predictors that could ultimately be used to identify patients who would benefit from prolonged ED monitoring and enable better utilization of ED resources. Copyright © 2015 American College of Allergy, Asthma & Immunology. Published by Elsevier Inc. All rights reserved.
    Annals of allergy, asthma & immunology: official publication of the American College of Allergy, Asthma, & Immunology 06/2015; DOI:10.1016/j.anai.2015.05.013 · 2.75 Impact Factor
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    ABSTRACT: Introduction The objective of this study was to compare the emergency department (ED) management and rate of admission of acute decompensated heart failure (ADHF) between two hospitals in Canada and the United States and to compare the outcomes of these patients. This was a health records review of adults presenting with ADHF to two EDs in Canada and the United States between January 1 and April 30, 2010. Outcome measures were admission to the hospital, myocardial infarction (MI), and death or relapse rates to the ED. Data were analysed using descriptive, univariate and multivariate analyses. In total, 394 cases were reviewed and 73 were excluded. Comparing 156 Canadian to 165 U.S. patients, respectively, mean age was 76.0 and 75.8 years; male sex was 54.5% and 52.1%. Canadian and U.S. ED treatments were noninvasive ventilation 7.7% v. 12.8% (p=0.13); IV diuretics 77.6% v. 36.0% (p<0.001); IV nitrates 4.5% v. 6.7% (p=0.39). There were significant differences in rate of admission (50.6% v. 95.2%, p<0.001) and length of stay in ED (6.7 v. 3.0 hours, p<0.001). Proportion of Canadian and U.S. patients who died within 30 days of the ED visit was 5.1% v. 9.7% (p=0.12); relapsed to the ED within 30 days was 20.8% v. 17.5% (p=0.5); and had MI within 30 days was 2.0% v. 1.9% (p=1.0). The U.S. and Canadian centres saw ADHF patients with similar characteristics. Although the U.S. site had almost double the admission rate, the outcomes were similar between the sites, which question the necessity of routine admission for patients with ADHF.
    Canadian Journal of Emergency Medicine 06/2015; DOI:10.1017/cem.2015.43 · 0.66 Impact Factor
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    ABSTRACT: Importance Assessment of morbidity is an important component of evaluating interventions for patients with out-of-hospital cardiac arrest (OHCA). Objective We evaluated among survivors of OHCA cognition, functional status, health-related quality of life and depression as functions of patient and emergency medical services (EMS) factors. Design Prospective cohort sub study of a randomized trial. Setting The parent trial studied two comparisons in persons with non-traumatic OHCA treated by EMS personnel participating in the Resuscitation Outcomes Consortium. Participants Consenting survivors to discharge. Main Outcome Measures Telephone assessments up to six months after discharge included neurologic function (modified Rankin score, MRS), cognitive impairment (Adult Lifestyle and Function Mini Mental Status Examination, ALFI-MMSE), health-related quality of life (Health Utilities Index Mark 3, HUI3) and depression (Telephone Geriatric Depression Scale, T-GDS). Results Of 15,794 patients enrolled in the parent trial, 729 (56% of survivors) consented. 644 respondents (88% of consented) completed≥1 assessment. Likelihood of assessment was associated with baseline characteristics and study site. Most respondents had MRS≤3 (82.7%), no cognitive impairment (82.7% ALFI-MMSE≥17), no severe impairment in health (71.6%, HUI3≥0.7) and no depression (90.1% T-GDS≤10). Outcomes did not differ by trial intervention or time from hospital discharge. Conclusions and Relevance The majority of patients in this large cohort who survived cardiac arrest and were interviewed had no, mild or moderate health impairment. Concern about poor quality of life is not a valid reason to abandon efforts to improve an EMS system's response to cardiac arrest. Copyright © 2015. Published by Elsevier Ireland Ltd.
    Resuscitation 05/2015; 93. DOI:10.1016/j.resuscitation.2015.05.011 · 3.96 Impact Factor
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    ABSTRACT: We sought to 1) identify best practices for training and mentoring clinician researchers, 2) characterize facilitators and barriers for Canadian emergency medicine researchers, and 3) develop pragmatic recommendations to improve and standardize emergency medicine postgraduate research training programs to build research capacity. We performed a systematic review of MEDLINE and Embase using search terms relevant to emergency medicine research fellowship/graduate training. We conducted an email survey of all Canadian emergency physician researchers. The Society for Academic Emergency Medicine (SAEM) research fellowship program was analysed, and other similar international programs were sought. An expert panel reviewed these data and presented recommendations at the Canadian Association of Emergency Physicians (CAEP) 2014 Academic Symposium. We refined our recommendations based on feedback received. Of 1,246 potentially relevant citations, we included 10 articles. We identified five key themes: 1) creating training opportunities; 2) ensuring adequate protected time; 3) salary support; 4) infrastructure; and 5) mentorship. Our survey achieved a 72% (67/93) response rate. From these responses, 42 (63%) consider themselves clinical researchers (i.e., spend a significant proportion of their career conducting research). The single largest constraint to conducting research was funding. Factors felt to be positive contributors to a clinical research career included salary support, research training (including an advanced graduate degree), mentorship, and infrastructure. The SAEM research fellowship was the only emergency medicine research fellowship program identified. This 2-year program requires approval of both the teaching centre and each applying fellow. This program requires training in 15 core competencies, manuscript preparation, and submission of a large grant to a national peer-review funding organization. We recommend that the CAEP Academic Section create a process to endorse research fellowship/graduate training programs. These programs should include two phases: Phase I: Research fellowship/graduate training would include an advanced research university degree and 15 core learning areas. Phase II: research consolidation involves a further 1-3 years with an emphasis on mentorship and scholarship production. It is anticipated that clinician scientists completing Phase I and Phase II training at a CAEP Academic Section-endorsed site(s) will be independent researchers with a higher likelihood of securing external peer-reviewed funding and be able to have a meaningful external impact in emergency medicine research.
    Canadian Journal of Emergency Medicine 05/2015; 17(3):334-343. DOI:10.1017/cem.2015.63 · 0.66 Impact Factor
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    ABSTRACT: The vision of the recently created Canadian Association of Emergency Physicians (CAEP) Academic Section is to promote high-quality emergency patient care by conducting world-leading education and research in emergency medicine. The Academic Section plans to achieve this goal by enhancing academic emergency medicine primarily at Canadian medical schools and teaching hospitals. It seeks to foster and develop education, research, and academic leadership amongst Canadian emergency physicians, residents, and students. In this light, the Academic Section began in 2013 to hold the annual Academic Symposia to highlight best practices and recommendations for the three core domains of governance and leadership, education scholarship, and research. Each year, members of three panels are asked to review the literature, survey and interview experts, achieve consensus, and present their recommendations at the Symposium (2013, Education Scholarship; 2014, Research; and 2015, Governance and Funding). Research is essential to medical advancement. As a relatively young specialty, emergency medicine is rapidly evolving to adapt to new diagnostic tools, the challenges of crowding in emergency departments, and the growing needs of emergency patients. There is significant variability in the infrastructure, support, and productivity of emergency medicine research programs across Canada. All Canadians benefit from an investigation of the means to improve research infrastructure, training programs, and funding opportunities. Such an analysis is essential to identify areas for improvement, which will support the expansion of emergency medicine research. To this end, physician-scientist leaders were gathered from across Canada to develop pragmatic recommendations on the improvement of emergency medicine research through a comprehensive analysis of current best practices, systematic literature reviews, stakeholder surveys, and expert interviews.
    Canadian Journal of Emergency Medicine 05/2015; 17(3):328-333. DOI:10.1017/cem.2015.59 · 0.66 Impact Factor
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    ABSTRACT: Diagnosing pulmonary embolism can be difficult given its highly variable clinical presentation. Our objective was to determine whether a decrease in oxygen saturation or an increase in heart rate while ambulating could be used as an objective tool in the diagnosis of pulmonary embolism. This was a two-site tertiary-care-centre prospective cohort study that enrolled adult emergency department or thrombosis clinic patients with suspected or newly confirmed pulmonary embolism. Patients were asked to participate in a standardized 3-minute walk test, which assessed ambulatory heart rate and ambulatory oxygen saturation. The primary outcome was pulmonary embolism. We enrolled 114 patients, including 30 with pulmonary embolism (26.3%). A ≥2% absolute decrease in ambulatory oxygen saturation and an ambulatory change in heart rate >10 beats per minute (BPM) were significantly associated with pulmonary embolism. An ambulatory heart rate change of >10 BPM had a sensitivity of 96.6% (95% confidence interval [CI] 83.3 to 99.4) and a specificity of 31.0% (95% CI 22.1 to 45.0) for pulmonary embolism. A ≥2% absolute decrease ambulatory oxygen saturation had a sensitivity of 80.2% (95% CI 62.7 to 90.5) and a specificity of 39.3% (95% CI 29.5 to 50.0) for pulmonary embolism. The combination of both variables yielded a sensitivity of 100.0% (95% CI 87.0 to 100.0) and a specificity of 11.0% (95% CI 6.6 to 21.0). In summary, our study found that an ambulatory heart rate change of >10 BPM or a ≥2% absolute decrease in ambulatory oxygen saturation from baseline during a standardized 3-minute walk test are highly correlated with pulmonary embolism. Although the findings appear promising, neither of these variables can currently be recommended as a screening tool for pulmonary embolism until larger prospective studies examine their performance either alone or with pre-existing rules.
    Canadian Journal of Emergency Medicine 05/2015; 17(3):1-9. DOI:10.1017/cem.2014.45 · 0.66 Impact Factor
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    ABSTRACT: Variations in emergency department (ED) syncope management have not been well studied. The goals of this study were to assess variations in management, and emergency physicians' risk perception and disposition decision making. We conducted a prospective study of adults with syncope in six EDs in four cities over 32 months. We collected patient characteristics, ED management, disposition, physicians' prediction probabilities at index presentation and followed patients for 30 days for serious outcomes: death, myocardial infarction (MI), arrhythmia, structural heart disease, pulmonary embolism, significant hemorrhage, or procedural interventions. We used descriptive statistics, ROC curves, and regression analyses. We enrolled 3662 patients: mean age 54.3 years, and 12.9 % were hospitalized. Follow-up data were available for 3365 patients (91.9 %) and 345 patients (10.3 %) suffered serious outcomes: 120 (3.6 %) after ED disposition including 48 patients outside the hospital. After accounting for differences in patient case mix, the rates of ED investigations and disposition were significantly different (p < 0.0001) across the four study cities; as were the rates of 30-day serious outcomes (p < 0.0001) and serious outcomes after ED disposition (p = 0.0227). There was poor agreement between physician risk perception and both observed event rates and referral patterns (p < 0.0001). Only 76.7 % (95 % CI 68.1-83.6) of patients with serious outcomes were appropriately referred. There are large and unexplained differences in ED syncope management. Moreover, there is poor agreement between physician risk perception, disposition decision making, and serious outcomes after ED disposition. A valid risk-stratification tool might help standardize ED management and improve disposition decision making.
    Internal and Emergency Medicine 04/2015; DOI:10.1007/s11739-015-1237-1 · 2.41 Impact Factor
  • International journal of cardiology 03/2015; 189:12-14. DOI:10.1016/j.ijcard.2015.03.388 · 6.18 Impact Factor
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    ABSTRACT: Continuous positive airway pressure (CPAP) is commonly used in the treatment of acute cardiogenic pulmonary edema (ACPE) and acute exacerbations of chronic obstructive pulmonary disease (AECOPD). In-hospital evidence is robust: CPAP has been shown to improve respiratory status and to reduce intubation rates. There is less evidence on prehospital CPAP, although the emergency medical services (EMS) adoption of this modality is increasing. The objectives of this study were to 1) measure the effectiveness of prehospital CPAP on morbidity, mortality, and transport times; and 2) audit the selection of patients by medics for appropriateness and safety. We conducted a before-and-after study from August 1 to October 31 in 2010 and 2011, before and after the implementation of prehospital CPAP in a city of one million people with large rural areas. Medics were trained to apply CPAP to patients with respiratory distress and a presumed diagnosis of ACPE or AECOPD. Charts were selected using the search criteria of the chief complaint of shortness of breath, emergent transport to hospital, and any patients receiving CPAP in the field. Data extracted from ambulance call reports and hospital records were analysed with appropriate univariate statistics. A total of 373 patients enrolled (186 pre-non-invasive ventilation [NIV] and 187 post-NIV), mean age 71.5 years, female 51.4%, and final diagnoses of ACPE 18.9%, AECOPD 21.9%. In the post group of 84 patients meeting NIV criteria, 41.6% received NIV; and of 102 patients not meeting the criteria, 5.2% received NIV. There were 12 minor adverse events in 36 applications (33.3%) as per protocol. Comparing post versus pre, there were higher rates of emergency department (ED) NIV (20.0% v. 13.4%, p<0.0001) and higher overall mortality (18.8% v. 14.9%, p<0.0001). There were no differences in ED intubation (2.1% v. 2.3%, p<0.001) and length of stay (6.8 v. 8.7 days, p=0.24). Despite the robust in-hospital data supporting its use, we could not find benefit from CPAP in our prehospital setting with respect to morbidity, mortality, and length of stay. EMS must exercise caution in making the decision to invest in the equipment and training required to implement prehospital CPAP.
    Canadian Journal of Emergency Medicine 03/2015; DOI:10.1017/cem.2014.60 · 0.66 Impact Factor
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    ABSTRACT: A cardiac source is often implicated in strokes where the deficit includes aphasia. However, less is known about the etiology of isolated aphasia during transient ischemic attack (TIA). Our objective was to determine whether patients with isolated aphasia are likely to have a cardioembolic etiology for their TIA. We prospectively studied a cohort of TIA patients in eight tertiary-care emergency departments. Patients with isolated aphasia were identified by the treating physician at the time of emergency department presentation. Patients with dysarthria (i.e., a phonation disturbance) were not included. Potential cardiac sources for embolism were defined as atrial fibrillation on history, electrocardiogram, Holter monitor, atrial fibrillation on echocardiography, or thrombus on echocardiography. Of the 2,360 TIA patients identified, 1,155 had neurological deficits at the time of the emergency physician assessment and were included in this analysis, and 41 had isolated aphasia as their only neurological deficit. Patients with isolated aphasia were older (73.9±10.0 v. 67.2±14.5 years; p=0.003), more likely to have a history of heart failure (9.8% v. 2.6%; p=0.027), and were twice as likely to have any cardiac source of embolism (22.0% v. 10.6%; p=0.037). Isolated aphasia is associated with a high rate of cardioembolic sources of embolism after TIA. Emergency patients with isolated aphasia diagnosed with a TIA warrant a rapid and thorough assessment for a cardioembolic source.
    Canadian Journal of Emergency Medicine 03/2015; DOI:10.1017/cem.2014.63 · 0.66 Impact Factor
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    ABSTRACT: INTRODUCTION We sought to determine the ability of 9-1-1 dispatchers to accurately determine the presence of out-of-hospital cardiac arrest (OOHCA) over the telephone, and to determine the frequency with which CPR instructions are initiated and chest compressions delivered in patients not in cardiac arrest. METHODS We conducted a multi-center, prospective cohort study of adult OOHCA patients not witnessed by EMS for which resuscitation was attempted. Dispatchers were not health care professionals and received 6 weeks of training followed by a 6-month preceptorship. We reviewed 9-1-1 call digital recordings for all unconscious patients for which the possibility of cardiac arrest was considered using a piloted standardized data collection sheet. RESULTS We reviewed 2,260 recordings occurring between January 2008 and October 2009. Among those, 1,536 were confirmed OOHCA, and 724 were not. Among the 1,536 confirmed OOHCA cases, 1,012 were recognized by dispatchers and 524 were not. Among the 724 cases not in cardiac arrest, dispatchers suspected cardiac arrest was present in 490 and absent in 234. OOHCA diagnostic accuracy characteristics were: sensitivity 65.9% (95%CI 63.5-68.2%), specificity 32.3% (95%CI 29.0-35.9%), PPV 67.4%, and NPV 30.9%. Dispatchers believed that OOHCA was present in 490/2,260 (21.7%) cases when it was not, resulting in 54/490 (11.0%) patients inappropriately receiving chest compressions, or 54/2,260 (2.4%) of the whole cohort. CONCLUSIONS Dispatchers had a fair sensitivity and modest specificity for the recognition of OOHCA. We found a very small number of patients receiving CPR when not in cardiac arrest, supporting the current use of dispatch-assisted CPR instructions. Copyright © 2015. Published by Elsevier Ireland Ltd.
    Resuscitation 03/2015; 90. DOI:10.1016/j.resuscitation.2015.02.027 · 3.96 Impact Factor
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    ABSTRACT: To describe the findings in cerebrospinal fluid from patients with acute headache that could distinguish subarachnoid hemorrhage from the effects of a traumatic lumbar puncture. A substudy of a prospective multicenter cohort study. 12 Canadian academic emergency departments, from November 2000 to December 2009. Alert patients aged over 15 with an acute non-traumatic headache who underwent lumbar puncture to rule out subarachnoid hemorrhage. Aneurysmal subarachnoid hemorrhage requiring intervention or resulting in death. Of the 1739 patients enrolled, 641 (36.9%) had abnormal results on cerebrospinal fluid analysis with >1×10(6)/L red blood cells in the final tube of cerebrospinal fluid and/or xanthochromia in one or more tubes. There were 15 (0.9%) patients with aneurysmal subarachnoid hemorrhage based on abnormal results of a lumbar puncture. The presence of fewer than 2000×10(6)/L red blood cells in addition to no xanthochromia excluded the diagnosis of aneurysmal subarachnoid hemorrhage, with a sensitivity of 100% (95% confidence interval 74.7% to 100%) and specificity of 91.2% (88.6% to 93.3%). No xanthochromia and red blood cell count <2000×10(6)/L reasonably excludes the diagnosis of aneurysmal subarachnoid hemorrhage. Most patients with acute headache who meet this cut off will need no further investigations and aneurysmal subarachnoid hemorrhage can be excluded as a cause of their headache. © Perry et al 2015.
    BMJ Clinical Research 02/2015; 350(feb18 8):h568. DOI:10.1136/bmj.h568 · 14.09 Impact Factor
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    ABSTRACT: Guidelines for cardiopulmonary resuscitation recommend a chest compression rate of at least 100 compressions/min. A recent clinical study reported optimal return of spontaneous circulation with rates between 100 and 120/min during cardiopulmonary resuscitation for out-of-hospital cardiac arrest. However, the relationship between compression rate and survival is still undetermined. Prospective, observational study. Data is from the Resuscitation Outcomes Consortium Prehospital Resuscitation IMpedance threshold device and Early versus Delayed analysis clinical trial. Adults with out-of-hospital cardiac arrest treated by emergency medical service providers. None. Data were abstracted from monitor-defibrillator recordings for the first five minutes of emergency medical service cardiopulmonary resuscitation. Multiple logistic regression assessed odds ratio for survival by compression rate categories (<80, 80-99, 100-119, 120-139, ≥140), both unadjusted and adjusted for sex, age, witnessed status, attempted bystander cardiopulmonary resuscitation, location of arrest, chest compression fraction and depth, first rhythm, and study site. Compression rate data were available for 10,371 patients; 6,399 also had chest compression fraction and depth data. Age (mean ± SD) was 67 ± 16 years. Chest compression rate was 111 ± 19 per minute, compression fraction was 0.70 ± 0.17, and compression depth was 42 ± 12 mm. Circulation was restored in 34%; 9% survived to hospital discharge. After adjustment for covariates without chest compression depth and fraction (n = 10,371), a global test found no significant relationship between compression rate and survival (p = 0.19). However, after adjustment for covariates including chest compression depth and fraction (n = 6,399), the global test found a significant relationship between compression rate and survival (p = 0.02), with the reference group (100-119 compressions/min) having the greatest likelihood for survival. After adjustment for chest compression fraction and depth, compression rates between 100 and 120 per minute were associated with greatest survival to hospital discharge.
    Critical Care Medicine 01/2015; 43(4). DOI:10.1097/CCM.0000000000000824 · 6.15 Impact Factor
  • Ian G Stiell · Jeff S Healey · John A Cairns
    The Canadian journal of cardiology 12/2014; 31(3). DOI:10.1016/j.cjca.2014.11.027 · 3.94 Impact Factor

Publication Stats

17k Citations
2,859.37 Total Impact Points

Institutions

  • 1991–2015
    • University of Ottawa
      • • Department of Emergency Medicine
      • • Department of Epidemiology and Community Medicine
      Ottawa, Ontario, Canada
  • 1999–2014
    • Ottawa Hospital Research Institute
      • Clinical Epidemiology Program
      Ottawa, Ontario, Canada
    • North Shore Medical Center
      Salem, Massachusetts, United States
    • The University of Arizona
      Tucson, Arizona, United States
  • 1991–2013
    • The Ottawa Hospital
      • • Department of Emergency Medicine
      • • Department of Medicine
      Ottawa, Ontario, Canada
  • 2012
    • Orlando VA Medical Center
      Orlando, Florida, United States
  • 2010
    • Sultan Qaboos University
      Masqaţ, Muḩāfaz̧at Masqaţ, Oman
  • 1996–2010
    • University of Toronto
      • • Institute of Health Policy, Management and Evaluation
      • • Department of Medicine
      Toronto, Ontario, Canada
  • 2008
    • Government of Ontario, Canada
      XIA, Ontario, Canada
  • 2005
    • Queen's University
      • Department of Emergency Medicine
      Kingston, Ontario, Canada
    • McMaster University
      Hamilton, Ontario, Canada
  • 2004
    • University of North Carolina at Charlotte
      Charlotte, North Carolina, United States
  • 2000
    • Mount Sinai Medical Center
      New York, New York, United States
  • 1995–1999
    • University of British Columbia - Vancouver
      • Department of Emergency Medicine
      Vancouver, British Columbia, Canada