The objective of this study was to evaluate the utility of circumferential casting in the emergency department (ED), orthopedic follow-up visits, and radiographic follow-up in the management of children with wrist buckle fractures.

We performed a retrospective medical record review of all children < 18 years of age who presented to our tertiary care children’s hospital between July 1, 2000, and June 30, 2001, and were diagnosed with a fracture of the wrist, radius or ulna. Based on the radiology reports, we identified buckle fractures of the distal radius, the distal ulna, or both bones. We excluded children who had other types of fractures.

We identified 840 children with fractures of the wrist, radius, or ulna. Of these, 309 met our inclusion criteria. The median age of our study cohort was 9.2 years. Emergency physicians immobilized 269 of these fractures in circumferential casts; of these, 30 (11%) had cast complications. Of the 276 subjects who had orthopedic follow-up visits and radiographs, 184 (67%) had multiple visits and 127 (46%) had multiple radiographs performed. No subjects had fracture displacement identified on follow-up.

Orthopedic follow-up visits and radiographic follow-up may have minimal utility in the treatment of pediatric wrist buckle fractures. ED casting may pose more risk than benefit for these children. Splinting in the ED with primary care follow-up appears to be a reasonable management strategy for these fractures. A prospective study comparing ED splinting and casting for pediatric wrist buckle fractures is needed.

Our objective was to determine the practice patterns of Canadian emergency physicians with respect to the management of traumatic corneal abrasions.

After developing our instrument and pilot testing it on a sample of emergency residents, we randomly surveyed 470 members of the Canadian Association of Emergency Physicians, using a modified Dillman technique. We distributed a pre-notification letter, an 18-item survey, and appropriate follow-up surveys to non-responders. Those members with an email address (n = 400) received a Web-based survey, and those without (n = 70) received a survey by post. The survey focused on the indications and utilization of analgesics (oral and topical), cycloplegics, eye patches and topical antibiotics.

Our response rate was 64% (301/470), and the median age of respondents was 38 years. Most (77.7%) were male, 71.8% were full-time emergency physicians, 76.5% were emergency medicine certified, and 64.4% practised in teaching hospitals. Pain management preferences (offered usually or always) included oral analgesics (82.1%), cycloplegics (65.1%) and topical nonsteroidal anti-inflammatory drugs (NSAIDs) (52.8%). Only 21.6% of respondents performed patching, and most (71.2%) prescribed topical antibiotics, particularly for contact lens wearers and patients with ocular foreign bodies. Two-thirds of the respondents provided tetanus toxoid if a foreign body was present, and 46.2% did so even if a foreign body was not present. Most respondents (88.0%) routinely arranged follow-up.

This national survey of emergency physicians demonstrates a lack of consensus on the management of traumatic corneal abrasions. Further study is indicated to determine the optimal treatment, particularly regarding the use of topical NSAIDs.

To determine whether focused abdominal sonogram for trauma (FAST) in a rural hospital provides information that prompts immediate transfer to a tertiary care facility for patients with blunt abdominal trauma who would otherwise be discharged or held for observation.

Prior to the study, participating emergency physicians underwent a minimum of 30 hours of ultrasound training. All patients who presented with blunt abdominal trauma to our rural hospital between Mar. 1, 2002, and Apr. 30, 2003, were eligible for study. Following a history and physical examination, the emergency physician documented his or her disposition decision. A FAST was then performed, and the disposition reconsidered in light of the FAST results.

Sixty-seven FAST exams were performed on 65 patients. Three examinations (4.5%) were true-positive (95% confidence interval [CI] 0.9%–12.5%); 60 (89.6%) were true-negative (95% CI 79.7%–95.7%), 4 (6%) were false-negative (95% CI 1.7%–14.6%) and none (0%) were false-positive (95% CI 0%–5.4%). These values reflect sensitivity, specificity, negative predictive value and positive predictive values of 43%, 100%, 94% and 100% respectively. FAST results did not alter the decision to transfer any patient (0%: 95% CI 0.0%–5.4%), although one positive FAST may have led to an expedited transfer. One of 38 patients who was discharged after a negative FAST study returned 24 hours later because of worsening symptoms, and was ultimately found to have splenic and pancreatic injuries.

This study failed to demonstrate that FAST improves disposition decisions for patients with blunt abdominal trauma who are evaluated in a hospital without advanced imaging or on-site surgical capability. However, the study is not sufficiently powered to rule out a role for FAST in these circumstances, and our data suggest that up to 5.4% of transfer decisions could be influenced by FAST. Rural emergency physicians should not allow a negative FAST study to override a clinical indication for transfer to a trauma centre; however, positive FAST studies can be used to accelerate transfer for definitive treatment.

Our objective was to document and compare the views obtained at laryngoscopy during emergency department (ED) rapid sequence intubation (RSI) by anesthetists and emergency physicians of varying seniority and experience.

Data were prospectively collected on every intubation attempt in 7 urban Scottish EDs for 2 calendar years, commencing Jan. 11, 1999. Data included patient’s age, gender, grade and specialty of intubator, laryngoscopic grade, and number of intubation attempts. Quality of laryngoscopic visualization was graded using the Cormack–Lehane scale, with grades I and II considered good visualization. A descriptive analysis was performed, and key statistical comparisons made.

During the study period, 735 patients underwent RSI, and grade of intubation was documented in 672 cases (91%). In total, 68.2%, 23.4%, 6.1% and 2.4% of the intubations were classified as Cormack–Lehane grade I, II, III and IV respectively. Overall, anesthetists and anesthesia trainees achieved good laryngoscopic visualization in 94.0% of cases (95% confidence interval [CI], 90.8%–96.4%) and emergency physicians and emergency medicine trainees did so in 89.2% of cases (95% CI, 85.5%–92.3%; p = 0.027). Specialist registrars and senior house officers in anesthesia were more likely to obtain good visualization than their emergency medicine counterparts (p = 0.034 and 0.035 respectively). Consultants in emergency medicine were more likely to obtain good views than their anesthesia counterparts, but this difference was not statistically significant.

Anesthetic trainees obtain better laryngoscopic views than emergency medicine trainees, but these differences disappear with increasing emergency physician seniority, suggesting a training and experience effect. Emergency medicine trainees may benefit from additional focus on laryngoscopic visualization techniques early in their training period.

There are few reports in the medical literature describing removal of a coin from the upper esophageal tract of a child by an emergency physician. However, given the nature of their training and practice, emergency physicians are well suited to perform this common procedure. We describe our experience with this procedure.

This was a retrospective review of a continuous quality improvement data set from a university-based tertiary care pediatric emergency department between Nov. 1, 2003, and Mar. 31, 2004.

Thirteen children, with a median age of 20 months, underwent rapid sequence intubation and had coins successfully removed from their upper esophageal tract by emergency physicians. In 10 cases, the coin was visible at laryngoscopy and removed with Magill forceps. In 3 cases this approach failed and a Foley catheter was used to remove the coin. One child suffered a tonsillar abrasion and two sustained minor lip trauma, but all were extubated and discharged home from the emergency department with no significant complications. Eleven of the 13 patients were successfully followed up, and the parents reported no problems.

This pilot study suggests that the removal of a coin from the upper esophageal tract by an emergency physician can be both safe and effective. A larger study is needed before this procedure can be generally recommended.