John M. Tallon
Dalhousie University
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Journal of Neurotrauma | 2011
HyoChol Ahn; Jagbir Singh; Avery B. Nathens; Russell D. MacDonald; Andrew H. Travers; John M. Tallon; Michael G. Fehlings; Albert Yee
An interdisciplinary expert panel of medical and surgical specialists involved in the management of patients with potential spinal cord injuries (SCI) was assembled. Four key questions were created that were of significant interest. These were: (1) what is the optimal type and duration of pre-hospital spinal immobilization in patients with acute SCI?; (2) during airway manipulation in the pre-hospital setting, what is the ideal method of spinal immobilization?; (3) what is the impact of pre-hospital transport time to definitive care on the outcomes of patients with acute spinal cord injury?; and (4) what is the role of pre-hospital care providers in cervical spine clearance and immobilization? A systematic review utilizing multiple databases was performed to determine the current evidence about the specific questions, and each article was independently reviewed and assessed by two reviewers based on inclusion and exclusion criteria. Guidelines were then created related to the questions by a national Canadian expert panel using the Delphi method for reviewing the evidence-based guidelines about each question. Recommendations about the key questions included: the pre-hospital immobilization of patients using a cervical collar, head immobilization, and a spinal board; utilization of padded boards or inflatable bean bag boards to reduce pressure; transfer of patients off of spine boards as soon as feasible, including transfer of patients off spinal boards while awaiting transfer from one hospital institution to another hospital center for definitive care; inclusion of manual in-line cervical spine traction for airway management in patients requiring intubation in the pre-hospital setting; transport of patients with acute traumatic SCI to the definitive hospital center for care within 24 h of injury; and training of emergency medical personnel in the pre-hospital setting to apply criteria to clear patients of cervical spinal injuries, and immobilize patients suspected of having cervical spinal injury.
Canadian Journal of Anaesthesia-journal Canadien D Anesthesie | 2004
George Kovacs; J. Adam Law; John Ross; John M. Tallon; Kirk MacQuarrie; Dave Petrie; Sam Campbell; Chris Soder
PurposeThe responsibility of acute airway management often falls into the hands of non-anesthesiologists. Emergency physicians now routinely use neuromuscular blockade to facilitate intubation. The literature in support of this practice has almost exclusively been published in emergency medicine (EM) journals. This body of literature is presented and issues of educational support are discussed.SourceA narrative review of the literature on the practice of airway management by non-anesthesiologists.Principal findingsA significant proportion of acute airway management occurring outside the operating room is being performed by non-anesthesiologists. Rapid sequence intubation (RSI) is recognized as a core procedure within the domain of EM. RSI is being performed routinely by emergency physicians practicing in larger centres. Anesthesiologist support for the practice of RSI by non-anesthesiologists has been weak. Formal educational support outside of postgraduate training in the form of dedicated programs for advanced airway management are now being offered. The majority of the literature on the use of RSI by non-anesthesiologists represents retrospective case series, observational studies and registry data published in EM journals. The reported success rates for RSI performed by non-anesthesiologists is high. Complication rates are significant, however reporting consistency has been poor.ConclusionsThe role of non-anesthesiologists in acute airway management is significant. Despite shortcomings in methodology, current evidence and practice supports the use of RSI by trained emergency physicians. Constructive collaborative efforts between anesthesiology and EM need to occur to ensure that educational needs are met and that competent airway management is provided.RésuméObjectifLa responsabilité de l’assistance respiratoire d’urgence revient souvent à des médecins non-anesthésiologistes. Les urgentistes utilisent maintenant de routine le bloc neuromusculaire pour faciliter l’intubation. La documentation à l’appui de cette pratique a été publiée presque exclusivement dans les journaux de médecine d’urgence (MU). Nous présentons l’ensemble de ces documents et exposons les questions de formation.SourceUne revue traditionnelle de la documentation sur la pratique de l’assistance respiratoire par des non-anesthésiologistes.Constatations principalesUne proportion significative de l’assistance respiratoire d’urgence, réalisée à l’extérieur de la salle d’opération, relève de non-anesthésiologistes. L’intubation en séquence rapide (ISR) est reconnue comme une intervention centrale dans le domaine de la MU. L’ISR est généralement réalisée par des urgentistes dans les grands centres. Le soutien anesthésiologique pour la pratique de l’ISR par des non-anesthésiologistes est plutôt faible. Un soutien éducatif formel en dehors de la formation de spécialiste, par des programmes dédiés à l’assistance respiratoires avancée, est maintenant offert. La majorité des publications sur l’usage de l’ISR par des non-anesthésiologistes consiste en séries rétrospectives, études par observation et enregistrement de données publiées dans des journaux de MU. Les taux de succès rapportés pour l’ISR réalisée par des non-anesthésiologistes y sont élevés. Les taux de complications sont significatifs, quoique la cohérence des rapports laisse à désirer.ConclusionLe rôle des non-anesthésiologistes dans l’assistance respiratoire immédiate est significatif. Malgré des défauts de méthodologie, les preuves actuelles et la pratique appuient l’usage de l’ISR par des urgentistes formés. Des efforts de collaboration constructive entre l’anesthésiologie et la MU sont nécessaires pour répondre aux besoins éducationnels et assurer la compétence en assistance respiratoire.
Prehospital Emergency Care | 2010
Jennifer McVey; David Petrie; John M. Tallon
Abstract Objectives. 1) To compare the outcomes of adult trauma patients transported to a level I trauma center by helicopter vs. ground ambulance. 2) To determine whether using a unique “natural experiment” design to obtain the ground comparison group will reduce potential confounders. Methods. Outcomes in adult trauma patients transported to a tertiary care trauma center by air were compared with outcomes in a group of patients who were accepted by the online medical control physician for air transport, but whose air missions were aborted for aviation reasons (weather, maintenance, out on a mission); these patients were subsequently transported by ground ambulance instead. Outcomes were also analyzed for a third ground control group composed of all other adult trauma patients transported by ground during this time period. Data were collected by retrospective database review of trauma patients transferred between July 1, 1997, and June 30, 2003. Outcomes were measured by Trauma Injury Severity Score (TRISS) analysis. Z and W scores were calculated. Results. Three hundred ninety-seven missions were flown by LifeFlight during the study period vs. 57 in the clinical accept–aviation abort ground transport group. The mean ages, gender distributions, mechanisms of injury, and Injury Severity Scores (ISSs) were similar in the two groups. Per 100 patients transported, 5.61 more lives were saved in the air group vs. the clinical accept–aviation abort ground transport group (Z = 3.37). As per TRISS analysis, this is relative to the expected mortality seen with a similar group in the Major Trauma Outcomes Study (MTOS). The Z score for the clinical accept–aviation abort ground transport group was 0.4. The 1,195 patients in the third all-other ground control group had a higher mean age, lower mean ISS, and worse outcomes according to TRISS analysis (W = –2.02). Conclusions. This unique natural experiment led to better matched air vs. ground cohorts for comparison. As per TRISS analysis, air transport of the adult major trauma patient is associated with significantly improved survival as compared with ground transport.
Injury-international Journal of The Care of The Injured | 2009
Heather Wilson; James Ellsmere; John M. Tallon; Andrew W. Kirkpatrick
BACKGROUND The term occult pneumothorax (OP) describes a pneumothorax that is not suspected on the basis of either clinical examination or initial chest radiography, but is subsequently detected on computed tomography (CT) scan. The optimal management of OP in the blunt trauma setting remains controversial. Some physicians favour placement of a thoracostomy tube for patients with OP, particularly those undergoing positive pressure ventilation (PPV), while others favour close observation without chest drainage. This study was conducted both to determine the incidence of OP and to describe its current treatment status in the blunt trauma population at a Canadian tertiary trauma centre. Of interest were the rates of tube thoracostomy vs. observation without chest drainage and their respective outcomes. METHODS A retrospective review was conducted of the Nova Scotia Trauma Registry. The data on all consecutive blunt trauma patients between October 1994 and March 2003 was reviewed. Outcome measures evaluated include length of stay, discharge status-dead vs. alive, intervention and time to intervention (tube thoracostomy and its relation to institution of PPV). Direct comparison was made between the OP with tube thoracostomy group and OP without tube thoracostomy group (observation or control group). They were compared in terms of their baseline characteristics and outcome measures. RESULTS In 1881 consecutive blunt trauma patients over a 102-month period there were 307 pneumothoraces of which 68 were occult. Thirty five patients with OP underwent tube thoracostomy, 33 did not. Twenty nine (82.8%) with tube thoracostomy received positive pressure ventilation (PPV), as did 16 (48.4%) in the observation group. Mean injury severity score (ISS) for tube thoracostomy and observation groups were similar (25.80 and 22.39, p=0.101) whereas length of stay (LOS) was different (17.4 and 10.0 days, p=0.026). Mortality was similar (11.4% and 9.1%). There were no tension pneumothoraces. CONCLUSION The natural history of OP in blunt trauma patients at our institution appears to be one of uneventful resolution irrespective of ISS, need for PPV, or placement of tube thoracostomy. This study suggests an interesting hypothesis that observation of the blunt trauma patient with OP, without tube thoracostomy, may be safe and contribute to a shorter hospital stay. These are observations that would benefit from further study in a large, prospective randomised controlled trial.
Canadian Journal of Emergency Medicine | 2006
Sam Campbell; Kirk Magee; George Kovacs; David Petrie; John M. Tallon; Robert McKinley; David G. Urquhart; Linda Hutchins
OBJECTIVES To examine the safety of emergency department (ED) procedural sedation and analgesia (PSA) and the patterns of use of pharmacologic agents at a Canadian adult teaching hospital. METHODS Retrospective analysis of the PSA records of 979 patients, treated between Aug. 1, 2004, and July 31, 2005, with descriptive statistical analysis. This represents an inclusive consecutive case series of all PSAs performed during the study period. RESULTS Hypotension (systolic blood pressure < or = 85 mm Hg) was documented during PSA in 13 of 979 patients (1.3%; 95% confidence interval [CI] 0.3%-2.3%), and desaturation (SaO2 < or = 90) in 14 of 979 (1.4%; Cl 0.1%-2.7%). No cases of aspiration, endotracheal intubation or death were recorded. The most common medication used was fentanyl (94.0% of cases), followed by propofol (61.2%), midazolam (42.5%) and then ketamine (2.7%). The most frequently used 2-medication combinations were propofol and fentanyl (P/F) followed by midazolam and fentanyl (M/F), used with similar frequencies 58.1% (569/979) and 41.0% (401/979) respectively. There was no significant difference in the incidence of hypotension or desaturation between the P/F and M/F treated groups. In these patients, 9.1% (90/979) of patients received more than 2 different drugs. CONCLUSIONS Adverse events during ED PSA are rare and of doubtful clinical significance. Propofol/fentanyl and midazolam/fentanyl are used safely, and at similar frequencies for ED PSA in this tertiary hospital case series. The use of ketamine for adult PSA is unusual in our facility.
Annals of Surgery | 2014
Maria Santana; Henry T. Stelfox; Mark Asbridge; Chad G. Ball; Peter Cameron; Dianne Dyer; Claire Marie Fortin; Louis Hugo Francescutti; Kenneth M. Jaffe; Andrew W. Kirkpatrick; Karen S. Kmetik; John B. Kortbeek; Lynne Moore; Avery B. Nathens; Tom Noseworthy; Nicolas Phan; Frederick P. Rivara; Bryan Singleton; Sharon E. Straus; Marc F. Swiontkowski; John M. Tallon; Andrew H. Travers; David Zygun
Objective:To develop and evaluate evidence-informed quality indicators of adult injury care. Background:Injury is a leading cause of morbidity and mortality, but there is a lack of consensus regarding how to evaluate injury care. Methods:Using a modification of the RAND/UCLA Appropriateness Methodology, a panel of 19 injury and quality of care experts serially rated and revised quality indicators identified from a systematic review of the literature and international audit of trauma center quality improvement practices. The quality indicators developed by the panel were sent to 133 verified trauma centers in the United States, Canada, Australia, and New Zealand for evaluation. Results:A total of 84 quality indicators were rated and revised by the expert panel over 4 rounds of review producing 31 quality indicators of structure (n = 5), process (n = 21), and outcome (n = 5), designed to assess the safety (n = 8), effectiveness (n = 17), efficiency (n = 6), timeliness (n = 16), equity (n = 2), and patient-centeredness (n = 1) of injury care spanning prehospital (n = 8), hospital (n = 19), and posthospital (n = 2) care and secondary injury prevention (n = 1). A total of 101 trauma centers (76% response rate) rated the indicators (1 = strong disagreement, 9 = strong agreement) as targeting important health improvements (median score 9, interquartile range [IQR] 8–9), easy to interpret (median score 8, IQR 8–9), easy to implement (median score 8, IQR 7–8), and globally good indicators (median score 8, IQR 8–9). Conclusions:Thirty-one evidence-informed quality indicators of adult injury care were developed, shown to have content validity, and can be used as performance measures to guide injury care quality improvement practices.
Journal of Emergency Medicine | 1998
John D. Rizos; Bruno E. DiGravio; Michael J. Sehl; John M. Tallon
This prospective cohort study evaluated the effectiveness and safety of a selective discharge policy for patients treated with racemic epinephrine (RE) and intramuscular (IM) dexamethasone (DEX) in the emergency department (ED). Children younger than 13 years of age presenting to the ED with croup who were treated with RE and IM DEX and discharged home were enrolled in the study. Patients were discharged home if they were free of intercostal retractions and stridor at rest, following a 2 h observation period. Telephone follow up determined whether further medical attention for croup was required within 48 h of discharge from the ED. Eighty-two patients were enrolled in the study over a one year period. Six of these patients (7%) required follow up for croup within 48 h of discharge and 2 (2%) required admission. We conclude that a subset of patients with croup treated with RE and IM DEX in the ED can be safely discharged home.
Canadian Journal of Emergency Medicine | 2002
Aaron K. Sibley; John M. Tallon
BACKGROUND Riding all-terrain vehicles (ATVs) is a popular recreational activity, with approximately 1.5 million users in Canada. Despite legislation aimed at reducing injury rates, ATV-related incidents remain a major cause of trauma and death. This paper reviews the epidemiology of major injury associated with ATV use in Nova Scotia. METHODS The Nova Scotia Trauma Registry was used to identify all adults over age 15 who sustained major ATV-related trauma (Injury Severity Score [ISS] >/=12) within a 5-year period. Demographic variables, temporal statistics, alcohol use, helmet use, injury characteristics and injury outcome variables, including ISS, length of stay (LOS), Glasgow Coma Scale score and discharge status were evaluated. RESULTS Twenty-five patients met the inclusion criteria. Most (92%) were males, and 64% were between 16 and 34 years of age. Most injuries occurred between 1300 hrs and 1900 hrs, 52% occurred on the weekend, and 40% occurred in the spring. The average ISS was 22.1, and injuries to the central nervous system comprised 39% of all major injuries. Alcohol was involved in up to 56% of all incidents, and only 4 patients (16%) were known to be wearing a helmet at the time of injury. Average hospital LOS was 21.6 days. INTERPRETATION ATV-related incidents are a continuing source of major injury. This paper describes the epidemiology of ATV-related major trauma presenting to the sole tertiary care referral centre in one province. Information gained from this study should be used to influence ATV public education programs.
CJEM | 2010
Jan L. Jensen; Ka Wai Cheung; John M. Tallon; Andrew H. Travers
This systematic review included controlled clinical trials comparing tracheal intubation (TI) with alternative airway techniques (AAT) (bag mask ventilation and use of extraglottic devices) performed by paramedics in the prehospital setting. A priori outcomes to be assessed were survival, neurologic outcome, airway management success rates and complications. We identified trials using EMBASE, MEDLINE, CINAHL, The Cochrane Library, Web of Science, author contacts and hand searching. We included 5 trials enrolling a total of 1559 patients. No individual study showed any statistical difference in outcomes between the TI and AAT groups. Because of study heterogeneity, we did not pool the data. This is the most comprehensive review to date on paramedic trials. Owing to the heterogeneity of prehospital systems, administrators of each system must individually consider their airway management protocols.
Preventive Medicine | 2014
Mark Asbridge; Robert Mann; Michael D. Cusimano; John M. Tallon; Chris Pauley; Jürgen Rehm
OBJECTIVE To examine whether alcohol and cannabis consumption increase crash risk among non-fatally injured bicyclists (N=393) seen in three Canadian emergency departments, between April 2009 and July 2011. METHOD Employing a case-crossover design, cannabis and alcohol were identified through blood sample or by self-report. All cyclists involved in a crash and exposure status (cannabis and alcohol) were compared between case period (current crash) and two control periods: prior to the last time the victim cycled around the same time of day; and the typical use prior to bicycling. Crash risk was assessed through conditional fixed effects logistic regression models. RESULTS Approximately 15% of cyclists reported using cannabis just prior to the crash, and 14.5% reported using alcohol. Cannabis use identified by blood testing or self-report in the case period and by self-report in the control period yielded a crash risk of 2.38 (1.04-5.43); however, when self-report was used for both the case and control periods the estimate was 0.40 (0.12-1.27). Alcohol use, as measure either in blood or self-report, was associated with an odds ratio of 4.00 (95% CI: 1.64-9.78); results were similar when alcohol was measured by self-report only. CONCLUSION Cannabis and alcohol use each appear to increase the risk of a non-fatal injury-related crash among bicyclists, and point to the need for improved efforts to deter substance use prior to cycling, with the help of regulation, increased education, and greater public awareness. However, cannabis results should be interpreted with caution, as the observed association with crash risk was contingent on how consumption was measured.