Introduction: To date, there has been minimal research on advance directives (ADs) among elderly patients in Canadian emergency departments (EDs). The purpose of this study was to determine the prevalence of ADs among elderly patients visiting an urban ED. We also explored whether there were factors associated with the existence of an AD and possible barriers to having one. Methods: This prospective study ran between October and December 2008. Individuals over the age of 70 who presented to the ED between 7 am and 7 pm, 7 days a week, were considered for enrolment. Exclusion criteria included previous enrolment and inability to provide informed consent. A team of nurses who specialize in assessment of geriatric patients administered a study instrument consisting of 28 questions. Topics included demographics, level of education, medical information, and knowledge of and attitudes toward ADs. Results: The results from 280 participants, with an average age of 80.6 years, were analyzed. Thirty-five percent of participants reported that they knew what an AD was; 19.3% of participants said they had an AD, but only 5.6% brought it to the hospital; 50.7% were interested in further information regarding ADs; and 67.9% of participants felt that it was important for physicians to know their wishes about life support. Conclusion: Knowledge of ADs among elderly patients visiting an urban Canadian ED is limited and is likely a significant factor precluding wider prevalence of ADs. There is interest in further discussion about ADs in this population group.

Cardiopulmonary resuscitation (CPR) is an inherently traumatic procedure. Successful resuscitations are often complicated by iatrogenic injuries to structures of the neck, thorax, or abdomen. Rib and sternal fractures are the most frequently induced injuries. However, rare and life-threatening trauma to vital organs such as the heart may also occur during CPR. We describe a novel case of CPR-associated right ventricular rupture in a woman with acute-on-chronic pulmonary embolism and no known pre-existing cardiac disease. We propose that chest compressions in the setting of elevated right ventricular pressure resulted in cardiac rupture, in this case. RÉSUMÉLa réanimation cardiorespiratoire (RCR) est en ellemême une manoeuvre traumatique. Les réanimations couronnées de succès se compliquent souvent de lésions iatrogènes aux structures du cou, du thorax ou de l'abdomen. Les fractures de côtes ou du sternum sont les lésions les plus fréquentes attribuables à la RCR. Toutefois, il peut arriver que des traumas extrêmement graves soient causés à des organes vitaux comme le coeur, mais le phénomène est rare. Sera exposé ici un nouveau cas de rupture du ventricule droit, associée à la RCR chez une femme ayant subi une embolie pulmonaire aiguë accompagnée de signes chroniques, mais ne souffrant pas d'une maladie cardiaque préexistante connue. Aussi sommes-nous d'avis que les compressions thoraciques effectuées dans le contexte d'une pression ventriculaire droite élevée se sont soldées par la rupture de la structure cardiaque.Keywords: autopsy, resuscitation, cardiac injury, iatrogenic, pulmonary embolism CASE REPORTA 79-year-old woman with osteoporosis, dyslipidemia, and 1 year of unexplained weight loss (less than 30 lb) was on her way to see her family physician. She had booked the appointment because she had been feeling generally unwell and fatigued for several weeks-her condition worsening in recent days. She collapsed in her residential driveway, and paramedics attended to her within 10 minutes. At the scene, she was pulseless with agonaltype respirations, and the paramedics initiated CPR. On arrival at the local emergency department, the patient had a Glasgow Coma Scale of 3 and vital signs were absent. In the hospital, the patient received continued standard resuscitative efforts, including chest compressions, four external cardiac defibrillation attempts, oxygen delivery via bag-valve-mask and boluses of epinephrine, calcium, and bicarbonate. Chest compressions resulted in rib fractures and an unusual swelling of the right neck. The patient never achieved return of spontaneous circulation, and the health care providers ceased resuscitation efforts after 25 minutes of standard total CPR protocol.A postmortem examination was requested to determine the cause of death. On opening the thorax, extensive blood was present throughout the soft tissues