A prospective study of pain control in the emergency department

The most common complaint in the emergency department is pain. The management of acute pain, however, has not been well studied. This prospective study was designed to assess pain intensity and relief along with satisfaction in the emergency department. Adult patients with a primary complaint of acute pain were asked to complete a two-part questionnaire administered by a research assistant. The first part was completed on arrival and the second part on discharge from the emergency department. The respondents were not permitted to see the first part of the questionnaire while completing the second. The questionnaire used an unmarked, horizontal 10-cm visual analog scale along with short answer questions to measure pain, relief, and satisfaction. Choice of drug therapy was decided by the physician according to usual treatment methods. Fifty-seven people presented with the chief complaint of pain. Of those, 30 (53%) were treated with medications. The mean level of pain on admission for treated patients was 6.64 compared with a mean level of pain on discharge of 4.02 (P =.0001). Untreated patients had a mean admission visual analog scale score of 4.19. Compared with treated patients, this difference was statistically significant (P =.001). A mean visual analog scale score of 5.43, representing the mean amount of pain relief, was reported among treated patients. Treated patients also reported a visual analog scale score of 6.46 in overall satisfaction with pain management. The results of this study indicate that there is a significant and clinical difference in levels of pain and satisfaction between admission and discharge in these patients in the emergency department.     

Gestalt for shock and mortality in the emergency department: A prospective study

Objective

The diagnosis of shock in patients presenting to the emergency department (ED) is often challenging. We aimed to compare the accuracy of experienced emergency physician gestalt against Li's pragmatic shock (LiPS) tool for predicting the likelihood of shock in the emergency department, using 30-day mortality as an objective standard.

Ultrasonic guidance and the complications of central line placement in the emergency department

Report by Joel Dunning, RCS Research Fellow
Checked by James Williamson, Clinical Fellow     

Medication-related visits to the emergency department: a prospective study

OBJECTIVE: To assess the prevalence, preventability, category, and severity of drug-related problems; medications involved; common causes of preventable medication-related visits (MRVs); and cost of MRVs. METHODS: In this prospective, observational study of emergency department visits, patients were identified as having MRVs by use of a questionnaire. The patients or their representatives were interviewed to assess whether the emergency department visit was caused by a medication-related problem. Patient selection was consecutive. A blinded panel of pharmacists and one physician was used to assess study objectives. RESULtS: Of the 253 patients interviewed, 71 patients (28.1%) presenting to the emergency department had a medication-related reason for their visits. Of the 71 MRVs, 50 (70.4%) were judged to be preventable and 21 (29.6%) nonpreventable. The data showed that MRVs are most often caused by an adverse drug reaction, followed by overprescribing of the correct medication. The severity of MRVs was most often classified as moderate. The most common medications involved were cardiovascular agents. The preventable MRVs were mostly due to noncompliance issues, inappropriate prescribing, inappropriate monitoring, and lack of patient education. The average cost to the institution was approximately $1444 per preventable MRV. CONCLUSIONS: In our study, the prevalence of MRVs was higher than in previous studies due to the prospective nature of the study and the assistance of drug experts in identifying and classifying the incidents. Areas identified for improvement included compliance issues with patients, education of healthcare workers regarding prescribing and monitoring of medications, and patient education.     

Comparison of two intraosseous access devices in adult patients under resuscitation in the emergency department: A prospective, randomized study

Introduction

Current guidelines recommend intraosseous (IO) vascular access in adults if peripheral venous access is unavailable. Most available data derive from children, animal models, cadaver studies or the prehospital setting. Therefore we compared two different IO access devices in adults under resuscitation in the hospital setting.

Patients and methods

This prospective, randomized clinical study compared two different IO access devices in adults (≥18 years of age) under trauma or medical resuscitation admitted to our emergency department with impossible peripheral venous access. Each adult was randomized to either spring-loaded BIG Bone Injection Gun or battery-powered EZ-IO. Outcome measures included success rates on first attempt, procedure times and complications.

Results

Forty consecutive adults under resuscitation were enrolled. Twenty patients received the BIG, another twenty patients the EZ-IO. Over all success rate on first attempt was 85% and mean procedure time 2.0 min ± 0.9. Comparing the two devices, success rate on first attempt was 80% for the BIG versus 90% for the EZ-IO and mean procedure time was 2.2 min ± 1.0 for the BIG versus 1.8 min ± 0.9 for the EZ-IO. The differences between both IO devices were not statistically significant. No other relevant complications like infection, extravasation or bleeding were observed.

Conclusions

IO vascular access was a reliable and safe method to gain rapid vascular access for in-hospital adult emergency patients under resuscitation. Further studies are necessary regarding comparative effectiveness of different IO devices.     

Stress levels during emergency care: A comparison between reality and simulated scenarios

PurposeMedical simulation is fast becoming a standard of health care training throughout undergraduate, postgraduate and continuing medical education. Our aim was to evaluate if simulated scenarios have a high psychological fidelity and induce stress levels similarly to real emergency medical situations.Materials and MethodsMedical residents had their stress levels measured during emergency care (real-life and simulation) in baseline (T1) and immediately post-emergencies (T2). Parameters measuring acute stress were: heart rate, systolic and diastolic blood pressure, salivary α-amylase, salivary interleukin-1β, and State-Trait Anxiety Inventory score.ResultsTwenty-eight internal medicine residents participated in 32 emergency situations (16 real-life and 16 simulated emergencies). In the real-life group, all parameters increased significantly (P < .05) between T1 and T2. In the simulation group, only heart rate and interleukin-1β increased significantly after emergencies. The comparison between groups demonstrates that acute stress response (T2 – T1) and State-Trait Anxiety Inventory score (in T2) did not differ between groups.ConclusionsAcute stress response did not differ between both groups. Our results indicate that emergency medicine simulation may create a high psychological fidelity environment similarly to what is observed in a real emergency room.     

The effectiveness of intradermal sterile water injection for low back pain in the emergency department: A prospective,randomized controlled study

AimLow back pain (LBP) is a common musculoskeletal complaint among emergency department (ED) admissions. In this study, it was aimed to compare the effectiveness of systemic treatment with intradermal sterile water injection (ISWI) treatment protocol combined with systemic therapy in patients with LBP of unclear chronicity.MethodsA prospective randomized, unblinded, controlled clinical study was conducted on patients admitted to the ED for LBP of unclear chronicity. One hundred twelve patients were randomly assigned to two groups; Group ISWI (n = 56) administered ISWI in the LBP region of patients along with systemic intravenous dexketoprofen therapy, while the other group (n = 56) received only systemic intravenous dexketoprofen therapy. The treatment methods' effectiveness was compared by measuring the pain intensity with the Visual Analog Scale (VAS) at admission, 10th minutes, 20th minutes, 30th minutes, and 24 h later. Also, opioid and analgesic consumptions in 24 h after treatment and patient satisfactions were compared.ResultsIn the treatment of LBP, ISWI treatment was found to be more effective in relieving pain than systemic therapy alone (p < 0.001). Also, it was observed that opioid consumption in the ED and analgesic consumption within 24 h after treatments were decreased in the ISWI group (p < 0.001). The patient satisfaction in the ED was statistically increased (p < 0.001).DiscussionIn this unblinded study, ISWI with systemic therapy improved pain outcomes more than systemic therapy alone. Further research is needed to determine whether this was due entirely to placebo effect.     

The blizzard of 1996: A pediatric emergency department

Objective. To determine the effect of the blizzard of 1996 on the utilization of a pediatric emergency department (ED). Methods. The study consisted of a retrospective analysis of ED visits prior to, during, and after the storm using a computerized ED log, ED medical records, and Surface Weather Observations. The setting was a suburban academic pediatric center in the mid-Atlantic region. Participants included all patients who visited the ED during the 36-hour storm period, the 72 hours before the storm, and the 72 hours after the storm. Number of visits, age, mode of arrival, triage acuity level, admission rate, and the ten most common discharge diagnoses for each time period were gleaned from medical records. Results. The ED census rose 35% above baseline during the 24 hours before the storm. During the 36-hour storm period, the census dropped to 15% of the census prior to the storm. Mode of arrival, age, triage acuity level, admission rate, and the ten most common discharge diagnoses for children seen in the ED during the storm period were not significantly different from those for children seen during the 36 hours before the storm. During the 72 hours after the storm (test period), the census was 40% less than that during the control period (72 hours before the storm). By the fourth day, the census had returned to normal. During the test period, there was a significant increase in the triage acuity level of patients. The percentage of children triaged as urgent, emergent, or critical was 29%, compared with 15% triaged in those categories during the control period (p < 0.05). Also, the overall admission rate increased from 8% during the control period to 22% during the test period (p < 0.01). Conclusions. Among other effects, a significant increase in severity of presentations to a pediatric ED following a severe storm can be observed.     

Characterizing pediatric emergency department visits during the COVID-19 pandemic

ObjectiveWe determine how pediatric emergency department (ED) visits changed during the COVID-19 pandemic in a large sample of U.S. EDs.MethodsUsing retrospective data from January–June 2020, compared to a similar 2019 period, we calculated weekly 2020–2019 ratios of Non-COVID-19 ED visits for adults and children (age 18 years or less) by age range. Outcomes were pediatric ED visit rates before and after the onset of pandemic, by age, disposition, and diagnosis.ResultsWe included data from 2,213,828 visits to 144 EDs and 4 urgent care centers in 18 U.S. states, including 7 EDs in children's hospitals. During the pandemic period, adult non-COVID-19 visits declined to 60% of 2019 volumes and then partially recovered but remained below 2019 levels through June 2020. Pediatric visits declined even more sharply, with peak declines through the week of April 15 of 74% for children age < 10 years and 67% for 14–17 year. Visits recovered by June to 72% for children age 14–17, but to only 50% of 2019 levels for children < age 10 years. Declines were seen across all ED types and locations, and across all diagnoses, with an especially sharp decline in non-COVID-19 communicable diseases. During the pandemic period, there was 22% decline in common serious pediatric conditions, including appendicitis.ConclusionPediatric ED visits fell more sharply than adult ED visits during the COVID-19 pandemic, and remained depressed through June 2020, especially for younger children. Declines were also seen for serious conditions, suggesting that parents may have avoided necessary care for their children.     

End-tidal capnometry during emergency department procedural sedation and analgesia: a randomized,controlled study

BACKGROUND: This prospective, randomized trial was undertaken to evaluate the utility of adding end-tidal capnometry (ETC) to pulse oximetry (PO) in patients undergoing procedural sedation and analgesia (PSA) in the emergency department (ED). METHODS: The patients were randomized to monitoring with or without ETC in addition to the current standard of care. Primary endpoints included respiratory adverse events, with secondary endpoints of level of sedation, hypotension, other PSA-related adverse events and patient satisfaction.RESULTS: Of 986 patients, 501 were randomized to usual care and 485 to additional ETC monitoring. In this series, 48% of the patients were female, with a mean age of 46 years. Orthopedic manipulations (71%), cardioversion (12%) and abscess incision and drainage (12%) were the most common procedures, and propofol and fentanyl were the sedative/analgesic combination used for most patients. There was no difference in patients experiencing de-saturation (SaO₂<90%) between the two groups; however, patients in the ETC group were more likely to require airway repositioning (12.9% vs. 9.3%, P=0.003). Hypotension (SBP<100 mmHg or <85 mmHg if baseline <100 mmHg) was observed in 16 (3.3%) patients in the ETC group and 7 (1.4%) in the control group (P=0.048).CONCLUSIONS: The addition of ETC does not appear to change any clinically significant outcomes. We found an increased incidence of the use of airway repositioning maneuvers and hypotension in cases where ETC was used. We do not believe that ETC should be recommended as a standard of care for the monitoring of patients undergoing PSA.     

The predictors of perforated appendicitis in the pediatric emergency department: A retrospective observational cohort study

ObjectiveAppendiceal perforation has significant effects on perioperative morbidity and postoperative outcome. The present study aimed to identify possible predictive factors associated with perforated appendicitis (PA) in children at admission in the emergency department (ED).MethodsIn this retrospective observational cohort study, consecutive medical records of children <18 years old with surgically and histopathologically confirmed acute appendicitis (AA) over three years (2013–2015) were analyzed. Patients were divided into two groups: PA and non-perforated appendicitis (NPA). The differences between the two groups and potential predictors of PA were explored using univariate and multivariate analyses.ResultsDuring the study period, 295 patients underwent an appendectomy and had confirmatory AA diagnoses. Ninety-two patients had a PA (31.2%). In the univariate analysis, male gender, vomiting, diarrhea, fever, elevated white blood cell count (WBC) levels, and high C-reactive protein (CRP) were identified as predictors of PA. In the multivariate analysis, male gender (odds ratio [OR]: 3.133; 95% confidence interval [CI]: 1.610–6.096); vomiting (OR: 2.346; 95% CI: 1.141–4.822); diarrhea (OR: 4.549; 95% CI: 1.850–11.181); fever (OR: 3.429; 95% CI: 1.765–6.663); elevated WBC (OR: 2.962; 95% CI: 1.491–5.884) and elevated CRP (OR: 3.061; 95% CI: 1.267–7.396) were variables that predicted the PA in children.ConclusionOur data indicate that several clinical and biochemical parameters can reliably distinguish between pediatric PA and NPA at admission in the emergency department.     

Early prediction of pediatric acute kidney injury from the emergency department: A pilot study

BackgroundIdentifying acute kidney injury (AKI) early can inform medical decisions key to mitigation of injury. An AKI risk stratification tool, the renal angina index (RAI), has proven better than creatinine changes alone at predicting AKI in critically ill children.ObjectiveTo derive and test performance of an “acute” RAI (aRAI) in the Emergency Department (ED) for prediction of inpatient AKI and to evaluate the added yield of urinary AKI biomarkers.MethodsStudy of pediatric ED patients with sepsis admitted and followed for 72 h. The primary outcome was inpatient AKI defined by a creatinine >1.5× baseline, 24–72 h after admission. Patients were denoted renal angina positive (RA+) for an aRAI score above a population derived cut-off. Test characteristics evaluated predictive performance of the aRAI compared to changes in creatinine and incorporation of 4 urinary biomarkers in the context of renal angina were assessed.Results118 eligible subjects were enrolled. Mean age was 7.8 ± 6.4 years, 16% required intensive care admission. In the ED, 27% had a +RAI (22% had a >50% creatinine increase). The aRAI had an AUC of 0.92 (0.86–0.98) for prediction of inpatient AKI. For AKI prediction, RA+ demonstrated a sensitivity of 94% (69–99) and a negative predictive value of 99% (92–100) (versus sensitivity 59% (33–82) and NPV 93% (89–96) for creatinine ≥2× baseline). Biomarker analysis revealed a higher AUC for aRAI alone than any individual biomarker.ConclusionsThis pilot study finds the aRAI to be a sensitive ED-based tool for ruling out the development of in-hospital AKI.     

Nebulized fentanyl versus intravenous morphine in children with suspected limb fractures in the emergency department: A randomized controlled trial

Objective: To compare the efficacy of nebulized fentanyl (NF) with i.v. morphine (IVM) in paediatric patients presenting to the ED with clinically suspected limb fractures. Methods: A convenience sample of patients aged 4–13 years, presenting with clinically suspected limb fractures, were randomized to receive either NF at 4 µg/kg or IVM at 0.1 mg/kg. Pain scores were assessed at 0, 15 and 30 min using the Wong and Baker faces pain scale (0–10). Vital signs and adverse effects were also recorded. Results: Of the 77 patients enrolled in the study, data were available for analysis on 73 patients. Of those, 36 received NF and 37 received IVM. The two groups were similar in terms of demographics and initial pain scores. Mean pain score at 15 min was decreased by 3.06 (NF) and by 1.97 (IVM) (difference 1.09; 95% CI 2.32 to ?0.32). At 30 min the decreases were 3.6 (NF) and 3.0 (IVM), respectively (difference 0.6; 95% CI 1.89 to ?0.65). Decreases in pain scores for both NF and IVM were statistically significant (P < 0.0001), but the difference in the effect of NF and IVM did not reach statistical significance. There was no significant change in any vital signs or serious adverse events in either group. Conclusion: NF in a dose of 4 µg/kg given via a standard nebulizer provided clinically significant improvements in pain scores, comparable to IVM. NF should be considered as a treatment option for use in children presenting in acute pain.