The Effect of a Cartoon and an Information Video About Intravenous Insertion on Pain and Fear in Children Aged 6 to 12 Years in the Pediatric Emergency Unit: A Randomized Controlled Trial

IntroductionIntravenous insertion is the most common invasive procedure made for administering intravascular fluid and medicine. Peripheral venous catheterization may cause pain, fear, and stress in children. This study aimed to compare the effects of watching a cartoon and an information video about intravenous insertion on the pain and fear levels of children aged 6-12 years.MethodsThe study was an experimental, randomized controlled clinical trial. It was conducted with 477 children aged 6-12 years randomized into 3 groups: the informative animated video group, the cartoon group, and the control group. Fear and pain perception were evaluated on the basis of the feedback from the child, observer nurse, and parents. The Children’s Fear Scale was used to evaluate the fear level and the Wong-Baker FACES Scale was used to assess pain levels. Data were analyzed using one-way analysis of variance, the chi-square test, and the intraclass correlation coefficient test.ResultsThe children who watched the information video before the intravenous insertion procedure and those who watched a cartoon during the procedure had lower mean pain and fear scores as evaluated by the child (pain: F = 278.67, P = 0.001; fear: F = 294.88, P = 0.001), parent (pain: F = 279.53, P = 0.001; fear: F = 294.47, P = 0.001), and nurse (pain: F = 286.88, P = 0.001; fear: F = 300.81, P = 0.001) than children in the control group.DiscussionThis study showed that watching an animation video or a cartoon was effective in lowering children’s perceived level of pain and fear during an intravenous insertion intervention.     

The Effect of Virtual Reality and Buzzy on First Insertion Success,Procedure-Related Fear,Anxiety, and Pain in Children during Intravenous Insertion in the Pediatric Emergency Unit: A Randomized Controlled Trial

IntroductionDistraction methods such as virtual reality and cold vibration device are recommended during intravenous interventions. Few studies have focused on the impact of nonpharmacological interventions on intravenous insertion success.MethodsA randomized controlled study evaluated effect of virtual reality and cold vibration device application on first-attempt intravenous insertion success and procedure-related pain, fear, and anxiety during intravenous insertion in children. Children aged 4 to 10 years (N = 150) undergoing peripheral intravenous catheterization insertion in the pediatric emergency department were randomized to 1 of 3 groups: virtual reality, cold vibration (Buzzy), and control group. Distraction technique of talking and asking questions of children was used in control group. Primary outcome was first-attempt intravenous insertion success; secondary outcomes were procedure-related pain, fear, and anxiety. Study data were collected using Difficult Intravenous Access score, Emotional Appearance Scale for Children, Wong-Baker Faces Pain Rating Scale, Color Analog Scale, Children's Anxiety Meter-State, and Child Fear Scale. Data were analyzed using chi-square test, Fisher exact test, and Kruskal–Wallis test.ResultsThere were no significant differences in first-attempt intravenous insertion success rates (virtual reality = 47.2%, Buzzy® = 50%, control = 46.9%), preprocedural emotional appearance scores, and procedure-related pain and anxiety scores. There was no difference between groups for vital signs before, during, and at fifth minute of procedure.DiscussionVirtual reality and Buzzy may decrease procedure-related fear in children during intravenous insertion. This research has shown that pediatric emergency nurses can reduce pain and anxiety by talking to children, and simple distractions such as asking questions are as effective as more technological ones.     

Clinical Outcomes of Children Treated with Intravenous Prochlorperazine for Migraine in a Pediatric Emergency Department

Background: Prochlorperazine is the only treatment that has been studied so far in a randomized controlled trial and found to reduce pain at 1 h in children with migraine who presented to an emergency department (ED). Objective: To evaluate the rate of treatment failure associated with prochlorperazine used in children with severe migraine in a pediatric ED. Methods: This study was a retrospective chart review of patients < 18 years of age who visited the ED of a tertiary care pediatric hospital between November 2005 and June 2007. All patients diagnosed with migraine by the emergency physicians were included in the study. Charts were evaluated by a data abstractor blinded to the study hypothesis using a standardized datasheet. Inter-rater agreement was measured. Prochlorperazine treatment failure was defined as either administration of further rescue therapy, a hospitalization, or a return visit to the ED within 48 h for symptom recurrence or side effects from the medication. Results: Prochlorperazine was administered in 92 episodes of migraine, including 43 confirmed by a pediatric neurologist; all received diphenhydramine to prevent akathisia. A total of 13 (14%) of these patients had a treatment failure: 8 patients received one or more further rescue therapies after the administration of prochlorperazine; 5 patients were hospitalized, including 3 who had received further rescue therapy; and 3 patients returned to the ED within 48 h due to symptom recurrence. Conclusion: There was a treatment failure rate of 14% with the use of prochlorperazine in association with diphenhydramine for severe migraine in children seen in a pediatric ED.     

Active and Passive Distraction Interventions in a Pediatric Emergency Department to Reduce the Pain and Anxiety During Venous Blood Sampling: A Randomized Clinical Trial

IntroductionDistraction is a method that is easy to use in emergency departments and effective in relieving procedural pain and anxiety. This study aimed to determine the effect of 2 new distraction methods—1 active distraction (rotatable wooden toy) and 1 passive distraction (toy wristband)—on procedural pain, fear, and anxiety in children during venous blood sampling.MethodsThis study was a randomized controlled experimental study. The sample consisted of 216 children aged 6 years to 12 years. They were divided into 3 groups using the block randomization procedure: active distraction group (n = 72); passive distraction group (n = 72); and control group (n = 72). The levels of pain and anxiety in the children were measured before and during the blood sampling by the children themselves, their parents, and the researcher using the Visual Analog Scale, the Wong-Baker FACES Pain Rating Scale, and the Children’s Fear Scale.ResultsThe children and their parents included in the control and experimental groups had similar sociodemographic characteristics. The active distraction group had lower levels of procedural pain, fear, and anxiety than the other groups (children’s visual analog scale score, F = 134.22; P < 0.05; Wong-Baker FACES Pain Rating Scale score, F = 137.54; P < 0.001; and Children’s Fear Scale score, F = 92.44; P < 0.001).DiscussionBoth the toy wristband and rotatable wooden toy interventions can be used to reduce procedural pain, fear, and anxiety in children during blood sampling in emergency departments.     

Using Buzzy,Shotblocker, and Bubble Blowing in a Pediatric Emergency Department to Reduce the Pain and Fear Caused by Intramuscular Injection: A Randomized Controlled Trial

IntroductionProcedural pain in general, and intramuscular (IM) injection pain in particular, is one of the most distressing and painful health care experiences for children. Pharmacologic and nonpharmacologic methods are used as forms of pain control for children undergoing acute painful interventions in emergency departments.MethodsThis study was a prospective, randomized controlled trial. The sample consisted of children aged 5 to 10 years old who required IM injections. Children were placed in 4 subgroups through randomization, using a computer program: the Buzzy (MMJ Labs. Atlanta, GA) group (n = 40), the ShotBlocker (Bionix Development Corporation, Toledo, OH) group (n = 40), the bubble-blowing group (n = 40), and the control group (n = 40). Immediately before and after the injection, the children, their parents, and an observer were asked to evaluate the child’s level of fear. The Oucher scale was also employed by the observers, children, and parents immediately after the procedure to assess the level of pain in the children in each group.ResultsNo statistically significant difference was determined between the control and intervention groups in terms gender, age, previous pain experienced with injection, the parent who was with the child, the parent’s age. A significant difference was found between the intervention and control groups in terms of levels of pain and fear during IM injection. Pain and fear were notably less in the group of children receiving the Buzzy intervention.DiscussionThe Buzzy intervention should be used when children are undergoing IM injections to reduce their levels of pain and fear.     

A Clinical Trial of Propofol vs Midazolam for Procedural Sedation in a Pediatric Emergency Department

OBJECTIVE: To compare the effectiveness, recovery time from sedation, and complication rate of propofol with those of midazolam when used for procedural sedation in the pediatric emergency department (PED). METHODS: A prospective, blinded, randomized, clinical trial comparing propofol and midazolam was conducted in the PED of a tertiary pediatric center. Eligible patients were aged 2-18 years with isolated extremity injuries necessitating closed reduction. All patients received morphine for pain, then were randomized to receive propofol or midazolam for sedation. Vital signs, pulse oximetry, and sedation scores were recorded prior to sedation and every 5 minutes thereafter until recovery. Recovery time, time from cast completion to discharge, and other time intervals during the PED course and all sedation-related complications were also recorded. RESULTS: Between August 1996 and October 1997, 91 patients were enrolled. Demographic data, morphine doses, and sedation scores were similar between the propofol and midazolam groups. Mean +/- SD recovery time for the propofol group was 14.9+/-11.1 minutes, compared with 76.4+/-47.5 minutes for the midazolam group, p<0.001. Mild transient hypoxemia was the most significant complication, occurring in 5 of 43 (11.6%) patients given propofol and 5 of 46 (10.9%) patients given midazolam (odds ratio 1.08, 95% CI = 0.24 to 4.76). CONCLUSION: In this study, propofol induced sedation as effectively as midazolam but with a shorter recovery time. Complication rates for propofol and midazolam were comparable, though the small study population limits the power of this comparison. Propofol may be an appropriate agent for sedation in the PED; however, further study is necessary before routine use can be recommended.     

Randomized Clinical Trial of Propofol Versus Ketamine for Procedural Sedation in the Emergency Department

Objectives: The objective was to compare the occurrence of respiratory depression, adverse events, and recovery duration of propofol versus ketamine for use in procedural sedation in the emergency department (ED). Methods: This was a randomized nonblinded prospective clinical trial of adult patients undergoing procedural sedation for painful procedures in the ED. Patients with pain before the procedure were treated with intravenous (IV) morphine sulfate until their pain was adequately treated at least 20 minutes before starting the procedure. Patients were randomized to receive either propofol 1 mg/kg IV followed by 0.5 mg/kg every 3 minutes as needed or ketamine 1.0 mg/kg IV followed by 0.5 mg/kg every 3 minutes as needed. Doses, vital signs, nasal end‐tidal CO₂ (ETCO₂), and pulse oximetry were recorded. Subclinical respiratory depression was defined as a change in ETCO₂ of >10 mm Hg, an oxygen saturation of <92% at any time, or an absent ETCO₂ waveform at any time. Clinical interventions related to respiratory depression were noted during the procedure, including the addition of or increase in the flow rate of supplemental oxygen, the use of a bag‐valve mask apparatus, airway repositioning, or stimulation to induce breathing. After the procedure, patients were asked if they experienced pain during the procedure and had recall of the procedure. Physicians were asked to describe any adverse events or the occurrence of recovery agitation. Results: One‐hundred patients were enrolled; 97 underwent sedation and were included in the analysis. Fifty patients received propofol and 47 received ketamine. Subclinical respiratory depression was seen in 20 of 50 patients in the propofol group and 30 of 47 patients in the ketamine group (p = 0.019, effect size 22.8%; 95% CI = 4.0% to 43.6%). Clinical interventions related to respiratory depression were used in 26 of 50 propofol patients and 19 of 47 ketamine patients (p = 0.253, effect size = ?13.7%; 95% CI = ?33.8% to 6.4%). The median times of the procedures were 11 minutes (range = 4 to 33 minutes) for the ketamine group versus 10 minutes (range = 5 to 33 minutes) for the propofol group (p = 0.256). The median time to return to baseline mental status after the procedure was completed was 14 minutes (range = 2 to 47 minutes) for the ketamine group and 5 minutes (range = 1 to 32 minutes) for the propofol group (p < 0.001). Pain during the procedure was reported by 3 of 50 patients in the propofol group and 1 of 47 patients in the ketamine group (effect size = ?3.9%, 95% confidence interval [CI] = ?11.9 to 4.1). Recall of some part of the procedure was reported by 4 of 50 patients in the propofol group and 6 of 47 patients in the ketamine group (effect size = 4.8%, 95% CI = ?7.6% to 17.1%). Forty‐eight of 50 procedures were successful in the propofol group and 43 of 47 in the ketamine group (p = 0.357, effect size = 0.3%; 95% CI = ?7.8% to 8.4%). Recovery agitation was reported in 4 of 50 in the propofol group and 17 of 47 in the ketamine group (effect size = 28.2%, 95% CI = 12.4% to 43.9%). Conclusions: This study detected a higher rate of subclinical respiratory depression in patients in the ketamine group than the propofol group. There was no difference in the rate of clinical interventions related to respiratory depression, pain, or recall of the procedure between the groups. Recovery agitation was seen more frequently in patients receiving ketamine than in those receiving propofol. The time to regain baseline mental status was longer in the ketamine group than the propofol group. This study suggests that the use of either ketamine or propofol is safe and effective for procedural sedation in the ED. ACADEMIC EMERGENCY MEDICINE 2010; 17:604–611 © 2010 by the Society for Academic Emergency Medicine     

The Emergency Department as a Potential Site for Smoking Cessation Intervention: A Randomized, Controlled Trial

OBJECTIVE: To assess the effect of physician counseling and referral on smoking cessation rates and attendance at a smoking cessation program. METHODS: This was a prospective, randomized clinical trial set in a suburban, community teaching hospital emergency department (ED). During study hours, dedicated research associates enrolled consecutive, stable, oriented patients who were smokers. Eligible, consenting patients were randomized to one of two intervention groups. The control group received a two-page "Stop Smoking" pamphlet from the American Heart Association (AHA). Patients in the intervention group were given the AHA pamphlet along with pharmacologic information and standardized counseling by the attending emergency physician, including written and oral referral to a smoking cessation program. The primary outcome measures were telephone contact/attendance at the smoking cessation program by the intervention group and the rate of smoking cessation in both study groups at three months post-ED visit. Categorical data were analyzed by chi-square and Fisher's exact tests. Rank data were analyzed by Mann-Whitney tests and continuous data by t-tests. All tests were two-tailed with alpha set at 0.05. RESULTS: One hundred fifty-two patients were enrolled; 78 were randomized to the intervention group. Nearly 70% of patients (103) were available for telephone follow-up. The study groups were statistically similar with regard to baseline demographic characteristics and the prevalence of moderate or severe nicotine addiction. None of the patients (0%) in the intervention group contacted or attended the smoking cessation program during the study period (95% CI = 0-4%). The percentages of patients who stopped smoking after three months were similar in the two groups [10.4% (5/48) control vs 10.9% (6/55) intervention; p = 1]. CONCLUSION: The authors found no difference in the smoking cessation rates between ED patients who received written material and those who were counseled by emergency physicians. Referral of patients who smoked to a cessation program was unsuccessful.     

A Randomized, Double-blind Controlled Study of Jet Lidocaine Compared to Jet Placebo for Pain Relief in Children Undergoing Needle Insertion in the Emergency Department

Objectives: The objectives were to determine whether pretreatment with needleless jet‐delivered lidocaine decreases self‐reported pain in children undergoing needle insertion in the emergency department (ED) and to explore whether pretreatment with a jet device decreases self‐reported pain in children undergoing needle insertion in the ED. Methods: This study examined needle insertion pain in children 5–18 years of age. In the first phase of this study, children received either pretreatment with jet‐delivered lidocaine (0.2 mL of buffered 1% lidocaine; n = 75) or pretreatment with jet‐delivered placebo (0.2 mL of preservative‐free normal saline; n = 75) 60 seconds before undergoing needle insertion. This phase of the study had a randomized, double‐blind, placebo‐controlled design. In the second phase, an unblinded, nonconcurrent, nonintervention control group (n = 47) was examined to describe any effect of using the jet device. Patients reported pain upon administration of the jet device and at needle insertion using a 100‐mm color analog scale (CAS). Patients also reported their satisfaction with this device. The physicians and nurses performing needle insertions were asked to rate their ability to visualize the vein and their satisfaction with the device. Results: The mean (±standard deviation [SD]) needle insertion pain score for jet lidocaine, 28 (±7) mm, was similar to the mean needle insertion pain score for jet placebo, 34 (±7) mm. The mean needle insertion pain score for both the jet lidocaine and the jet placebo groups were lower than the needle insertion pain scores for the no device group, 52 (±8) mm. The majority of patients receiving the jet device reported that they would request this device for future needle insertions. Providers’ ratings of their ability to visualize veins and the patient cooperation were similar in all three groups. Conclusions: Jet‐delivered lidocaine is no more effective than jet‐delivered placebo in providing local anesthesia for needle insertion. Jet lidocaine and jet placebo may provide superior analgesia compared to no local anesthetic pretreatment.     

Impact of a Triage Liaison Physician on Emergency Department Overcrowding and Throughput: A Randomized Controlled Trial

Background Triage liaison physicians (TLPs) have been employed in overcrowded emergency departments (EDs); however, their effectiveness remains unclear.
Objectives To evaluate the implementation of TLP shifts at an academic tertiary care adult ED using comprehensive outcome reporting.
Methods A six-week TLP clinical research project was conducted between December 9, 2005, and February 9, 2006. A TLP was deployed for nine hours (11 ^am to 8 ^pm) daily to initiate patient management, assist triage nurses, answer all medical consult or transfer calls, and manage ED administrative matters. The study was divided into three two-week blocks; within each block, seven days were randomized to TLP shifts and the other seven to control shifts. Outcomes included patient length of stay, proportion of patients who left without complete assessment, staff satisfaction, and episodes of ambulance diversion.
Results TLPs assessed a median of 14 patients per shift (interquartile range, 13–17), received 15 telephone calls per shift (interquartile range, 14–20), and spent 17–81 minutes per shift consulting on the telephone. The number of patients and their age, gender, and triage score during the TLP and control shifts were similar. Overall, length of stay was decreased by 36 minutes compared with control days (4:21 vs. 4:57; p = 0.001). Left without complete assessment cases decreased from 6.6% to 5.4% (a 20% relative decrease) during the TLP coverage. The ambulance wait time and number of episodes of ambulance diversion were similar on TLP and control days.
Conclusions A TLP improved important outcomes in an overcrowded ED and could improve delivery of emergency medical care in similar tertiary care EDs.     

Randomized Clinical Trial of Propofol With and Without Alfentanil for Deep Procedural Sedation in the Emergency Department

Objectives: The objectives were to compare the efficacy, occurrence of adverse events, and recovery duration of propofol with and without alfentanil for use in procedural sedation in the emergency department (ED). Methods: This was a randomized nonblinded prospective trial of adult patients undergoing procedural sedation for painful procedures in the ED. Patients with pain before the procedure were given intravenous (IV) morphine sulfate until their pain was adequately treated at least 20 minutes before starting the procedure. Patients received 1 mg/kg propofol either with or without a supplemental dose of 10 μg/kg alfentanil for deep procedural sedation. Doses, vital signs, nasal end‐tidal CO₂ (ETCO₂), pulse oximetry, and bispectral electroencephalographic (EEG) analysis scores were recorded. Subclinical respiratory depression was defined as a change in ETCO₂ of >10 mmHg, an oxygen saturation of <92% at any time, or an absent ETCO₂ waveform at any time. Clinical events related to respiratory depression were noted during the procedure, including the addition of or increase in the flow rate of supplemental oxygen, the use of a bag‐valve mask apparatus, airway repositioning, or stimulation to induce breathing. After the procedure, patients were asked if they experienced pain during the procedure or had recall of the procedure. Results: A total of 150 patients were enrolled; 146 underwent sedation and were included in the analysis. Seventy‐four patients received propofol, and 71 received propofol with alfentanil. No clinically significant complications were noted. Subclinical respiratory depression was seen in 24/74 patients in the propofol group and 30/71 patients in the propofol/alfentanil group (effect size = 9.8%, 95% CI = –5.8% to 25.5%). Clinical signs of respiratory depression included an increase in supplemental oxygen use in 25 of the 74 propofol patients and 31 of the 71 propofol/alfentanil patients (effect size 9.9%, 95% CI = –5.9% to 25.7%), the use of bag‐valve mask apparatus in seven patients in the propofol group and 12 in the propofol/alfentanil group (effect size = 5.6%, 95% CI = –3.5% to 18.4%), airway repositioning in 13 propofol patients and 20 propofol/alfentanil patients (effect size = 10.6%, 95% CI = –3.0% to 24.2%), and stimulation to induce breathing in 11 propofol patients and 20 propofol/alfentanil patients (effect size = 13.3%, 95% CI = 0.1% to 26.5%). The total time of the procedure was longer for the alfentanil/propofol group (median = 11 minutes, range = 5–22 minutes) than for the propofol group (median = 9 minutes, range = 1 to 43 minutes; effect size = 1.93 minutes, 95% CI = 0.73 to 2.58, p = 0.02). Pain during the procedure was reported by 10 of the 74 patients in the propofol group and 7 of the 71 patients in the propofol/alfentanil group (effect size = 4.5%, 95% CI = –6.8% to 14.1%). Recall of some part of the procedure was reported by 12 patients in the propofol group and 9 in the propofol/alfentanil group (effect size = 3.5%, 95% CI = –7.9% to 15.0%). All procedures were successfully completed. Conclusions: The use of supplemental alfentanil with propofol for procedural sedation did not result in a difference in reported pain or recall immediately after the procedure. There was an increase in the proportion of patients who required stimulation to induce respiration during the procedure in patients who received propofol with supplemental alfentanil. The addition of supplemental opioid to procedural sedation with propofol does not appear beneficial.     

Patient Navigation to Reduce Emergency Department (ED) Utilization Among Medicaid Insured,Frequent ED Users: A Randomized Controlled Trial

BackgroundSome Medicaid enrollees frequently utilize the emergency department (ED) due to barriers accessing health care services in other settings.ObjectivesTo determine whether an ED-initiated Patient Navigation program (ED-PN) designed to improve health care access for Medicaid-insured frequent ED users could decrease ED visits, hospitalizations, and costs.MethodsWe conducted a prospective, randomized controlled trial comparing ED-PN with usual care (UC) among 100 Medicaid-enrolled frequent ED users (defined as 4–18 ED visits in the prior year), assessing ED utilization during the 12 months pre- and post-enrollment. Secondary outcomes included hospitalizations, outpatient utilization, hospital costs, and Medicaid costs. We also compared characteristics between ED-PN patients with and without reduced ED utilization.ResultsOf 214 eligible patients approached, 100 (47%) consented to participate. Forty-nine were randomized to ED-PN and 51 to UC. Sociodemographic characteristics and prior utilization were similar between groups. ED-PN participants had a significant reduction in ED visits and hospitalizations during the 12-month evaluation period compared with UC, averaging 1.4 fewer ED visits per patient (p = 0.01) and 1.0 fewer hospitalizations per patient (p = 0.001). Both groups increased outpatient utilization. ED-PN patients showed a trend toward reduced per-patient hospital costs (−$10,201, p = 0.10); Medicaid costs were unchanged (−$5,765, p = 0.26). Patients who demonstrated a reduction in ED usage were older (mean age 42 vs. 33 years, p = 0.03) and had lower health literacy (78% low health literacy vs. 40%, p = 0.02).ConclusionAn ED-PN program targeting Medicaid-insured high ED utilizers demonstrated significant reductions in ED visits and hospitalizations in the 12 months after enrollment.     

Screening and Brief Intervention to Reduce Marijuana Use Among Youth and Young Adults in a Pediatric Emergency Department

Objectives: Marijuana was involved in 209,563 emergency department (ED) visits in 2006, according to the Drug Abuse Warning Network. Although screening and brief intervention (SBI) has been effective in changing drinking among ED patients in a number of studies, tests of marijuana SBI in a pediatric emergency department (PED) have not yet been reported. The aim of this pilot study was to test whether SBI is effective in reducing marijuana consumption among youth and young adults presenting to a PED with a diverse range of clinical entities. Methods: A three‐group randomized controlled preliminary trial was structured to test 1) differences between Intervention (Int) and standard Assessed Control (AC) groups in marijuana consumption, from baseline to 12 months, and 2) the feasibility of adding a Nonassessed Control (NAC) group to evaluate regression to the mean and assessment reactivity. Patients aged 14–21 years in an urban, academic PED were screened during 2006–2007, using standardized risk factor questions. Subjects were eligible if they used marijuana three or more times in the past 30 days, but were excluded for co‐occurring high‐risk alcohol use. Consented enrollees were randomized to NAC, AC, and Int groups in a two‐stage process that permitted blinding to status during assessment and follow‐up. NACs received a resource handout, written advice about marijuana use risks, and a 12‐month follow‐up appointment. ACs were assessed using standardized instruments and received resources, written advice, and 3‐ and 12‐month follow‐up appointments. The Int group received assessment, resources, written advice, 3‐ and 12‐month appointments, a 20‐minute structured conversation conducted by older peers, and a 10‐day booster telephone call. A peer educator utilized a motivational style interview protocol adapted for adolescents to elicit daily life context and future goals, provide feedback, review pros and cons of marijuana use, assess readiness to change, evaluate strengths and assets, negotiate a contract for change, and make referrals to treatment and/or other resources. Measurements included demographic information; 30‐day self‐report of marijuana use; attempts to quit, cut back, or change conditions of use; and risk factor questions repeated at follow‐up. Results: Among 7,804 PED patients screened, 325 were eligible; 210 consented and enrolled (Int, n = 68; AC, n = 71; NAC, n = 71), with a 12‐month follow‐up rate of 71%. For the primary objective, we compared Int to AC. At 12 months, Int participants were more likely to be abstinent for the past 30 days than ACs (odds ratio [OR] for reported abstinence = 2.89, 95% confidence interval [CI] = 1.22 to 6.84, p < 0.014). The Int group had greater reduction in days used, baseline to 12 months, controlling for baseline (Int = –7.1 vs. AC = –1.8), were less likely to have been high among those who smoked (OR = 0.39, 95% CI = 0.17 to 0.89, p < 0.05), and were more likely to receive referrals. In a linear regression model controlling for baseline use, NACs smoked 4 fewer days per month than ACs, but consumption was not significantly different, suggesting no assessment reactivity effect. Conclusions: A preliminary trial of SBI promoted marijuana abstinence and reduced consumption among PED patients aged 14–21 years. A no‐contact condition for the NAC group over the year after enrollment was insufficient to capture enrollees for follow‐up across a range of baseline acuity.     

Intramuscular Droperidol versus Intramuscular Dimenhydrinate for the Treatment of Acute Peripheral Vertigo in the Emergency Department: A Randomized Clinical Trial

OBJECTIVE: The emergency department (ED) treatment of acute peripheral vertigo (APV) has not been well studied. The purpose of this study was to determine the efficacy of intramuscular (IM) droperidol vs IM dimenhydrinate, in the treatment of ED patients with APV. METHODS: The study was a randomized, double-blinded clinical trial, performed at a suburban, teaching ED. A convenience sample of adult patients with symptoms and signs consistent with rigid diagnostic criteria for APV were randomized to one of two treatment groups. Patients more than 65 years of age were excluded to reduce the likelihood of diagnostic misclassification. Demographic and historical features were recorded on a standardized data form. Patients recorded their initial level (t0) of discomfort on a 10-centimeter (cm) visual analog scale (VAS). Treatment group 1 received 2.5 mg droperidol IM, while treatment group 2 received 50 mg dimenhydrinate IM. After 30 minutes (t30), patients again recorded the severity of their symptoms on the VAS. Chi-square, t-tests, and Mann-Whitney were used for statistical comparison as appropriate. All tests were two-tailed, with alpha set at 0.05. Primary outcome parameters were the mean change in VAS score from t0 to t30, and the percentage of patients in each treatment group who felt well enough to go home after t30 without further ED intervention. RESULTS: There were 20 patients in the droperidol group and 20 in the dimenhydrinate group. The two groups were similar with respect to mean age (40 +/- 13 years droperidol vs. 42 +/- 13 years dimenhydrinate; p = 0.6), female sex (60% vs. 50%; p = 0.7), and mean median duration of symptoms [3 (interquartile range 2-12) vs 9 (interquartile range 2-30) hours; p = 0.2]. Mean initial t0 VAS scores were 7.2 +/- 2.3 and 7.8 +/- 1.9 (p = 0.47). Both treatment groups had mean reductions in VAS scores at t30 of 3.3 [95% confidence interval (95% CI) = 2.3 to 4.3]. At t30, 42% of patients in the droperidol group and 45% of patients in the dimenhydrinate group felt well enough to go home without further ED intervention. CONCLUSIONS: The authors found no difference between the therapeutic efficacies of IM droperidol and dimenhydrinate for the treatment of acute peripheral vertigo.     

A Randomized, Controlled Trial of Sucrose Analgesia in Infants Younger Than 90 Days of Age Who Require Bladder Catheterization in the Pediatric Emergency Department

Objectives: To determine whether an oral sucrose solution improves pain response for infants undergoing bladder catheterization in an emergency department (ED) population. Methods: A randomized, double‐blinded study comparing the analgesic effects of a sucrose solution to placebo for infants ≤90 days of age and requiring bladder catheterization. Infants with prior bladder catheterization, previous painful procedures that day, or neurological or genital abnormalities were excluded. Infants were assigned baseline pain scores and then given 2 mL of sucrose or water 2 minutes before catheterization. Trained pediatric ED nurses rated the infants for pain, presence of cry, and time to return to baseline. Results: Eighty‐three patients were enrolled; 40 were randomized to sucrose, and 40, to placebo. Baseline pain scores were similar within each age group. Overall, sucrose did not produce a significant analgesic effect. In subgroup analysis, infants 1–30 days of age receiving sucrose showed a smaller change in pain scores (2.9 vs. 5.3, p = 0.035), were less likely to cry with catheterization (29% vs. 72%, p = 0.008), and returned to baseline more rapidly after catheter removal (10 seconds vs. 37 seconds, p = 0.04) compared with infants who received placebo. Infants older than 30 days of age who received sucrose did not show statistically significant differences in pain scores, crying, or time to return to baseline behavior. Conclusions: There was no overall treatment effect when using an oral sucrose solution before bladder catheterization in infants younger than 90 days of age. However, infants younger than or equal to 30 days of age who received sucrose had smaller increases in pain scores, less crying, and returned to baseline more rapidly than infants receiving placebo. Older infants did not show an improved pain response with oral sucrose.     

Ambulance Diversion as a Proxy for Emergency Department Crowding: The Effect on Pediatric Mortality in a Metropolitan Area

Objectives: The objective was to determine the prevalence of emergency department (ED) ambulance diversion among Houston pediatric hospitals and its association with mortality of pediatric patients. Methods: Hospital diversion and patient data between August 2002 and December 2004 were used to examine the impact of diversion on mortality of children under age 18 years. Patients were assumed to be exposed to ED crowding if diversion and admission or ED arrival times overlapped. Univariate and logistic regression were performed to determine if diversion was associated with mortality while controlling for age, illness severity, injury, and transfer status. Results: Mean hospital diversion hours as a percentage of operating hours were 10.58 (standard deviation [SD] ± 9). Overall, of 63,780 admissions, there were 4,095 (6.4%) children admitted during diversion. Fewer severely ill patients were admitted during diversion than nondiversion times (odds ratio [OR] = 0.72; 95% confidence interval [CI] = 0.66 to 0.78). The presence of diversion was protective for mortality (OR = 0.51; 95% CI = 0.34 to 0.77) in bivariate analysis. Mortality was associated with presence of major or extreme illness (OR = 60.7; 95% CI = 45.2 to 81.5), injury (OR=1.7; 95% CI = 1.4 to 2.1), and transfer status (OR = 6.3; 95% CI = 5.4 to 7.3). Using conditional logistic regression, major or extreme illness (OR = 50.7; 95% CI = 37.7 to 68.3), injury (OR 3.7; 95% CI = 2.9 to 4.7), and transfer (OR = 2.7; 95% CI = 2.2, 3.2) were associated with mortality, but diversion did not show any association with mortality. After combining ED and inpatient deaths, no association between diversion and mortality was observed. Conclusions: Hospital diversion due to ED crowding is common in pediatrics. The authors found no evidence of an association between diversion and ED and inpatient pediatric mortality.     

A Comparison of Two Different Tactile Stimulus Methods on Reducing Pain of Children During Intramuscular Injection: A Randomized Controlled Study

IntroductionPediatric patients in the emergency department often require intramuscular injection procedures, which may lead to pain, fear, and anxiety. The purpose of this study was to test a novel nonpharmacological intervention to reduce needle-related pain in the pediatric emergency department.MethodsThe study was conducted as a parallel-group, randomized controlled design. The study population consisted of 159 children aged 7 to 10 years cared for in the emergency department who received an intramuscular injection of ampicillin/sulbactam. The children were randomly assigned to Palm Stimulator, ShotBlocker, or control groups. The children’s preprocedure fear levels were evaluated using the Children’s Fear Scale, and their perceived pain levels during the procedure were evaluated using the Faces Pain Scale-Revised and Visual Analog Scale. Parents and observers also completed the pain level scores.ResultsAccording to all raters (child, parent, and observer), the Palm Stimulator group had the lowest mean Faces Pain Scale-Revised score averages (P < .001). The Visual Analog Scale score averages of the children in the Palm Stimulator group (Visual Analog Scale: M = 27.94, standard deviation = 19.13) were statistically significantly lower than the ShotBlocker (Visual Analog Scale: M = 46.07, standard deviation = 24.96) and control group (Visual Analog Scale: M = 53.43, standard deviation = 29.01) score averages (F = 14.94, η² = 0.16, P = .001).DiscussionThe results of this study support the effectiveness of the Palm Stimulator to reduce perceived pain in children during intramuscular injection administration in the pediatric emergency department.