Slower infusion of metoclopramide decreases the rate of akathisia

Objective

We investigated the difference in incidence of acute akathisia related to the rate of infusion in patients receiving metoclopramide for acute nausea, vomiting, or migraine headache in the emergency department (ED).

Methods

Randomized, prospective, double-blind clinical trial of patients aged 18 years and older who were to receive intravenous metoclopramide for the treatment of nausea, vomiting, or headache were eligible. Patients were excluded if they were taking medications that might mimic or mask akathisia, had a movement disorder, renal insufficiency, or were unable or unwilling to consent. Pregnant women and prisoners were also excluded. Subjects were randomized to receive 1 of 2 accepted metoclopramide administration regimens. The regimens included 10 mg of metoclopramide administered either as a 2-minute bolus (BG) or as a slow infusion for 15 minutes (IG). All patients received a normal saline placebo at the opposite rate to maintain blinding. The main outcome was development of akathisia noted at 60 minutes after drug administration as measured either with The Prince Henry Hospital akathisia rating scale or by sudden unexplained departure from the ED during treatment.

Results

One hundred twenty-seven patients were eligible for the study. Fifty-nine patients met exclusion criteria. Of the remaining 68 patients, 36 were randomized to the BG and 32 were randomized to the IG. In the BG, 11.1% of patients developed akathisia compared with 0% in the IG (P = .026). Four patients developed akathisia based on the scale and 2 departed suddenly from the ED.

Conclusions

Slower infusion of metoclopramide reduces the incidence of akathisia.     

Chest Pain A Manifestation of Migraine

Background

Chest pain is an alarming symptom; it justifies many visits to the emergency department (ED). The etiology is often unknown. Chest wall pain in the presence of migraine headache, although not a common occurrence, is intriguing when it resolves with antimigraine treatment.

Objectives

To characterize the manifestations and outcomes and investigate the relationship between chest wall pain and headache as a manifestation of migraine exacerbation.

Methods

Among patients visiting our ED, we identified those individuals whose pain originated in the chest wall in the setting of migraine exacerbation. Patients with clinical indications for specific treatments were dispositioned accordingly. Control of symptoms including chest pain and headache with antimigraine agents was considered the primary outcome. A prospective follow-up via telephone interview and medical records review was performed.

Results

We collected a convenience sample of 33 patients. All manifested migraine headache with an earlier onset than the chest pain, and all had taken medications prior to visiting the ED. Twelve patients reported a higher visual analog scale score for the headache than for the chest pain. Still, chest pain was the main complaint. The chest pain originated at the chest wall. Ten patients received sublingual nitroglycerin or opiates, or both; no pain relief was reported. However, all symptoms resolved with metoclopramide. On follow-up, 6 patients reported recurrence of chest pain with subsequent migraines.

Conclusions

Chest pain can be a complication of migraine. The treatment should be focused on migraine control. Migraine should be included in the differential diagnosis of chest pain.     

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.     

Effects of Inpatient Rehabilitation in Hip and Knee Osteoarthritis: A Naturalistic Prospective Cohort Study With Intraindividual Control of Effects

Objectives

To quantify pain, function, and health-related quality of life in comparison with normative data, and to quantify intervention effects.

Design

Naturalistic cohort study without a control group. Correction of the effects observed during the intervention by those observed during waiting time prior to the intervention.

Setting

Inpatient rehabilitation clinic.

Participants

Patients with hip (n=88) and knee (n=164) osteoarthritis.

Intervention

Comprehensive, multidisciplinary inpatient rehabilitation lasting 3 weeks.

Main Outcome Measures

Medical Outcomes Study 36-Item Short-Form Health Survey and Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC).

Results

Four or more comorbid conditions had 45.3% of the hip and 51.8% of the knee patients on entry to and discharge from the clinic. On entry, physical health and some dimensions of psychosocial health were significantly diminished compared with population norms. At discharge, hip osteoarthritis had improved by a corrected effect size of .20 to .47 in pain, .04 to .39 in function, and −.04 to .32 in psychosocial health. Knee osteoarthritis showed a corrected effect size of .43 to .62 in pain, .19 to .51 in function, and .19 to .30 in psychosocial health. All but 1 effect in WOMAC pain and WOMAC function were higher than the minimal clinically important differences.

Conclusions

Hip and knee osteoarthritis patients admitted to the inpatient intervention were affected by a substantial burden of disease and comorbidities. Inpatient rehabilitation resulted in small to moderate, statistically significant, and clinically important improvements in pain, function, and psychosocial health.     

A trial of midazolam vs diphenhydramine in prophylaxis of metoclopramide-induced akathisia

Study Objective

The study aimed to evaluate the effects of midazolam and diphenhydramine for the prevention of metoclopramide-induced akathisia.

Methods

This randomized, double-blind, and controlled trial aimed to investigate coadministered midazolam vs diphenhydramine in the prophylaxis of metoclopramide-induced akathisia. Patients 18 to 65 years of age who presented to the emergency department with primary or secondary complaints of nausea and/or moderate to severe vascular-type headache were eligible for this study. Patients were randomized to one of the fallowing 3 groups: (1) metoclopramide 10 mg + midazolam 1.5 mg; (2) metoclopramide 10 mg + diphenhydramine 20 mg; (3) metoclopramide 10 mg + placebo. Metoclopramide was administered as a 2-minute bolus infusion. Midazolam, diphenhydramine, and normal saline solution were administered as a 15-minute slow infusion. The whole procedure was observed; and akathisia and sedation scores and vital changes were recorded.

Results

There were significant differences among groups with respect to akathisia (P = .016) and sedation (P < .001). The midazolam group showed the lowest mean akathisia score but the highest mean sedation score. Akathisia scores of the diphenhydramine group were not different from placebo. There were significant differences among groups in terms of changes in mean vital findings such as respiration rates, pulse rates, and systolic blood pressures (P < .05). There were no significant difference among groups in terms of changes in mean diastolic blood pressures (P = .09).

Conclusion

Coadministered midazolam reduced the incidence of akathisia induced by metoclopramide compared to placebo but increased the rate of sedation. No difference was detected from diphenhydramine. Routine coadministered 20 mg diphenhydramine did not prevent metoclopramide-induced akathisia.     

Longitudinal Trends in the Treatment of Abdominal Pain in an Academic Emergency Department

Background

Abdominal pain is a top chief complaint of patients presenting to Emergency Departments (ED). Historically, uncertainty surrounded correct management. Evidence has shown adequate analgesia does not obscure the diagnosis, making it the standard of care.

Objective

We sought to evaluate trends in treatment of abdominal pain in an academic ED during a 10-year period.

Methods

We prospectively evaluated a convenience sample of patients in an urban academic tertiary care hospital ED from September 2000 through April 2010. Adult patients presenting with a chief complaint of abdominal pain were included in this study. Analgesic administration rates and times, pain scores, and patient satisfaction at discharge were analyzed to evaluate trends by year.

Results

There were 2,646 patients presenting with abdominal pain who were enrolled during the study period. Rates of analgesic administration generally increased each year from 39.9% in 2000 to 65.5% in 2010 (p value for trend <0.001). Similarly, time to analgesic administration generally decreased by year, from 116 min in 2000 to 81 min in 2009 (p < 0.001). There was no improvement in mean pain scores at discharge by year (p = 0.27) and 48% of patients during the 10-year period still reported moderate to severe pain at discharge. Patient satisfaction with pain treatment increased from a score of 7.1 to 9.0 during the study period (p < 0.005), following the trend of increase in analgesic administration.

Conclusions

In patients presenting to the ED with abdominal pain, analgesia administration increased and time to medication decreased during the 10-year period. Despite overall improvements in satisfaction, significant numbers of patients presenting with abdominal pain still reported moderate to severe pain at discharge.     

Work Ability Index Predicts Application for Disability Pension After Work-Related Medical Rehabilitation for Chronic Back Pain

Objective

To determine whether the Work Ability Index (WAI), a short 7-item self-report questionnaire addressing issues of perceived disability, impairment, and expectations for resuming work, predicts application for disability pension, recommendations for further treatment, and other adverse work-related criteria in patients with chronic back pain after rehabilitation.

Design

Cohort study with 3-month follow-up.

Setting

Seven inpatient rehabilitation centers.

Participants

Patients (N=294; 168 women; mean age, 49.9y) with chronic back pain.

Intervention

The WAI was completed at the beginning of rehabilitation. All patients were treated according to the German rehabilitation guidelines for chronic back pain and work-related medical rehabilitation.

Main Outcome Measure

Application for disability pension, as assessed by a postal questionnaire 3 months after discharge.

Results

Receiver operating characteristic curve analysis of the association between the WAI at baseline and subsequent application for disability pension revealed an area under the curve of .80 (95% confidence interval [CI], .62–.97). Youden index was highest when the WAI cutoff value was ≤20 points (sensitivity, 72.7%; specificity, 82.2%; total correct classification, 81.7%). After adjusting for age and sex, persons with a baseline WAI score of ≤20 points had 15.6 times (95% CI, 3.6–68.2) higher odds of subsequent application for disability pension, 4.9 times (95% CI, 1.5–16.8) higher odds of unemployment, and 6 times (95% CI, 2.4–15.2) higher odds of long-term sick leave at follow-up.

Conclusions

The WAI could help rehabilitation professionals identify patients with back pain with a high risk of a subsequent application for disability pension.     

Prednisone for Emergency Department Low Back Pain: A Randomized Controlled Trial

Background

Although oral corticosteroids are commonly given to emergency department (ED) patients with musculoskeletal low back pain (LBP), there is little evidence of benefit.

Objective

To determine if a short course of oral corticosteroids benefits LBP ED patients.

Methods

Design: Randomized, double-blind, placebo-controlled trial. Setting: Suburban New Jersey ED with 80,000 annual visits. Participants: 18–55-year-olds with moderately severe musculoskeletal LBP from a bending or twisting injury ≤ 2 days prior to presentation. Exclusion criteria were suspected nonmusculoskeletal etiology, direct trauma, motor deficits, and local occupational medicine program visits. Protocol: At ED discharge, patients were randomized to either 50 mg prednisone daily for 5 days or identical-appearing placebo. Patients were contacted after 5 days to assess pain on a 0–3 scale (none, mild, moderate, severe) as well as functional status.

Results

The prednisone and placebo groups had similar demographics and initial and discharge ED pain scales. Of the 79 patients enrolled, 12 (15%) were lost to follow-up, leaving 32 and 35 patients in the prednisone and placebo arms, respectively. At follow-up, the two arms had similar pain on the 0–3 scale (absolute difference 0.2, 95% confidence interval [CI] −0.2, 0.6) and no statistically significant differences in resuming normal activities, returning to work, or days lost from work. More patients in the prednisone than in the placebo group sought additional medical treatment (40% vs. 18%, respectively, difference 22%, 95% CI 0, 43%).

Conclusion

We detected no benefit from oral corticosteroids in our ED patients with musculoskeletal LBP.     

Pain Management: Association with Patient Satisfaction among Emergency Department Patients

Background

Patient satisfaction with emergency care is associated with timeliness of care, empathy, technical competence, and information delivery. Previous studies have demonstrated inconsistent findings regarding the association between pain management and patient satisfaction.

Objectives

This study was undertaken to determine the association between pain management and patient satisfaction among Emergency Department (ED) patients presenting with acute painful conditions.

Methods

In this survey study, a standardized interview was conducted at the Emergency Department at the University of Toledo Medical Center in May–July 2011. Participants were asked to answer 18 questions pertaining to patient satisfaction. Additional data collected included demographic information, pain scores, and clinical management.

Results

Among 328 eligible participants, 289 (88%) participated. The mean triage pain score on the verbal numeric rating scale was 8.2 and the mean discharge score was 6.0. The majority of patients (52%) experienced a reduction in pain of 2 or more points. Participants received one pain medication dose (44%), two medication doses (14%), three medication doses (5%), or four medication doses (2%). Reduction in pain scores of 2 or more points was associated with a higher number of medications administered. Reduction in pain scores was associated with higher satisfaction as scored on questions of patient perceptions of adequate assessment and response to pain, and treatment of pain.

Conclusions

There was a significant association between patient satisfaction and a reduction in pain of 2 or more points and number of medications administered. Effective pain management is associated with improved patient satisfaction among ED patients with painful conditions.     

Comprehensive pain management protocol reduces children's memory of pain at discharge from the pediatric ED

Background

Historically, pain has been poorly managed in the pediatric emergency department (ED) (PED), resulting in measurable psychosocial issues both acute and delayed.

Objective

The aim of the study was to measure the impact of protocolized pain management on patients with painful conditions or undergoing painful procedures in the PED.

Methods

We performed an analysis before and after the implementation of the protocol, dubbed the “Comfort Zone.” Validated, age-appropriate pain scales were performed. Validation (using Cronbach α, confirmatory factor analysis) was followed by comparison of responses between the pre- and posttests collected (χ² and Wilcoxon rank sum tests). Pain scores were collected at triage and at discharge. At triage, patients were asked to report pain levels. At discharge, they were asked to report their current pain and recall the level of pain during their stay. At triage, parents were asked to report about their perception of the child's pain. At discharge, they were asked to report about their perception of the child's current pain and recall the level of pain during the stay and during procedures, if done.

Results

Five hundred thirty-one patients were enrolled in the preprotocol group; 47% were women with a median age of 5 years (range, 30 days-18 years). Two hundred sixty-three patients were enrolled in the protocol group; 39% were women with a median age of 6 years (range, 30 days-18 years). Patient-recalled pain scores of the ED visit in the protocol group were significantly lower than those of the preprotocol group (Wong-Baker Faces Pain Scale, 5.07-4.01; P < .001); yet parent estimates of pain did not show a significant change at any point. Patient assessment of pain at ED discharge did not show a significant change either (Wong-Baker Faces Pain Scale, 1.99-1.56; P = .09). The Faces scale is not well validated for patients younger than 4, so that group had only parental assessment of pain and, consistent with the larger data set, showed no significant pain scale reduction at any point.

Conclusion

Protocolized pain management reduces patients' memory of pain during PED visits but may not affect parental memory of perceived pain or parent- and patient-reported pain at discharge.     

Algorithm for probable acute coronary syndrome using high-sensitivity troponin T assay vs fourth-generation troponin T assay

Background

Chest pain represents between 5% and 10% of annual visits to emergency departments (EDs) and near 25% of hospitalizations. Characterization of chest pain is sometimes difficult, and strategies should focus on preventing inappropriate discharge of patients with acute coronary syndrome. The goal of our study is to compare negative predictive value of the algorithm in the chest pain unit using the fourth-generation troponin T assay (4GTT) vs high-sensitivity troponin T assay (HSTT).

Methods

We included 600 patients with probable acute coronary syndrome, who were discharged from the chest pain unit without an acute coronary syndrome: 300 patients in the 4GTT group and 300 patients in the HSTT group. Clinical and laboratory variables were analyzed. All the patients were followed up at 30 days, and the cardiovascular events were recorded.

Results

Major cardiac events occurred in only 3 (1.2%) in the HSTT group vs 5 (1.7%) in the 4GTT group (P, nonsignificant). The negative predictive value was 99% in both groups. Emergency department length of stay was 4.3 ± 2.6 hours in HSTT group vs 10 ± 3.4 hours in the 4GTT group (P = .01).

Conclusion

The algorithm in the chest pain unit using HSTT showed to have the same negative predictive value as the algorithm with the 4GTT but with a shorter stay in the ED.     

Functional Outcomes in Traumatic Disorders of Consciousness: 5-Year Outcomes From the National Institute on Disability and Rehabilitation Research Traumatic Brain Injury Model Systems

Objective

To characterize the 5-year outcomes of patients with traumatic brain injury (TBI) not following commands when admitted to acute inpatient rehabilitation.

Design

Secondary analysis of prospectively collected data from the National Institute on Disability and Rehabilitation Research–funded Traumatic Brain Injury Model Systems (TBIMS).

Setting

Inpatient rehabilitation hospitals participating in the TBIMS program.

Participants

Patients (N=108) with TBI not following commands at admission to acute inpatient rehabilitation were divided into 2 groups (early recovery: followed commands before discharge [n=72]; late recovery: did not follow commands before discharge [n=36]).

Interventions

Not applicable.

Main Outcome Measures

FIM items.

Results

For the early recovery group, depending on the FIM item, 8% to 21% of patients were functioning independently at discharge, increasing to 56% to 85% by 5 years postinjury. The proportion functioning independently increased from discharge to 1 year, 1 to 2 years, and 2 to 5 years. In the late recovery group, depending on the FIM item, 19% to 36% of patients were functioning independently by 5 years postinjury. The proportion of independent patients increased significantly from discharge to 1 year and from 1 to 2 years, but not from 2 to 5 years.

Conclusions

Substantial proportions of patients admitted to acute inpatient rehabilitation before following commands recover independent functioning over as long as 5 years, particularly if they begin to follow commands before hospital discharge.     

Intravenous dexamethasone vs placebo as adjunctive therapy to reduce the recurrence rate of acute migraine headaches: a multicenter, double-blinded, placebo-controlled randomized clinical trial

Objectives

Some physicians prescribe corticosteroids as adjunctive therapy for patients with migraine headaches to decrease the rate of rebound headache. The efficacy of this practice has not been tested. Our objective is to determine the efficacy of single-dose dexamethasone as adjunctive therapy for emergency medicine patients with migraine headache in preventing headache recurrence at 3 and 30 days posttreatment.

Methods

From November 2004 to November 2005, we conducted a multicenter, double-blinded, placebo-controlled randomized clinical trial of adult patients who met the International Headache Society definition of migraine headache. After informed consent, patients were randomly assigned to one of two groups: receiving either placebo or 24 mg dexamethasone intravenously. To ensure generalizability, all other aspects of patient care were left to the discretion of the emergency physician. Clinical and demographic information was obtained; and patients were subsequently contacted at both 3 and 30 days to determine headache recurrence, current functional disability, and need for return to the ED. Our primary outcome measures were the recurrence of migraine headache at 3 and 30 days. We used Fisher exact to test for statistical significance.

Results

A total of 115 patients were enrolled, with 16 patients lost to follow-up at 3 days and 3 additional patients lost at 30 days. Baseline characteristics as well as adverse event profiles were equivalent in both study groups. At 3-day follow-up, 45% (95% confidence interval [CI] 31%-60%) of the placebo group had recurrence of their migraine compared with 35% (95% CI 24%-48%) in the dexamethasone group (P = .68). At 30-day follow-up, this relative reduction in migraine recurrence decreased to a 4% difference between the 2 groups (P = .68). Limitations include small sample size and significant proportion lost to follow-up.

Conclusion

A single dose of dexamethasone as adjunctive therapy for migraine headache does not decrease the recurrence of migraines at 3 or 30 days.     

Prehospital use of analgesics at home or en route to the hospital in children with extremity injuries

Purpose

The purpose of the study was to document prehospital analgesia (PA) for children with extremity injuries at home or en route to the hospital, as assessed by research personnel at the pediatric emergency department.

Methods

Two parallel groups of patients with fractures or soft-tissue injuries (STIs) were chosen for this prospective observational study. Patients 3 to 18 years of age with a limb or clavicle injury were enrolled. Parents or children were interviewed, pain assessed, and data from the emergency department charts collected.

Results

A total of 310 patients were recruited; their mean age was 10.2 years, and 62% had fractures. The median pain score was 4.0, with no significant difference between fractures and STI. Of the patients, 78% had PA, 73% received first aid (icing, immobilization), and 37% had medication, mostly acetaminophen and ibuprofen. Children with fractures and STI received PA at a similar rate; however, the time to first aid was shorter in those with fractures.

Conclusion

Most patients with moderate or severe pain did not receive prehospital pain medication. Parental education and moderate over-the-counter analgesics are needed for better pain relief.     

Skin lesions after intensive care procedures: Results of a prospective study

Purpose

To define the skin lesions produced by procedures used in the intensive care unit (ICU) and to examine patients 12 months after discharge from the ICU.

Material and Methods

This was a prospective clinical study in the 14-bed multidisciplinary ICU of a university hospital. Iatrogenic skin lesions (ISL) were examined in 316 patients after ICU discharge.

Results

A total of 189 patients were interviewed 12 months after ICU discharge. More than 85% of the patients had ISL after being discharged from the ICU. The patients with the highest Acute Physiology and Chronic Health Evaluation II score and longest average stay presented the highest number of ISLs. A total of 93 patients (49%) reported some skin lesions after 12 months. All patients who had undergone surgical tracheostomy reported the presence of a scar, but 4 of 24 patients who had undergone percutaneous tracheostomy reported no tracheostomy scar. Only 22% of all patients reported scars caused by vascular catheter access. About half (54.5%) of the patients reported secondary lesions caused by chest draining, and these were predominantly caused by the large-bore tube drainage. All patients reported the presence of a laparatomy scar.

Conclusions

Most patients had identified skin lesions resulting from ICU procedures. Half of all patients were aware of their lesions and reported them at 12 months. Future research is needed to understand whether these lesions cause problems to survivor's quality of life and whether the lesions lead to increased health care utilization.     

Derivation of a clinical prediction rule for evaluating patients with abdominal pain and diarrhea

Objective

The objective of the study was to develop a simple prediction rule to reliably identify abdominal pain patients with diarrhea who may require surgical intervention.

Methods

We performed a secondary analysis of a prospective cohort study of adults with acute nontraumatic abdominal pain and diarrhea in an urban emergency department (ED). Structured data collection included 109 historical and 28 physical examination items, laboratory and radiographic results, and final diagnosis. The main outcome was operative intervention.

Results

One thousand patients were enrolled; 174 patients with diarrhea were included in this analysis. Patients had a mean age of 39 ± 16 years and were likely to be female (64%) and black (60%). Fifteen (9%) patients received a surgical intervention from the ED. Clinical variables associated with the need for surgical intervention using univariate analysis were age older than 40 years, constant pain, and peritonitis on examination. Using recursive partitioning multivariate analysis, the derived prediction rule included 2 variables: age older than 40 years and constant pain. This rule had a sensitivity of 1.0 (95% confidence interval, 0.78-1.0) and specificity of 0.23 (95% confidence interval, 0.16-0.30).

Conclusion

Patients older than 40 years with constant abdominal pain and diarrhea are likely to have a surgical cause of their symptoms.     

Intravenous morphine titration to treat severe pain in the ED

Purpose

We assessed the safety of intravenous morphine titration in the emergency setting.

Methods

A total of 621 consecutive adult patients admitted in the ED with acute severe pain (visual analogue scale pain score >70) were included. Intravenous morphine titration was administered as a bolus of 2 (body weight ≤60 kg) or 3 mg (body weight >60 kg) with 5-minute interval between each bolus. Pain relief was defined as a visual analogue pain score of 30 or lower.

Results

The dose of morphine administered was 0.16 ± 0.10 mg/kg and the median number of boluses was 3. Pain relief was obtained in 512 (82%) patients. Morphine-induced adverse events occurred in 67 patients (11%) without severe adverse event. Titration was interrupted before pain relief had been obtained in 107 (17%) patients. In the remaining 514 patients, pain relief was obtained in 507 (99%) patients. Two variables were significantly associated with no pain relief: major protocol deviation (odds ratio, 17.3; 95% confidence interval, 10.0-30.1) and morphine-induced adverse effect (odds ratio, 13.0; 95% confidence interval, 6.7-25.3).

Conclusion

Intravenous morphine titration is a safe and effective option for severe pain when used according to a strict protocol.