The ‘Triple Rule Out’ CT Angiogram for Acute Chest Pain: Should it be Done,and If So,How?

Given the large number of individuals presenting to emergency departments with acute, undifferentiated chest pain and the frequent difficulty in discerning its etiology, there has been great interest in developing techniques that can improve the initial triage of these patients. The ‘Triple Rule Out” CT has recently been touted as a tool to quickly assess for life threatening causes of acute chest pain, namely acute coronary syndrome, pulmonary embolism, and aortic dissection. Initial studies suggest that this protocol is safe and compares favorably with the dedicated CT protocols but at the cost of increased doses of iodinated contrast and radiation. New scanner technology has started to address these limitations but the “Triple Rule Out” CT is still in its infancy. It remains to be seen whether or not this application can ultimately improve diagnostic efficiency, cost, and/or clinical decision making.     

Emergency Department Observation of Poisoned Patients: How Long Is Necessary?

OBJECTIVE: To compare the emergency physician disposition decisions after observation periods of two, four, and six hours in a single cohort of ED patients with acute intentional ingestion to determine the accuracy of disposition decisions at two and four hours relative to the six-hour period of observation. METHODS: This was a prospective observational study at two university hospital EDs. Study participants were patients with potentially toxic oral ingestions occurring less than six hours prior to ED presentation. Patients with isolated recreational drug or ethanol use were excluded. Structured data forms were completed at presentation, and two, four, and six hours later. Data included signs and symptoms consistent with toxic ingestion, physical examination, laboratory determinations, medications ingested, treatment, and suicide risk. At two and four hours, physicians were asked to determine whether they thought the patient was safe for medical clearance. These patients continued to be observed for six hours. The main outcome was whether patients initially thought to be appropriate for early medical clearance were ultimately cleared at six hours. RESULTS: There were 260 patients enrolled: 28 were immediately admitted to the hospital and 17 were immediately discharged; 215 entered ED observation. Patients had a mean age of 24 years; 55% were female; 50% were suicidal; 17% had toxidromes. Of the 215 observed patients, 106 (49%) were deemed safe for early medical clearance at two hours. All 106 were ultimately cleared at six hours (100%, 95% CI = 97% to 100%). Of the 109 not safe for early medical clearance at two hours, 61 (56%) were deemed safe for early medical clearance at four hours; all 61 were subsequently discharged at six hours (100%; 95% CI = 95% to 100%). Overall, 167 of 215 (77%) observed overdose patients were deemed safe for early medical clearance after two or four hours of observation. All 167 were ultimately cleared at six hours (100%; 95% CI = 98.2% to 100%). CONCLUSIONS: A large subset of overdose patients who are medically cleared after six hours of observation can be identified within two to four hours of presentation. No patient who was believed to be safe for medical clearance at either two or four hours had a complication within the six-hour time period (95% CI = 0% to 1.8%). These data suggest that asymptomatic patients with selected acute intentional ingestions can be released from medical observation in less than six hours.     

Do Children with Sickle Cell Disease Receive Disparate Care for Pain in the Emergency Department?

Background: There may be disparities in pain management practice in the emergency department (ED) for sickle cell disease patients (SCD) with vaso-occlusive episodes (VOE). Objectives: To compare pain management practice for children who presented to the ED with VOE to those with isolated long bone fractures (LBF). Methods: Children who presented with a VOE or a LBF to a children's hospital ED during 2005 were included. A retrospective medical chart review was conducted for each patient visit. Data collected included demographics, pain scores, time from triage to analgesia, and analgesic intervention. Results: Seventy-seven patients with SCD had 152 visits to the ED for pain, and 219 patients had 221 visits for LBF. Fifty-five patients (108 visits) with SCD and 123 patients (124 visits) with LBF received opiates. Subsequent analysis was done on these groups. Patients with SCD were older, less likely to be male and more likely to be African-American than the LBF group. Patients with SCD had higher triage pain scores (7.7 ± 2.5 vs. 6.7 ± 3.0, p = 0.005) and spent less time in the waiting room (7.4 ± 9.0 vs. 12.1 ± 26.8 min, p = 0.10), were given higher initial opiate doses (0.09 ± 0.03 vs. 0.07 ± 0.03 mg/kg morphine, p < 0.001); however, time from triage to analgesic intervention did not differ (69.0 ± 42.6 vs. 70.4 ± 57.1 min, p = 0.92). Conclusions: No disparities in care for children with sickle cell pain were identified. More timely administration of opiates needs to be encouraged, assuming other factors such as time of day, ED census, and acuity permit.     

Prehospital Nitroglycerin in Tachycardic Chest Pain Patients: A Risk for Hypotension or Not?

Background: The American Heart Association guidelines (AHA) guidelines list tachycardia as a contraindication for the administration of nitroglycerin (NTG), despite limited evidence of adverse events. We sought to determine whether NTG administered for chest pain was a predictor of hypotension (systolic blood pressure <90 mmHg) in patients with tachycardia, compared to patients without tachycardia (50≥ heart rate ≤100). Methods: We performed a retrospective cohort study using patient care reports completed by basic life support (BLS) providers in a large urban Canadian EMS system for the period 2010–2012. We used logistic regression to test the association between post-NTG hypotension and tachycardia, independent of pre-NTG blood pressure, age, sex, and comorbidities. Using identical models, we tested four secondary outcomes (drop in blood pressure, reduced consciousness, bradycardia, and cardiac arrest). Results: The cohort included 10,308 patients who were administered NTG by BLS in the prehospital setting; 2,057 (20%) of patients were tachycardic before NTG administration. Hypotension occurred in 320 of all patients (3.1%): 239 without tachycardia (2.9%) and 81 with tachycardia (3.9%). Compared to non-tachycardic patients, tachycardic patients showed increased adjusted odds of hypotension (AOR: 1.60; 95% CI: 1.23–2.08) or of a drop in blood pressure of 30mm Hg or greater (AOR: 1.11; CI: 1.00–1.24). Tachycardia was associated with decreased odds of bradycardia (OR: 0.33; CI: 0.17–0.64). We did not find a significant association between tachycardia and either post-NTG reduced level of consciousness or cardiac arrest. We did find a strong, significant association between pre-NTG blood pressure and post-NTG hypotension (AOR for units of 10mmHg: 0.64; CI: 0.61–0.69). Conclusion: Hypotension following prehospital administration of NTG was infrequent in patients with chest pain. However, while the absolute risk of NTG-induced hypotension was low, patients with pre-NTG tachycardia had a significant increase in the relative risk of hypotension. In addition, hypotension occurred most frequently in patients presenting with a lower pre-NTG blood pressure, which may prove to be a more discriminating basis for future guidelines. EMS medical directors should review BLS chest pain protocols to weigh the benefits of NTG administration against its risks.     

Does the U Stand for Useless? The Urine Drug Screen and Emergency Department Psychiatric Patients

Background

Behavioral emergencies account for a significant portion of emergency department (ED) visits in the United States. Substance abuse is common in this population and may precipitate or exacerbate preexisting psychiatric illness. Contrary to ED policy guidelines, many behavior health centers (BH) require a urine drug screen (UDS) in stable patients prior to transfer.

Opioid-Induced Hyperalgesia: Is It Clinically Relevant for the Treatment of Pain Patients?

There is a curious and paradoxic phenomenon, reliably demonstrated in animal models, that consists of an increased sensitivity to pain that is apparently induced by the very opioid drugs used to ameliorate the pain. This phenomenon is termed “opioid-induced hyperalgesia.” Whether opioid-induced hyperalgesia occurs in humans, and, if so, to what extent and consequence, is far less established. This is a critical question for attempting to treat pain. If opioid-induced hyperalgesia develops in a patient, it would masquerade as tolerance (because the clinical effectiveness of the opioid would be diminished), yet the appropriate clinical adjustment would be precisely the opposite to that of tolerance. It would be to decrease, rather than increase, the dose of opioid. We review the evidence, particularly the clinical evidence, about opioid-induced hyperalgesia and the postulated mechanisms. We conclude that given the clinical ramifications, opioid-induced hyperalgesia is one of the most understudied important aspects of opioid research.     

Care in the Emergency Department: How Crowded Is Overcrowded?

OBJECTIVES: To examine how emergency department (ED) overcrowding has been defined in the medical literature. METHODS: Using the National Library of Medicine's PubMed and MEDLINE databases (1966 to 2002), a comprehensive review of the English-language medical literature was conducted to identify explicit criteria for defining ED overcrowding. Inclusion criteria were original articles, editorials, and reviews; news articles and letters to the editor were excluded. Using a standardized extraction form, publications were described as primary if the title or an objective statement in the introductory or methods paragraph referred to crowding or overcrowding; all other citations were categorized as secondary. Each report was then evaluated to determine whether crowding or overcrowding was defined explicitly or implicitly. Explicit definitions included phrases such as "Crowding was defined as ..." or "Overcrowding occurred when ..."; other definitions were characterized as implicit. RESULTS: A total of 231 candidate articles were identified; 91 met inclusion criteria, and 53 (58%) were primary articles about ED crowding or overcrowding. Among these primary articles, 23 (43%) had explicit definitions of crowding or overcrowding. The definitions varied widely in content and focus, including ED, hospital, or external (nonhospital) factors. CONCLUSIONS: Although ED overcrowding has been a topic of frequent investigation, current definitions of the problem are often implicit or focus on factors outside of the ED itself. A more consistent approach to defining ED overcrowding would help to clarify the distinctions between causes, characteristics, and outcomes of overcrowding.     

Managing Pain with Algorithms: An Opportunity for Improvement? Or: The Development and Utilization of Algorithms to Manage Acute Pain

Pain management in a hospital setting remains a challenge today. Many health care providers remain anxious and uninformed regarding analgesic titration within a hospital setting. Overcoming the potential risks to obtain the benefits of opiate titration is a challenge within any health care setting. Virginia Commonwealth University, a tertiary medical center which houses schools of medicine, nursing, and pharmacy, evaluated the use of algorithms for managing acute pain. This article describes the Pain Committee's efforts and offers one potential intervention for safe analgesic opioid titration, an algorithm for acute pain management.     

Viral Meningitis: Which Patients Can Be Discharged from the Emergency Department?

Background

Even in an era when cases of viral meningitis outnumber bacterial meningitis by at least 25:1, most patients with clinical meningitis are hospitalized.

Objective

We describe the clinical characteristics of an unusual outbreak of viral meningitis that featured markedly elevated cerebrospinal fluid white blood cell counts (CSF WBC). A validated prediction model for viral meningitis was applied to determine which hospital admissions could have been avoided.

Methods

Data were collected retrospectively from patients presenting to our tertiary care center. Charts were reviewed in patients with CSF pleocytosis (CSF WBC > 7 cells/mm³) and a clinical diagnosis of meningitis between March 1, 2003 and July 1, 2003. Cases were identified through hospital infection control and by surveying all CSF specimens submitted to the microbiology laboratory during the outbreak.

Results

There were 78 cases of viral meningitis and 1 case of bacterial meningitis identified. Fifty-eight percent of the viral meningitis cases were confirmed by culture or polymerase chain reaction to be due to Enterovirus. Mean CSF WBC count was 571 cells/mm³, including 20 patients with a CSF WBC count > 750 cells/mm³ (25%) and 11 patients with values > 1000 cells/mm³ (14%). Sixty-four of 78 patients (82%) were hospitalized. Rates of headache, photophobia, nuchal rigidity, vomiting, and administration of intravenous fluids in the Emergency Department were no different between admitted and discharged patients. Only 26/78 (33%) patients with viral meningitis would have been admitted if the prediction model had been used.

Conclusions

Although not all cases of viral meningitis are necessarily suitable for outpatient management, use of a prediction model for viral meningitis may have helped decrease hospitalization by nearly 60%, even though this outbreak was characterized by unusually high levels of CSF pleocytosis.     

Emergency Department Procedural Sedation with Propofol: Is it Safe?

Propofol is a sedative agent gaining popularity for Emergency Department Procedural Sedation (EDPS). However, some institutions across the country continue to restrict the use of propofol secondary to safety concerns. The purpose of our study was to evaluate the complication rate of EDPS with propofol. We conducted a prospective, observational, multi-center study of EDPS patients aged ≥ 18 years, consenting to procedural sedation with propofol. Eighty-two patients from two Level I trauma centers were enrolled between August 1, 2002 and January 31, 2003. Transient hypoxemia was the only noted sedation complication. Nine patients (11%) had brief hypoxemia. The combined average hypoxemia time was 1.2 min (SD 0.4), and in all instances responded to simple airway maneuvers or increased oxygen concentration. No patient required advanced airway maneuvers such as intubation or even positive pressure ventilation. EDPS with propofol seems to be safe in our population.