Procedural Sedation and Analgesia in the Emergency Department: What Are the Risks?

The practitioner of emergency medicine is routinely faced with patients in need of emergent procedures and pain control and sedation. Our challenge is to make our patients' experiences as painless and as safe as possible, while maximizing our ability to perform the procedure at hand; this is not always an easy task given the propensity of each human body to react differently to interventions and stimuli. We can best meet this challenge by understanding how our patients and pharmaceutical agents intermingle in the risk-benefit equation we formulate before starting our "experiment." Coupling this information with fundamentally sound patient care and monitoring will minimize bad experiences with PSA for both the patient and practitioner.     

Is Emergency Department Cardioversion of Recent-onset Atrial Fibrillation Safe and Effective?

Background

Atrial fibrillation (AF) is a very common dysrhythmia presenting to Emergency Departments (EDs). Controversy exists regarding the optimal clinical therapy for these patients, which typically focuses on rhythm rate-control and admission or cardioversion and discharge home.

Clinical Question

Is ED cardioversion of recent-onset atrial fibrillation safe, effective, and does it result in positive meaningful patient outcomes?

Evidence Review

Five observation studies with nearly 1600 ED patients with atrial fibrillation treated with either rate-control or cardioversion were reviewed and results compiled.

Results

Overall, ED cardioversion for recent-onset AF seems safe and effective, with success rates ranging from 85.5% to 97% in these studies. Although further research should seek to identify patients at low risk for thromboembolic complication, more rigorously assess patient satisfaction, and show cost savings, emergency physicians should feel comfortable using this approach in select patients.

Conclusion

ED cardioversion for recent-onset AF seems safe and effective.     

Delirium in Emergency Departments: Is it Recognized?

BackgroundDelirium is a complex neurocognitive manifestation of an underlying medical or surgical abnormality such as substance abuse, infection, sepsis, or organ failure. A recognized risk factor for delirium is advanced age (age >65 years). The projected demographic changes over the next 2 decades suggest that the number of aging adults will grow dramatically, and emergency nurses will see an increasing number of older patients manifesting the wide range of neuropsychiatric symptoms associated with delirium.MethodAn examination of 5 commonly used delirium assessment tools was undertaken specific to clinical features, use, scoring, findings, advantages, and disadvantages.FindingsNumerous factors contribute to the lack of effective delirium recognition. However, emergency nurses, with educational support, can successfully use the delirium assessment tools to recognize delirium.ConclusionEmergency nurses face challenges in recognizing delirium. One key challenge for many of these nurses is the appropriate use of assessment tools suitable for the ED setting.     

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.     

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.     

Emergency Department Workload Increase: Dependence on Primary Care?

Background: Increasing demand for emergency care and crowded emergency departments (EDs) lead some planners to conclude that inconvenient primary care scheduling increases the number of “unnecessary” ED visits. The reasons that the planners argue for more primary care are: to increase funding for primary care; the unfounded notion that it is less expensive to see a primary care physician (PCP) than an Emergency Physician; and the impractical goal that the ED should be used only by intellectually interesting life- or limb-threatened patients or “true emergencies.” Objective: To explore the rates of patient-reported access to primary care in ambulatory presentations to a rural tertiary care ED. Methods: An observational study was performed in which an anonymous survey was given to a convenience sample of patients who presented by walking into the ED. Results: Overall, 70.4% (686/975) of respondents stated that they had a PCP, and 38.1 % (252/661) of the sample had attempted to contact their physicians before presenting to the ED. Of the group who attempted to contact their physicians, 62.8% (130) were neither spoken to nor seen by any doctor. These rates did not change by time of presentation or by day of the week. Conclusion: The results suggest that it is neither a lack of primary care, nor the time of day or night that drives patients to come to the ED.