Evolution in the choice of therapies used to treat latrodectism: Redback spider antivenom or standard analgesic medications. Nothing to rave about

Objectives

Redback spider (RBS) antivenom (RBSAV) use appears to have decreased since the results of the RAVE-2 antivenom efficacy study were released. The aims of this study were to assess change in RBSAV use over time and compare responses to treatment for antivenom and other analgesics.

Methods

Retrospective audit of RBS bite referrals to a toxicology unit, from January 2010 to January 2022. Data included demographics, pain severity, treatment (analgesia or RBSAV), response to treatment, re-presentation rate, adverse events, change in antivenom use over time.

Results

Of 270 presentations, 157 with moderate or severe pain were included (RBSAV n = 51, analgesia n = 106). Median age was 39 years, n = 81 (51%) female. Those receiving antivenom were more likely to report severe pain n = 46/51 (84%) versus n = 68/106 (58%) (P = 0.006). Eighty-three percent of antivenom doses were administered between 2010 and 2013. Analgesia-only group received various combinations of paracetamol, NSAIDs, and opioids. In those receiving RBSAV, 17/48 (35%), 26/48 (54%), 5/48 (10%) reported a partial, complete or no reduction in pain, respectively, versus 30/77 (39%), 43/77 (58%) and 4/77 (5%), for analgesia-only group. Post-treatment pain was not recorded in three RBSAV and 28 analgesia-only patients. Pain reduction was no different for intravenous and intramuscular antivenom. Re-presentation for ongoing pain was more common in the analgesia-only group, 16/106 (15%) versus 1/51 (2%) for antivenom (P = 0.013).

Conclusion

Antivenom use fell over the study period. There was no difference in pain relief between RBSAV and analgesia-only groups. RBSAV, regardless of route of administration, was no better than standard analgesics in pain reduction in the present study.     

Shortened preprocedural fasting in the pediatric emergency department

Background

There is no evidence of an association between fasting time and the incidence of adverse events during procedural sedation and analgesia. Pediatric and adult emergency medicine guidelines support avoiding delaying procedures based on fasting time. General pediatric guidelines outside emergent care settings continue to be vague and do not support a set fasting period for urgent and emergent procedures.

Computer-assisted optimization of aminophylline therapy in the emergency department

The emergency department (ED) is a unique setting for pharmacokinetic-guided drug administration because of the need to rapidly optimize therapy. We compared outcomes in patients receiving intravenous aminophylline according to population-based ED guidelines (group 1) or Bayesian-derived pharmacokinetic estimates (group 2), we determined predictors for admission or discharge in our study group, and we assessed the ability of a Bayesian pharmacokinetic model to estimate theophylline requirements in the ED. The study population was composed of 82 patients (42 males, 40 females) with a mean age of 43 +/- 15.5 years. Fifteen patients were excluded because of protocol violations. Of the 67 cases studied, 30 were assigned to group 1, and 37 were assigned to group 2. Patient demographics, baseline theophylline concentration, and theophylline loading dose did not differ significantly between treatment groups. The aminophylline maintenance infusion was significantly (P less than .001) lower in group 1 (0.4 +/- 0.2 mg/kg/h) than in group 2 (0.6 +/- 0.2 mg/kg/h). Serum theophylline concentrations at one hour post-loading-dose did not differ significantly between treatment groups; however, significant differences were observed at two hours post-load (P less than .002) and four hours post-load (P less than .001). Baseline peak flow rate (PFR) was significantly (P less than .03) higher in group 1 (170 +/- 85 L/min) than in group 2 (132 +/- 62 L/min), but did not differ significantly at any other times throughout the study. The PFR one hour post-load (PFR-1) was the strongest (P less than .003) predictor of outcome.(ABSTRACT TRUNCATED AT 250 WORDS)     

Complementary and alternative pain therapy in the emergency department

One primary reason patients go to emergency departments is for pain relief. Understanding the physiologic dynamics of pain, pharmacologic methods for treatment of pain, as well CAM therapies used in treatment of pain is important to all providers in emergency care. Asking patients about self-care and treatments used outside of the emergency department is an important part of the patient history. Complementary and alternative therapies are very popular for painful conditions despite the lack of strong research supporting some of their use. Even though evidenced-based studies that are double blinded and show a high degree of interrater observer reliability do not exist, patients will likely continue to seek out CAM therapies as a means of self-treatment and a way to maintain additional life control. Regardless of absolute validity of a therapy for some patients, it is the bottom line: "it seems to help my pain." Pain management distills down to a very simple endpoint, patient relief, and comfort. Sham or science, if the patient feels better, feels comforted, feels less stressed, and more functional in life and their practices pose no health risk, then supporting their CAM therapy creates a true wholistic partnership in their health care.CAM should be relatively inexpensive and extremely safe. Such is not always the case, as some patients have discovered with the use of botanicals. It becomes an imperative that all providers be aware of CAM therapies and informed about potential interactions and side effects when helping patients manage pain and explore adding CAM strategies for pain relief. The use of regulated breathing, meditation, guided imagery, or a massage for a pain sufferer are simple but potentially beneficial inexpensive aids to care that can be easily employed in the emergency department. Some CAM therapies covered here, while not easily practiced in the emergency department, exist as possibilities for exploration of patients after they leave, and may offer an improved sense of well-being and empowerment in the face of suffering and despair.The foundations of good nutrition, exercise, stress reduction, and reengagement in life can contribute much to restoring the quality of life to a pain patient. Adding nondrug therapies of physical therapy, cognitive-behavioral therapy, TENS, hypnosis, biofeedback, psychoanalysis, and others can complete the conventional picture. Adding in simple mind/body therapies, touch therapies, acupuncture, or others may be appropriate in select cases, and depending on the circumstances, may effect and enhance a conventional pain management program. Armed with an understanding of pain dynamics and treatments, practitioners can better meet patient needs, avoid serious side effects, and improve care when addressing pain management in the emergency department.     

Risk stratification of severe sepsis patients in the emergency department

Objective

To determine the efficacy of the Mortality in Emergency Department Sepsis (MEDS) score in the stratification of patients who presented to the emergency department (ED) with severe sepsis.

Methods

Adults who presented to the ED with severe sepsis were retrospectively recruited and divided into group A (MEDS score <12) and group B (MEDS score ⩾12). Their outcomes were evaluated with 28 day hospital mortality rate, length of hospital stay, Kaplan‐Meier survival analysis, and receiver operating characteristic (ROC) analysis. Discriminatory power of the MEDS score in mortality prediction was further compared with the Acute Physiology and Chronic Health Evaluation (APACHE) II model.

Results

In total, 276 patients (44.6% men and 55.4% women) were analysed, with 143 patients placed in group A and 133 patients in group B. Patients with MEDS score ⩾12 had a significantly higher mortality rate (48.9% v 17.5%, p<0.01) and higher median APACHE II score (25 v 20 points, p<0.01). Significant difference in mortality risk was also demonstrated with Kaplan‐Meier survival analysis (log rank test, p<0.01). No difference in the length of hospital stay was found between the groups. ROC analysis indicated a better performance in mortality prediction by the MEDS score compared with the APACHE II score (ROC 0.75 v 0.62, p<0.01).

Conclusion

Our results showed that mortality risk stratification of severe sepsis patients in the ED with MEDS score is effective. The MEDS score also discriminated better than the APACHE II model in mortality prediction.     

Perceived vs. actual distractions in the emergency department

IntroductionThe emergency department (ED) has been shown to be an interrupt-driven workplace fraught with potential for distractions and interruptions that increase the potential for medical error. Accuracy of provider perception of these distractions and interruptions has yet to be investigated.MethodsAn observational two-phase study was conducted over a 9-week period in the highest acuity zone of the ED at an urban, academic medical center with about 90,000 visits/year. Phase I, conducted over the initial 5-weeek period, consisted of observers recording the type and frequency of all overhead pages in the ED. In phase II, conducted over the final 4-week period, direct observation of faculty and residents was done to record all individual interruptions for different levels of training. Actual data was compared to provider perceptions, as determined by survey responses.Results2438 overhead pages were recorded and occurred, on average, 23.2 times per shift. The perceived rate of overhead pages was 43.2 per shift. 333 individual interruptions occurred, on average, 4.26 times per shift. The perceived rate was 53.5 per shift. Attending providers perceived a significantly higher number of individual interruptions compared to all resident providers.ConclusionThe perceived amount and rate of distractions and interruptions are significantly higher than the actual amount and rate of distractions and interruptions. Attending physicians both perceive and experience more distractions and interruptions. Further work should be done to evaluate the power of provider perception, and the potential contribution of inaccurate perception to medical error and provider burnout.     

Selective use of blood cultures in emergency department pneumonia patients

Our objectives were to identify factors associated with positive blood cultures and to evaluate blood culture use in the management of hospitalized pneumonia patients to limit their use. A retrospective chart review was conducted at a community teaching hospital. Emergency Department patients with an admission diagnosis of pneumonia during calendar years 2001-2002 were included. Patients younger than age 18 years and those with a non-pneumonia discharge diagnosis were excluded. Of 684 eligible patients, 23 (3.4%) had true positive blood cultures. All organisms were sensitive to empiric antibiotics. Three risk factors were associated with positive blood cultures: oxygen saturation < 90%, serum sodium < 130 and respiratory rate > 30 breaths/min. No patient had antibiotic coverage broadened based on blood culture results. Positive blood culture rates were low and did not affect the clinical management of pneumonia patients. We recommend eliminating blood cultures in community-acquired pneumonia (CAP) patients, but obtaining blood cultures in patients at risk for multi-drug resistant pathogens, such as health-care-associated pneumonia (HCAP) patients.     

Stroke patient evaluation in the emergency department before pharmacologic therapy

The standard of care for acute thromboembolic stroke is changing rapidly with the advent of new pharmacologic therapies. The deterioration of focal cerebral ischemia to infarction can be lessened with timely restoration of cerebral blood flow. As pharmacologic therapy of acute stroke evolves, emergency physicians will increasingly facilitate its implementation. The purpose of this study was to elucidate those factors significantly affecting the acute stroke patient's emergency department (ED) evaluation time. The pretreatment ED evaluations of 20 patients entered in an ongoing trial of a fibrinolytic agent (ancrod) for acute ischemic stroke were reviewed. Pretreatment screening factors included the assessment of hematologic status, concurrent illness, and potential neoplastic disease or cerebral hemorrhage as the etiology for the neurological deficit. The following factors had a statistically significant effect on pretreatment evaluation time (range, 2.6 to 11.4 hours) by multiple linear regression analysis: time from arrival until bleeding time completed (P less than .005), time from arrangement of computed head tomography until its completion (P less than .05), chosen site of treatment (ED v neurological step-down unit; P less than .005), order of patient entry (P less than .01), and time from arrival until completion of fibrinogen level assay (P less than .05). These results emphasize the need to coordinate and streamline the clinical evaluation process. The use of the ED as the site of treatment, abbreviating the time until pharmacologic therapy, has not been previously documented. Expedient completion of an evaluation compatible with safe pharmacologic therapy of acute ischemic stroke will dictate the time of definitive therapy. These results should assist other institutions considering rapid pharmacologic therapy for acute ischemic stroke.     

Pharmacological therapy of acute cardiogenic pulmonary oedema in the emergency department

This paper critically reviews the major drug types that are currently used in the management of acute cardiogenic pulmonary oedema. As decompensated heart failure becomes an increasingly common problem in emergency departments in the developed world, optimization of emergency drug therapy for these critically ill patients is essential. The evidence base for 'routine therapy' in the ED is considered. The review also briefly considers emerging pharmacological therapies that may have an impact on future management of cardiogenic pulmonary oedema.     

Different triage categorization using Emergency Severity Index (ESI) method in emergency department

Objective

Triage is basically a categorization process to prioritize various treatments for patients based on the types of disease, severity, prognosis and resource availability. However, the term triage is more appropriate to be used in the context of natural disaster or mass casualties. Within the context of emergency situation in emergency department, the term triage refers to a method used to assess the severity of patients’ condition, determine the level of priority, and mobilize the patients to the suitable care unit. ESI is a new concept of triage using five scales in classifying the patients in emergency department. The real implementation of this concept demands nurses have to immediately make assessment about patients’ condition right away, besides they must give their final decision, whether to move the patients to the ward or to let them leave the hospital.

Clinical presentation and management of an Aruban rattlesnake bite in the Netherlands

Bites by Aruban Rattlesnake (Crotalus durissus unicolor) are rare and not known to induce severe envenomations. Here, we present a case of a 57 year-old man bitten by his pet Aruban Rattlesnake (Crotalus durissus unicolor). He was admitted to hospital within 15?min. Three and a half hours later his fibrinogen concentration decreased to 0.6?g/L (normal: 2.0–4.0). Nine hours post-bite, he was treated with polyvalent snake antivenom covering Crotalus durissus. Three hours later his fibrinogen became undetectable while at that time clotting times were prolonged (PT 38.7?s (normal: 12.5–14.5) and aPTT 40?s (normal: 25–35)). His platelet count remained within normal limits. Creatine kinase (CK) concentrations reached a maximum of 1868?U/L (normal:?<200) 16?h post-bite. After a second antivenom dose, 10.5?h after the first antivenom administration, clotting times returned to normal. Fibrinogen was restored to normal within three days. He was discharged from hospital on day five. In conclusion, administration of polyvalent snake antivenom covering Crotalus durissus snakebites shows cross-neutralization and is effective in the treatment of patients bitten by Crotalus durissus unicolor.     

Procedural sedation in children with autism spectrum disorders in the emergency department

Background and objectivesChildren with autism spectrum disorder (ASD) present more frequently to the emergency department (ED) than children with normal development, and frequently have injuries requiring procedural sedation. Our objective was to describe sedation practice and outcomes in children with ASD in the ED.MethodsWe performed a retrospective chart review of children with ASD who underwent sedation at two tertiary care EDs between January 2009–December 2016. Data were collected on children 1–18 years of age with ASD who were sedated in the ED.ResultsThere were 6020 ED visits by children with ASD, 126 (2.1%) of whom received sedation. The most frequent indications for sedation were laceration repair (24.6%), incision and drainage (17.5%), diagnostic imaging (14.3%), and physical examination (11.9%). The most common sedatives used were ketamine (50.8%) and midazolam (50.8%). Ketamine was most commonly given intravenously (71.9%), while midazolam was usually given intranasally (71.9%). Procedures could not be completed in 4 (3.2%) patients, and adverse events were noted in 23 (18.3%) patients. Only four (3.2%) patients required supplemental oxygenation, and one received positive pressure ventilation.ConclusionsChildren with autism in the ED commonly received sedation; one in four of which were for non-painful diagnostic procedures or physical examination. Over one-third received sedation via a non-parenteral route for intended minimal sedation. Sedative medication dosing and observed adverse events were similar to those reported previously in children without ASD. Emergency providers must be prepared to meet the unique sedation needs of children with ASD.     

Ocular examination techniques for the emergency department

The purpose of this article is to provide a guide to assist the Emergency Physician in examining the eye. The evaluation of a patient with eye problems consists of a history, visual acuity, pupil examination, external examination, extra ocular movements, visual fields, and color vision. The patient is then examined at the slit lamp. After the slit lamp examination, the fundus and optic nerve is examined with a direct ophthalmoscope and intraocular pressure is measured. Special tests such as a plain film study and computed tomography (CT) scan may be obtained when indicated and, finally, referral to an ophthalmologist can be made for a dilated fundus examination, ultrasound studies of the eye and orbit, and surgical treatment.     

Equipment organization in the emergency department adult resuscitation area

It is important to design the resuscitation area in the emergency department to avoid restrictions to movement of personnel around the patient and to enable rapid and efficient access to equipment. The delivery of monitors and gases from above will reduce interference to flow by mechanical components. Preassembled airway equipment and the organization of equipment using an intuitive system, such as anatomic arrangement, aids in the rapid location of needed equipment.     

Thoracentesis in the emergency department

Presented is a review of thoracentesis, a procedure with which the emergency physician should be familiar. The pathophysiology of pleural effusions is described and is followed by a review of the clinical presentation and diagnosis. Special attention is given to technique and interpretation of results.     

Urolithiasis in the emergency department

Urolithiasis commonly presents to the emergency department with acute, severe, unilateral flank pain. Patients with a suspected first-time stone or atypical presentation should be evaluated with a noncontrast computed tomography scan to confirm the diagnosis and rule out alternative diagnoses. Narcotics remain the mainstay of pain management but in select patients, nonsteroidal anti-inflammatories alone or in combination with narcotics provide safe and effective analgesia in the emergency department. Whereas most kidney stones can be managed with pain control and expectant management, obstructing kidney stones with a suspected proximal urinary tract infection are urological emergencies requiring emergent decompression, antibiotics, and resuscitation.     

Hyperpyrexia in the emergency department

The differential diagnosis of the hyperpyrexic patient in the emergency department is extensive. It includes sepsis, heat illness including heat stroke, neuroleptic malignant syndrome, malignant hyperthermia, serotonin syndrome and thyroid storm. Each of these possible diagnoses has distinguishing features that may help to differentiate one from another. However, establishing the correct diagnosis is a challenge in the setting of the obtunded emergency patient who gives no history and where there may be limited access to any past medical or drug history. This paper presents such a case and reviews the features of the differential diagnoses and management of the hyperpyrexic patient.