Use of a triage pain protocol in the ED

Purposes

This study was designed to evaluate the ability of a triage pain protocol to improve frequency and time to delivery of analgesia for musculoskeletal injuries in the emergency department (ED).

Basic Procedures

Frequency and time to analgesic administration were measured before and after use of a triage pain protocol. The protocol allowed analgesic medications to be given at the time of triage.

Main Findings

Time to medication administration was 76 minutes (95% confidence interval [CI], 68-84 minutes) before and 40 minutes (95% CI, 32-47 minutes) after the protocol. Five hundred fifty-nine (70%) of 800 patients received analgesics using the protocol compared with 212 of 471 (45%) patients prior.

Principal Conclusions

Use of a triage pain protocol increased the number of patients with musculoskeletal injury who received pain medication in the ED. Use of the protocol also resulted in a decrease in the time to analgesic medication administration.     

Racial/ethnic differences in emergency care for joint dislocation in 53 US EDs

Objective

The aim of the study was to investigate racial/ethnic differences in emergency care for patients with joint dislocation.

Methods

We performed a secondary analysis of the dislocation component of the National Emergency Department Safety Study. Using a principal diagnosis of dislocation, we identified emergency department (ED) visits for joint dislocations in 53 urban EDs across 19 US states between 2003 and 2005. Quality of care was evaluated based on 9 guideline-concordant care measures.

Results

Of the 1945 patients included in this analysis, 1124 (58%) were white; 561 (29%), black, and 260 (13%), Hispanic. One-third of the 53 EDs cared for 51% of minority patients. After multivariable adjustment, black patients were less likely to receive any analgesic treatment (odds ratio [OR], 0.68; 95% confidence interval [CI], 0.51-0.90) or opioid treatment (OR, 0.64; 95% CI, 0.41-0.997), waited longer to receive analgesia (mean difference in time to analgesic treatment, 32 minutes; 95% CI, 16-52 minutes), and were less likely to receive reassessments of pain (OR, 0.49; 95% CI, 0.34-0.70) compared with white patients. There were no ethnic disparities in most of the care measures between Hispanic and white patients. There were no disparities in initial pain assessment, pre- and postprocedural neurovascular assessment, procedural monitoring, or success of joint reduction across the racial/ethnic groups.

Conclusions

Black patients presenting to the ED with joint dislocations received lower quality of care in some, but not all, areas compared with white patients. Future interventions should target these areas to eliminate racial disparities in dislocation care.     

Efficacy of high-flow oxygen therapy in all types of headache: a prospective,randomized, placebo-controlled trial

Objective

We aimed to assess the efficacy of oxygen inhalation therapy in emergency department (ED) patients presenting with all types of headache.

Method

We performed a prospective, randomized, double-blinded, placebo-controlled trial of patients presenting to the ED with a chief complaint of headache. The patients were randomized to receive either 100% oxygen via nonrebreather mask at 15 L/min or the placebo treatment of room air via nonrebreather mask for 15 minutes in total. We recorded pain scores at 0, 15, 30, and 60 minutes using the visual analog scale. At 30 minutes, the patients were assessed for the need for analgesic medication. Patient headache type was classified by the treating emergency physician using standardized diagnostic criteria.

Results

A total of 204 patients agreed to participate in the study and were randomized to the oxygen (102 patients) and placebo (102 patients) groups. Patient headache types included tension (47%), migraine (27%), undifferentiated (25%), and cluster (1%). Patients who received oxygen therapy reported significant improvement in visual analog scale scores at all points when compared with placebo: 22 mm vs 11 mm at 15 minutes (P < .001), 29 mm vs 13 mm at 30 minutes (P < .001), and 55 mm vs 45 mm at 60 minutes (P < .001). When questioned at 30 minutes, 72% of patients in the oxygen group and 86% of patients in the placebo group requested analgesic medication (P = .005).

Conclusion

In addition to its role in the treatment of cluster headache, high-flow oxygen therapy may provide an effective treatment of all types of headaches in the ED setting.     

Patient anxiety may influence the efficacy of ED pain management

Objective

The aim of this study was to evaluate the incidence of anxiety and rates of anxiety treatment in emergency department (ED) patients presenting with pain-related complaints.

Methods

We prospectively evaluated patients in an urban academic tertiary care hospital ED from 2000 through 2010. We enrolled a convenience sample of adult patients presenting with pain and recorded patient complaint, medication administration, satisfaction, and pain and anxiety scores throughout their stay. We stratified patients into 4 different groups according to anxiety score at presentation (0, none; 1-4, mild; 5-7, moderate; 8-10, severe).

Results

We enrolled 10?664 ED patients presenting with pain-related complaints. Patients reporting anxiety were as follows: 25.7%, none; 26.1%, mild; 23.7%, moderate; and 24.5%, severe. Although 48% of patients described moderate to severe anxiety at ED presentation and 60% were willing to take a medication for anxiety, only 1% received anxiety treatment. Thirty-five percent of patients still reported moderate/severe anxiety at discharge. Severe anxiety at ED presentation was associated with increased demand for pain medication (odds ratio [OR], 1.40; 95% confidence interval [CI], 1.10-1.79) and anxiety medication (OR, 4.34; 95% CI, 3.68-5.11) during the ED stay and decreased satisfaction with the treatment of pain (β coefficient = − 0.328; P < .001). After adjusting for age, sex, and presentation pain scores, patients who reported severe anxiety were more likely to receive an analgesic (OR, 1.33; 95% CI, 1.19-1.50) and an opioid (OR, 1.25; 95% CI, 1.11-1.41) during the ED stay.

Conclusion

Anxiety may be underrecognized and undertreated in patients presenting with pain-related complaints. Patients reporting severe anxiety were less likely to report satisfaction with the treatment of their pain, despite higher rates of analgesic administration.     

Prospective, 10-year evaluation of the impact of Hispanic ethnicity on pain management practices in the ED

Introduction

Hispanic ethnicity has been reported as an independent risk factor for oligoanalgesia in the emergency department (ED).

Objectives

The objectives are to compare pain management practices in White and Hispanic patients in the ED to determine whether treatment differences exist.

Methods

Prospective analysis of a convenience sample of patients presenting to an urban, academic, tertiary-care ED over the 10-year period from 2000 to 2010. We compared patients with pain-related complaints of any nature, who self-identified their race as White or Hispanic, and evaluated initial morphine administration/dosing, arrival/disposition pain scores, and overall ED satisfaction scores (0-10 scale).

Results

Fifteen thousand sixty patients were enrolled. Eighty-one point 2 percent (n, 12 232) of the patients were White and 11.2% (n, 1680), Hispanic. White and Hispanic patients reported similar pain at presentation (6.7 vs 7.3, P < .001) and discharge/admission (4.6 vs 4.8, P = .14). Hispanic patients were not less likely to receive an analgesic during the ED visit (odds ratio, 1.06; confidence interval, 0.96-1.17; P = .62), nor less likely to receive an opioid analgesic (odds ratio, 0.97; confidence interval, 0.88-1.08; P = .70). Hispanic patients, on average, received similar initial doses of morphine (4.1 vs 4.3 mg, P = .29) and had similar wait times from arrival to initial dose of morphine (82 vs 86 minutes). Overall ED satisfaction scores were the same (8.7 vs 8.7, P = .65).

Conclusion

White and Hispanic patients were similar in rates of initial morphine administration for pain-related complaints. These findings contrast with previous studies reporting lower rates of initial analgesia administration among Hispanic patients in the ED.     

Inadequate provision of postintubation anxiolysis and analgesia in the ED

Introduction

Patients intubated in the emergency department (ED) often have extended ED stays. We hypothesize that ED intubated patients receive inadequate postintubation anxiolysis and analgesia after rapid sequence induction (RSI).

Methods

This was a retrospective cohort study of every adult intubated in a tertiary-care ED (July 2003-June 2004). Patients were included if they underwent RSI, remained in the ED for more than 30 minutes post intubation, and survived to admission. Presuming a mean patient weight of 70 kg, we defined adequacy of anxiolysis and analgesia on the provision postintubation of weight-based doses of lorazepam (0.77 mg/h) or midazolam (4.2 mg/h) and fentanyl (35 μg/h), referenced from pharmaceutical texts. Demographic data, time in ED, and dosage of each medication given were abstracted. The proportion, with 95% confidence intervals (CIs), of patients receiving inadequate anxiolysis and analgesia were computed.

Results

One hundred seventeen patients met the inclusion criteria. Mean time in the ED was 4.2 hours (SD ± 3.1 hours). Thirty-nine patients received no anxiolytic (33%, CI 25%-43%), and 62 received no analgesic (53%, CI 44%-62%). Twenty-three patients received neither anxiolytic nor analgesic (20%, CI 13%-28%). Of 70 patients given postintubation vecuronium, 67 received either no or inadequate anxiolysis or analgesia (96%, CI 87%-99%). Overall, 87 of 117 patients received no or inadequate anxiolysis (74%, CI 65%-82%); and 88 of 117 received no or inadequate analgesia (75%, CI 66%-83%).

Conclusion

Patients undergoing RSI in the ED frequently receive inadequate postintubation anxiolysis and analgesia.     

Efficacy and feasibility of acupuncture for patients in the ED with acute,nonpenetrating musculoskeletal injury of the extremities

Objectives

We conducted a pilot study to assess the efficacy of acupuncture as an analgesic intervention for patients presenting to the emergency department (ED) after minor acute trauma to the extremities. In addition, we sought to assess the feasibility of performing acupuncture in this setting.

Methods

Acupuncture was used as primary analgesia for a convenience sample of ED patients with acute, nonpenetrating extremity injury. Efficacy was measured using a visual analog scale before treatment, immediately after acupuncture (time 0), and every 30 minutes thereafter. A telephone call was made to patients within 72 hours to ascertain pain levels using a 0 to 10 numerical rating scale. Markers of feasibility included average time patients spent in the fast track area of the ED vs average time in the department (TID) for all fast track patients with similar injury.

Results

Of 47 patients approached, 20 (43%) consented to participate. The mean age of those who consented was 33 years, and 70% (n = 14) were male. Median change in visual analog scale score for preacupuncture vs time 0 was 16 mm, with range of 0 to 60 mm. Median numerical rating scale score at time of discharge and at follow-up was 3. Median TID was 135 minutes, with a range of 55 to 255 minutes. Patients with extremity injury who did not receive acupuncture had a median TID of 90 minutes.

Conclusions

This study suggests that acupuncture can be an effective analgesic intervention for patients with acute injury to the extremities. Acupuncture did not increase patients' TID. Minor complications were reported.     

Behavioral Problems of Seniors in an Emergency Department

Background

Behavioral disorders are frequent in seniors with cognitive impairments. The ailment responsible for presentation to the Emergency Department (ED), in combination with preexisting conditions, can bring about a temporary cognitive disturbance or worsen an existing cognitive disturbance, thus increasing the frequency of behavioral disorders.

Study Objectives

The purpose of this research was to investigate whether there is any connection between pain, cognitive impairment, time in the ED, presence or absence of a supportive escort, and behavioral disorders exhibited by a senior.

Methods

The study sample consisted of 140 seniors aged 69 years and older who visited the ED. Data collected included personal data, presence or absence of an escort, length of stay in the ED, and formal reproducible evaluation of cognition, behavior, and pain.

Results

Behavioral disorders were found to be present in 18% of the total sample and in 25% of the group of seniors who suffered from cognitive impairment. The presence of cognitive impairment was found to increase by almost sevenfold the risk of a behavioral disorder. Presence of severe pain increased the risk of a behavioral disorder even more (odds ratio 63). Seniors with cognitive impairment who spent a longer-than-average time period in the ED exhibited behavioral disorders that were more severe than disorders in seniors without cognitive impairment. There was no moderating effect on behavioral disturbances by the presence of a supportive escort observed.

Conclusions

The findings of this study suggest that the risk of behavioral disorders in seniors attending the ED may be predicted by screening them for cognitive impairment and pain, and by monitoring the time period they are in the ED.     

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.     

National ED crowding and hospital quality: results from the 2013 Hospital Compare data

Objectives

We explored Hospital Compare data on emergency department (ED) crowding metrics to assess characteristics of reporting vs nonreporting hospitals, whether hospitals ranked as the US News Best Hospitals (2012-2013) vs unranked hospitals differed in ED performance and relationships between ED crowding and other reported hospital quality measures.

Methods

An ecological study was conducted using data from Hospital Compare data sets released March 2013 and from a popular press publication, US News Best Hospitals 2012 to 2013. We compared hospitals on 5 ED crowding measures: left-without-being-seen rates, waiting times, boarding times, and length of stay for admitted and discharged patients.

Results

Of 4810 hospitals included in the Hospital Compare sample, 2990 (62.2%) reported all ED 5 crowding measures. Median ED length of stay for admitted patients was 262 minutes (interquartile range [IQR], 215-326), median boarding was 88 minutes (IQR, 60-128), median ED length of stay for discharged patients was 139 minutes (IQR, 114-168), and median waiting time was 30 minutes (IQR, 20-44). Hospitals ranked as US News Best Hospitals 2012 to 2013 (n = 650) reported poorer performance on ED crowding measures than unranked hospitals (n = 4160) across all measures. Emergency department boarding times were associated with readmission rates for acute myocardial infarction (r = 0.14, P < .001) and pneumonia (r = 0.17, P < .001) as well as central line–associated bloodstream infections (r = 0.37, P < .001).

Conclusions

There is great variation in measures of ED crowding across the United States. Emergency department crowding was related to several measures of in-patient quality, which suggests that ED crowding should be a hospital-wide priority for quality improvement efforts.     

Prospective evaluation of the treatment of pain in the ED using computerized physician order entry

Background

Treatment of pain in the emergency department (ED) is a significant area of focus, as previous studies have noted generally inadequate treatment of pain in ED patients. Previous studies have not evaluated the impact of computerized physician order entry (CPOE) on the treatment of pain in the ED. We sought to evaluate treatment of pain before and after implementation of CPOE in an academic ED.

Methods

We prospectively enrolled a convenience sample of patients presenting to the ED with a pain-related complaint in 4-month periods before and after CPOE implementation. We compared numbers who received pain medications, time from registration to administration of pain medication, and repeat dosing of pain medication.

Results

Six hundred forty-six ED patients participated in the pre-CPOE period, whereas 592 patients participated post-CPOE. Similar numbers of patients received pain medications in the pre-CPOE and post-CPOE periods (55% vs 59%; P = .139), whereas those in the post-CPOE period were more likely to receive a repeat dose of pain medications (10.5% vs 17.6%; P < .001).

Conclusion

The use of CPOE in the ED may offer modest benefits in the treatment of patients with pain-related complaints.     

Triage pain scales cannot predict analgesia provision to pediatric patients with long-bone fracture

Purpose

This study evaluated the effects of pain assessment at triage on analgesia provision to pediatric patients with closed long-bone fractures in the emergency department (ED).

Methods

This was a retrospective cohort study conducted at a university-affiliated teaching hospital. Children who presented to the ED of a teaching hospital with the main diagnosis of a closed fracture of the extremities in 2007 constituted the study cohort. We reviewed the charts and collected the following variables regarding the subjects' ED visits: patient demographics, pain scale reassessment, category of fracture, associated injuries, time from triage to the first administration pain medication, and the route and type of analgesic. The data were divided on the basis of triage in accordance with pain assessment or other triage modifiers.

Results

In our study, 211 (54.7%) patients enrolled received analgesia. Oral acetaminophen was the most commonly prescribed medication (131 patients, 62.1%), whereas opioids were used in only 24 (11.4%) patients. The average time taken to deliver analgesia to children arriving in our ED was 70 minutes. The logistic regression analysis indicated that enrolled patients triaged based on the pain assessed at triage was not associated with the subsequent provision of analgesia. Analgesia provision was not associated with patients with moderate or severe pain assessed at triage as compared to patients with mild pain.

Conclusion

The pain management of pediatric patients with closed long-bone fractures in the ED was inadequate and delayed. Moreover, the pain assessment at triage did not predict analgesia provision to these patients.     

Transbuccal fentanyl for rapid relief of orthopedic pain in the ED

Objectives

This study's objectives were to assess administration of a rapidly dissolving transbuccal fentanyl tablet to patients in emergency department (ED) with orthopedic extremity pain. The main end point was time required to achieve a 2-point drop on a 0 to 10 pain scale.

Methods

In this double-blind trial, subjects received either transbuccal fentanyl, 100 μg, and a swallowed placebo, or a swallowed oxycodone/acetaminophen, 5/325-mg pill, and a nonanalgesic transbuccal comparator. Pain assessment occurred every 5 minutes for an hour, and vital signs were monitored for 2 hours.

Results

Transbuccal fentanyl was associated with faster pain relief onset (median, 10 vs 35 minutes; P < .0001). Secondary end points (pain relief magnitude, rescue medication rate, subject preference for medication on future visit) favored transbuccal fentanyl. No vital sign abnormalities or significant side effects occurred in the ED or on 100% next-day follow-up.

Conclusions

Transbuccal fentanyl shows promise for continued investigation as a means to safely provide rapid and effective pain relief for ED patients.     

Racial disparity in analgesic treatment for ED patients with abdominal or back pain

Objective

Research on how race affects access to analgesia in the emergency department (ED) has yielded conflicting results. We assessed whether patient race affects analgesia administration for patients presenting with back or abdominal pain.

Methods

This is a retrospective cohort study of adults who presented to 2 urban EDs with back or abdominal pain for a 4-year period. To assess differences in analgesia administration and time to analgesia between races, Fisher exact and Wilcoxon rank sum test were used, respectively. Relative risk regression was used to adjust for potential confounders.

Results

Of 20?125 patients included (mean age, 42 years; 64% female; 75% black; mean pain score, 7.5), 6218 (31%) had back pain and 13?907 (69%) abdominal pain. Overall, 12?109 patients (60%) received any analgesia and 8475 (42%) received opiates. Comparing nonwhite (77 %) to white patients (23%), nonwhites were more likely to report severe pain (pain score, 9-10) (42% vs 36%; P < .0001) yet less likely to receive any analgesia (59% vs 66%; P < .0001) and less likely to receive an opiate (39% vs 51%; P < .0001). After controlling for age, sex, presenting complaint, triage class, admission, and severe pain, white patients were still 10% more likely to receive opiates (relative risk, 1.10; 95% confidence interval, 1.06-1.13). Of patients who received analgesia, nonwhites waited longer for opiate analgesia (median time, 98 vs 90 minutes; P = .004).

Conclusions

After controlling for potential confounders, nonwhite patients who presented to the ED for abdominal or back pain were less likely than whites to receive analgesia and waited longer for their opiate medication.     

Is Pelvic Ultrasound Associated with an Increased Time to Appendectomy in Pediatric Appendicitis?

Background

Appendicitis is a common pediatric condition requiring urgent surgical intervention to prevent complications. Pelvic ultrasound (US) as a diagnostic aid has become increasingly common. Despite its advantages, evidence suggests US can lead to delayed definitive management.

Objective

The objective was to test the hypothesis that US is associated with an increased time to appendectomy in children with acute appendicitis.

Methods

A chart review was conducted of all children aged 0−17 years who presented to the pediatric emergency department (ED) with a discharge diagnosis of appendicitis. The primary outcome variable was the interval between initial evaluation to appendectomy between patients who received an US and those who did not.

Results

Of 662 cases included, 424 patients (64%) underwent a pelvic US and 238 patients underwent an appendectomy without US. Median time interval from initial evaluation in the ED by a physician to appendectomy among patients who received an US was 9.7 h (interquartile range [IQR]: 6.8−15.0 h) compared with 5.5 h (IQR: 3.8−8.6 h) among patients who did not receive an US (Mann-Whitney, p < 0.001). The increased time to appendectomy in patients who received an US was dependent on the patient being female and presenting to the ED after hours (univariate analysis of variance test for interaction, p < 0.05).

Conclusions

Female pediatric patients and those presenting after hours that undergo an US have a significantly increased time to appendectomy compared with those who do not undergo diagnostic imaging.     

Time to antibiotics for septic shock: evaluating a proposed performance measure

Purposes

International guidelines recommend antibiotics within 1 hour of septic shock recognition; however, a recently proposed performance measure is focused on measuring antibiotic administration within 3 hours of emergency department (ED) arrival. Our objective was to describe the time course of septic shock and subsequent implications for performance measurement.

Basic procedures

Cross-sectional study of consecutive ED patients ultimately diagnosed with septic shock. All patients were evaluated at an urban, academic ED in 2006 to 2008. Primary outcomes included time to definition of septic shock and performance on 2 measures: antibiotics within 3 hours of ED arrival vs antibiotics within 1 hour of septic shock definition.

Main findings

Of 267 patients with septic shock, the median time to definition was 88 minutes (interquartile range, 37-156), and 217 patients (81.9%) met the definition within 3 hours of arrival. Of 221 (83.4%) of patients who received antibiotics within 3 hours of arrival, 38 (17.2%) did not receive antibiotics within 1 hour of definition. Of 207 patients who received antibiotics within 1 hour of definition, 11.6% (n = 24) did not receive antibiotics within 3 hours of arrival. The arrival measure did not accurately classify performance in 23.4% of patients.

Principal conclusions

Nearly 1 of 5 patients cannot be captured for performance measurement within 3 hours of ED arrival due to the variable progression of septic shock. Use of this measure would misclassify performance in 23% of patients. Measuring antibiotic administration based on the clinical course of septic shock rather than from ED arrival would be more appropriate.     

Ultrasound-guided femoral nerve blocks in elderly patients with hip fractures

Objectives

The primary objective of this study was to determine the feasibility of ultrasound-guided femoral nerve blocks in elderly patients with hip fractures in the emergency department (ED). The secondary objective was to examine the effectiveness of this technique as an adjunct for pain control in the ED.

Methods

This prospective observational study enrolled a convenience sample of 13 patients with hip fractures. Ultrasound-guided femoral nerve block was performed on all participants. To determine feasibility, time to perform the procedure, number of attempts, and complications were measured. To determine effectiveness of pain control, numerical rating scores were assessed at baseline and at 15 minutes, 30 minutes, and hourly after the procedure for 4 hours. Summary statistics were calculated for feasibility measures. Wilcoxon matched-pairs signed-rank tests and Friedman analysis of variance test were used to compare differences in pain scores.

Results

The median age of the participants was 82 years (range, 67-94 years); 9 were female. The median time to perform the procedure was 8 minutes (range, 7-11 minutes). All procedures required only one attempt; there were no complications. After the procedure, there were 44% and 67% relative decreases in pain scores at 15 minutes (P ≤ .002) and at 30 minutes (P ≤ .001), respectively. Pain scores were unchanged from 30 minutes to 4 hours after the procedure (P ≤ .77).

Conclusions

Ultrasound-guided femoral nerve blocks are feasible to perform in the ED. Significant and sustained decreases in pain scores were achieved with this technique.     

Management of Benign Paroxysmal Positional Vertigo: A Randomized Controlled Trial

Background

Benign paroxysmal positional vertigo (BPPV) is a common presenting problem.

Objective

Our aim was to compare the efficacy of vestibular rehabilitation (maneuver) vs. conventional therapy (medications) in patients presenting to the emergency department (ED) with BPPV.

Methods

This was a prospective, single-blinded physician, randomized pilot study comparing two groups of patients who presented to the ED with a diagnosis of BPPV at a Level 1 trauma center with an annual census of approximately 75,000. The first group received standard medications and the second group received a canalith repositioning maneuver. The Dizziness Handicap Inventory was used to measure symptom resolution.

Results

Twenty-six patients were randomized; 11 to the standard treatment arm and 15 to the interventional arm. Mean age ± standard deviation of subjects randomized to receive maneuver and medication were 59 ± 12.6 years and 64 ± 11.2 years, respectively. There was no significant difference in mean ages between the two treatment arms (p = 0.310). Two hours after treatment, the symptoms between the groups showed no difference in measures of nausea (p = 0.548) or dizziness (p = 0.659). Both groups reported a high level of satisfaction, measured on a 0−10 scale. Satisfaction in subjects randomized to receive maneuver and medication was 9 ± 1.5 and 9 ± 1.0, respectively; there was no significant difference in satisfaction between the two arms (p = 0.889). Length of stay during the ED visit did not differ between the treatment groups (p = 0.873). None of the patients returned to an ED for similar symptoms.

Conclusions

This pilot study shows promise, and would suggest that there is no difference in symptomatic resolution, ED length of stay, or patient satisfaction between standard medical care and canalith repositioning maneuver. Physicians should consider the canalith repositioning maneuver as a treatment option.