Acute Pain In Emergency Department Research Articles

Intravenous paracetamol compared to non-steroidal anti-inflammatory drugs and opioids for acute pain in emergency departments.

Intravenous paracetamol compared to non-steroidal anti-inflammatory drugs and opioids for acute pain in emergency departments.

“Low-dose ketamine versus morphine in the treatment of acute pain in the emergency department: A meta-analysis of 15” randomized controlled trials

ObjectiveTo compare the effectiveness and safety of ketamine and morphine in adult patients with acute pain in emergency department (ED) by using a meta-analysis method. MethodsThis study was based on the Cochrane methodology for conducting a meta-analysis. Only randomized controlled trials (RCTs) were eligible for this study, with an experimental group that received low-dose ketamine and a control group that received morphine. The participants were adults who had acute pain in the ED. The primary outcome measures were the numeric rating scale (NRS) and visual analog scale (VAS). The secondary outcome measures were the complete resolution of pain, NRS reduction ≥3 points, NRS reduction ≥50% or 60%, change of NRS score, change of VAS score, rescue analgesia, satisfaction and adverse events. Subgroup analysis was performed for studies with intravenous and intranasal administration of ketamine. The Review Manager Database was used to analyze the included studies. Results15 RCTs involving 1768 patients were included. The ketamine group had lower NRS scores than morphine group at 30 min (MD, −0.77 [95% CI, −0.93 to −0.61]; p < 0.00001), while the morphine had better analgesic effects at 120 min after treatment (MD, 0.33 [95% CI, 0.15 to 051]; p = 0.0003). The subjects of complete resolution of pain in the ketamine group performed better than those in the morphine group at 15 min (RR 3.18, 95% CI 1.75 to 5.78; p = 0.0001). Compared with the morphine group, the ketamine group had a lower incidence of adverse events requiring intervention (RR, 0.34 [95% CI, 0.18 to 0.66]; p = 0.001). Subgroup analysis of intravenous ketamine showed that ketamine had lower VAS score than the morphine group at 30 min. However, also on the 30-min VAS score, intranasal ketamine analgesia was less effective than morphine. ConclusionsKetamine had better analgesic effects in the early stages after treatment, while morphine maintained more durable effects. Compared with morphine, ketamine had a lower incidence of adverse events requiring intervention. The results of subgroup analysis showed that intravenous administration of ketamine was more effective than intranasal administration.

IV Acetaminophen for Acute Pain in Emergency Departments

&#x0D; For adults with moderate to severe pain in the emergency department (ED), IV acetaminophen may offer similar levels of pain relief and a similar risk of adverse events as oral acetaminophen or IV nonsteroidal anti-inflammatory drugs (NSAIDs).&#x0D; For adults with moderate to severe pain in the ED, IV acetaminophen may offer a similar or modestly lower level of pain relief, and a lower risk of adverse events, when compared to IV opioids.&#x0D; We did not find any studies on the cost-effectiveness of IV acetaminophen compared to oral acetaminophen, IV NSAIDs, or IV opioids for treating patients with moderate to severe pain in the ED that met our inclusion criteria.&#x0D; One guideline recommends IV NSAIDs for the initial management of moderate to severe pain for patients in the ED. IV acetaminophen is recommended instead of IV opioids alone.&#x0D;

Effectiveness of Intranasal Analgesia in the Emergency Department.

In the Emergency Department (ED), pain is one of the symptoms that are most frequently reported, making it one of the most significant issues for the emergency physician, but it is frequently under-treated. Intravenous (IV), oral (PO), and intramuscular (IM) delivery are the standard methods for administering acute pain relief. Firstly, we compared the safety and efficacy of IN analgesia to other conventional routes of analgesia to assess if IN analgesia may be an alternative for the management of acute pain in ED. Secondly, we analyzed the incidence and severity of adverse events (AEs) and rescue analgesia required. We performed a narrative review-based keywords in Pubmed/Medline, Scopus, EMBASE, the Cochrane Library, and Controlled Trials Register, finding only twenty randomized Clinical trials eligible in the timeline 1992-2022. A total of 2098 patients were analyzed and compared to intravenous analgesia, showing no statistical difference in adverse effects. In addition, intranasal analgesia also has a rapid onset and quick absorption. Fentanyl and ketamine are two intranasal drugs that appear promising and may be taken simply and safely while providing effective pain relief. Intravenous is simple to administer, non-invasive, rapid onset, and quick absorption; it might be a viable choice in a variety of situations to reduce patient suffering or delays in pain management.

Low-dose Fosphenytoin for Aborting Acute Trigeminal Neuralgia Pain: A Case Report.

While the typical treatment for trigeminal neuralgia is carbamazepine, the dose must be gradually titrated over time to achieve pain control, which makes the drug a less than ideal candidate for treatment for acute exacerbation of pain due to trigeminal neuralgia in the emergency department (ED) setting. The literature for other effective treatments for acute exacerbations of trigeminal neuralgia is currently lacking. We discuss a case where intravenous (IV) fosphenytoin was used for treatment of acute pain due to trigeminal neuralgia in the ED. This is a case of a 35-year-old male diagnosed with trigeminal neuralgia who presented with acute facial pain. His history and physical exam were consistent with an acute exacerbation of his trigeminal neuralgia. The patient was refractory to multiple doses of standard pain medication in the ED, and the decision was made to attempt IV fosphenytoin to relieve his pain. He was given 250 milligrams of fosphenytoin that was infused via IV over 10 minutes. By the end of the infusion, the patient had reported complete resolution of his pain. Fosphenytoin is a viable treatment option for pain relief in patients with acute exacerbation of trigeminal neuralgia. It may be a more favorable drug to use in the ED for acute pain given that carbamazepine must be titrated to effect. It is also possible that lower doses of fosphenytoin may provide equally beneficial analgesic effect than what is described in the literature, as pain relief was achieved in our case with approximately 3 milligrams/kilogram of fosphenytoin.

Subanaesthetic single-dose ketamine as an adjunct to opioid analgesics for acute pain management in the emergency department: a systematic review and meta-analysis

ObjectiveTo evaluate the effectiveness of a subanaesthetic single-dose ketamine (SDK) as an adjunct to opioids for acute pain in emergency department (ED) settings.DesignSystematic review and meta-analysis.MethodsA systematic search was performed...

Emergency Department Experience and the Use of Non-Pharmacologic Treatment for Acute Pain Among Patients with Sickle Disease

Background: Appropriate management for patients presenting to the Emergency Department (ED) with acute pain from vaso-occlusive episodes (VOE) primarily includes treatment with parenteral opioid and non-opioid analgesia and fluids if the episode is uncomplicated. Non-pharmacological strategies that significantly affect non-physical aspects of behavioral, social, and cultural life, have been studied for pain treatment in sickle cell patients; however, the data on the effectiveness of these methods are limited. Objectives: This work aims to assess the overall ED experience among patients seeking care for acute VOE. We also aim to assess any effective alternative pain management strategies used by patients to treat their acute pain symptoms. Methods: We conducted ED follow up assessments for patients who sought care in the ED for acute pain from vaso-occlusive episodes from January 1, 2022- July 15, 2022. These were brief individual phone interviews. The semi-structured interview guide was created using a hospital specific patient experience questionnaire in addition to questions pertaining to pain management in the acute and day-to-day settings, demographic data including, age, sex, emergency department visit characteristics (length of stay (LOS), emergency severity index assignment (ESI), time to first opioid). The interviews were analyzed using a framework matrix analysis. This qualitative data reduction technique was used to review, summarize, and classify the interview data. NVivo 20 qualitative data analysis software includes a framework matrix tool used to manage data and facilitate this analysis in which participant comments about key content were aggregated and entered for review. Results: Overview: Among the 21 patients who met study criteria, eight participants are included in this analysis. Six participants identified as male, and two participants identified as female. ED Experience: Patients rated their ED care from a 3/10 to a 10/10 (avg 6.4, +/- 2.6). Common themes included prolonged wait times for pain management (6/8 participants). Five of the eight patients interviewed expressed gratitude for the care provided though noted some room for improvement. One participant noted "they could have been nicer to me. It's like they don't talk to each other" (2/8 participants). Patients also expressed frustration when intravenous access issues arise and compounding delays in treatment. Pain management: Three of the eight patients interviewed reported using scheduled opioids (oxycodone-5 patients, and methadone-2 patients) at home every 3-8 hours. One patient declined to answer questions about home opioid use. All patients received hydromorphone for acute management in the ED. Two of the eight patients expressed knowledge of their care coordination pain management plan. Alternative pain management: Five of the eight patients used heat or hot packs as their primary alternative pain management and specifically referenced this as an intervention that they would find helpful in the ED. Two patients prioritized distractions such as video games or other screen time. One patient relied on family support, massages, and meditation. Conclusions: Patients experiencing acute pain from VOE rely on the ED for care. Optimizing that care will not only improve patient's health, but also their well-being. Considering complementary alternatives for acute pain management including heat therapy (packs, blankets) as well as massage (heated chair) or distractions (video games, reading or movies) may provide additional benefits while patients seek care for acute pain crises.

Nurses' Perceptions of the Management of Acute Pain in Emergency Departments: Cross-sectional Study.

This study aimed to describe registered nurses' perceptions of acute pain management in emergency departments. The study design was a cross-sectional survey carried out in accordance with Strengthening the Reporting of Observational Studies in Epidemiology guidelines. One hundred one nurses from 5 different emergency departments participated in the survey. Data were analyzed using descriptive methods, nonparametric tests, and principal component analysis. Continuing education was significantly related to pain management. Nurses who had received continuing pain management education thought more often that challenges in pain management impact patients' acute pain management than those who had not received education. Nurses reported that patients received inadequate pain medication. The most used nonpharmacological methods were ice therapy and postural care. The nurses reported that music and conversation with the patient ameliorated the patients' acute pain. Nurses stated that their lack of knowledge concerning pain management and workload affected their acute pain management. Study results emphasize the need to develop ongoing pain management education for registered nurses and in addition to further research of nonpharmacological alleviation method in emergency departments.

Pain assessment tools for use with children in acute pain in the emergency department.

There is a lack of timely administration of an appropriate analgesic for children in acute pain in emergency departments in the UK and elsewhere. Unrelieved acute pain may result in deterioration in a child's physical and psychological condition therefore assessment is essential to enable triage nurses to offer an appropriate analgesic. This should be achieved by using a validated pain assessment tool which, where appropriate, enables the child to self-report their pain. This article describes various validated pain assessment tools for use with children with acute pain and considers how triage nurses can determine which is the most appropriate to use. Regardless of which tool is selected, it is important to offer the child an analgesic and to reassess their pain at appropriate intervals.

The Safety of High-Dose Intranasal Fentanyl in the Pediatric Emergency Department.

This study aimed to determine if the use of intranasal (IN) fentanyl in the pediatric emergency department of 2 to 5 μg/kg at doses greater than 100 μg is associated with adverse events in pediatric patients. We performed a retrospective chart review of patients receiving IN fentanyl at an urban, tertiary care emergency department in Memphis, TN, from January 1, 2011, to December 31, 2017. All adverse events documented through the hospital's voluntary safety reporting system involving IN fentanyl were reviewed to determine patient outcomes. A total of 3205 patients received greater than 100 μg of IN fentanyl during the study period from 2011 to 2017. The average (SD) patient age was 13.7 (2.65) years, ranging from 5 to 18 years. The mean (SD) initial dose was 162 (30) μg ranging from 102 to 265 μg (2 doses were given greater than 200 μg in the study period). Initial average (SD) dose for weight was 2.62 (0.5) μg/kg. A total of 13 adverse events were documented, with only 3 occurring at doses greater than 100 μg. No patients required the reversal agent naloxone or invasive respiratory support. To our knowledge, this is the first study using doses greater than 100 μg of IN fentanyl in a pediatric population. Our results indicate that fentanyl can be safely administered at doses of greater than 100 μg without any clinically significant adverse outcomes observed for 7 years of use. It is our hope that this information will increase utilization of IN fentanyl for treatment of acute pain in emergency departments and in the prehospital setting.

Evaluation of sex disparities in opioid use among ED patients with sickle cell disease, 2006–2015

Acute pain from a vaso-occlusive crisis (VOC) is a leading reason patients with sickle cell disease (SCD) visit the emergency department (ED). Prior studies suggest that women and men receive disparate ED treatment for acute pain in EDs. We aim to determine sex differences in analgesic use among patients with SCD presenting to the ED. This cross-sectional study uses data from the National Hospital Ambulatory Medical Care Survey (NHAMCS), 2006-2015. We identified ED patients with a primary diagnosis of SCD. Among patients with SCD, we evaluated sex differences in the use of opioid analgesia using logistic regression (adjusting for patient and visit characteristics). Analyses accounted for survey design and weighting. When evaluating the effect of sex on any opioid medication use in this population, though not significant, the odds that male patients were prescribed opioids was 1.5 (95% CI 0.8-2.8) times that of female patients after adjusting for age, the reason for visit, region, insurance status, and pain score. There was no significant difference in pain scores between male patients, 8.1 (95% CI 7.55-8.68) compared to female patients, 7.4 (95% CI 6.7-8.12). In this nationally representative sample of ED visits among patients with SCD, there was no conclusive evidence of sex disparities in opioid prescribing. Though there is evidence of a trend signaling that male patients with SCD were more likely than female patients to be prescribed an opioid.

Opioid Use During the Six Months After an Emergency Department Visit for Acute Pain: A Prospective Cohort Study

Despite the frequent use of opioids to treat acute pain, the long-term risks and analgesic benefits of an opioid prescription for an individual emergency department (ED) patient with acute pain are still poorly understood and inadequately quantified. Our objective was to determine the frequency of recurrent or persistent opioid use during the 6 months after the ED visit METHODS: This was a prospective, observational cohort study of opioid-naive patients presenting to 2 EDs for acute pain who were prescribed an opioid at discharge. Patients were followed by telephone 6 months after the ED visit. Additionally, we reviewed the statewide prescription monitoring program database. Outcomes included frequency of recurrent and persistent opioid use and frequency of persistent moderate or severe pain 6 months after the ED visit. Persistent opioid use was defined as filling greater than or equal to 6 prescriptions during the 6-month study period. During 9 months beginning in November 2017, 733 patients were approached for participation. Four hundred eighty-four met inclusion criteria and consented to participate. Four hundred ten patients (85%) provided 6-month telephone data. The prescription monitoring database was reviewed for all 484 patients (100%). Most patients (317/484, 66%; 95% confidence interval 61% to 70%) filled only the initial prescription they received in the ED. One in 5 patients (102/484, 21%; 95% confidence interval 18% to 25%) filled at least 2 prescriptions within the 6-month period. Five patients (1%; 95% confidence interval 0% to 2%) met criteria for persistent opioid use. Of these 5 patients, all but 1 reported moderate or severe pain in the affected body part 6 months later. Although 1 in 5 opioid-naive ED patients who received an opioid prescription for acute pain on ED discharge filled at least 2 opioid prescriptions in 6 months, only 1% had persistent opioid use. These patients with persistent opioid use were likely to report moderate or severe pain 6 months after the ED visit.

Solitary neurofibroma of the floor of the mouth: rare localization at lingual nerve with intraoral excision

BackgroundNeurofibromas (NF) are benign tumors of the peripheral nerves that are composed of Schwann cells, perineural-like cells and fibroblasts. The differential diagnosis for a solitary intraneural variant of neurofibroma arising in the floor of the mouth is broad and includes a submandibular gland neoplasm and adenopathy, among others. The intraoral approach is the best choice for a medium-sized lesion.Case presentationWe report a rare case of a solitary neurofibroma of the floor of the mouth in a 31-year-old male. The patient consulted the dental emergency department for acute pain of the left mandible. Systematic clinical examination revealed the presence of a mass in the left mouth floor. The panoramic x-ray was not conclusive and the magnetic resonance imaging (MRI) revealed a well-defined soft tissue lesion with homogenous isosignal intensity on the T1-weighted image, high intensity signal on the T2-weighted image and heterogeneous enhancement following contrast-enhancement on the T1-weighted Fast Sat image. The surgical excision of the soft-tissue neoplasm was accomplished by an intraoral approach. The specimen was sent for histopathologic analysis and Immunohistochemical studies which confirmed the diagnosis of a myxoid predominant intraneural solitary neurofibroma.ConclusionThe diagnosis of neurofibroma was confirmed by histopathological evaluation and immunohistochemical studies which also excluded other entities in the histopathologic differential diagnosis including schwannoma and a malignant peripheral nerve sheath tumor among other. Localized (solitary) neurofibromas most often occur as sporadic lesions, however; diagnosis of a solitary neurofibroma prompts clinical evaluation to exclude the remote possibility of neurofibromatosis. The purpose of this case report is to raise awareness of the uncommon presentation of neurofibroma and to document the successful management of such a lesion using an intraoral approach.

Utilization of Acupuncture Services in the Emergency Department Setting: A Quality Improvement Study.

Patients often present to the emergency department (ED) for pain. As opioid fatalities rise, alternative treatments are warranted for pain management. Acupuncture, a nonpharmacological treatment involving the insertion of needles into skin or tissue at specific points within the body, may help to decrease acute pain. Our study aimed to assess the utilization and impact of acupuncture in the ED for acute pain management. We conducted a retrospective analysis of purposefully collected quality improvement data. Patients who were ≥18 years old and who presented to the ED at an urban medical center in Wisconsin during 2017 were offered acupuncture services based on their emergency severity index (ESI; range: highest severity [1] - lowest severity [5]), reason for visit, and physician approval. Paired t-tests were used to examine mean differences between pre- and post-acupuncture pain, stress, anxiety, and nausea scores (range: none [0] - worst [10]). Multivariable regression models also were constructed. A total of 379 patients received acupuncture. Patients presented predominately with an ESI score of 3 (68.9%) or 4 (24.8%); 46.4% received opioids in the ED. Mean pre- and post-acupuncture pain scores significantly differed (6.5 vs 3.4; P<0.001); receiving opioids during the ED visit was not associated with improved pain scores (P=0.948). Stress (5.7 vs 1.9), anxiety (4.8 vs 1.6), and nausea (1.6 vs 0.6) scores also improved (P<0.001) following acupuncture. Emergency department acupuncture significantly decreased pain, stress, anxiety, and nausea. Our findings support a larger randomized controlled trial to further assesses the impact of acupuncture for acute pain in other ED settings.

To Evaluate Prophylactic Use of Antiemetic (Ondansetron) with Opioid Analgesics (Tramadol) for Acute Pain in Emergency Department

To Evaluate Prophylactic Use of Antiemetic (Ondansetron) with Opioid Analgesics (Tramadol) for Acute Pain in Emergency Department

Opioid Prescription Practices at Discharge and 30-Day Returns in Children with Sickle Cell Disease and Pain

Background: Acute pain episodes in children with sickle cell disease (SCD) represent a leading cause of readmissions. Lack of evidence-based guidelines contributes to variability in the management of children with SCD after hospitalization for acute pain. However, the impact of treatment variability on readmissions in this population has not been well studied. We examined prescription practices at time of discharge in children with SCD and acute pain to determine their impact on incidence of 30-day Emergency Department (ED) revisits and readmissions. We hypothesize that prescription of scheduled opioids after discharge for acute pain episodes is associated with lower 30-day ED revisits and readmissions when compared to the prescription of as needed or no opioids.Methods: We performed a single-institution, retrospective study of all patients with SCD aged 7 to 21 who were hospitalized or discharged from the ED with a diagnosis of acute pain episode from June 2009 to May 2014. Patients with ≥ 8 hospitalizations in a single year were excluded from the analysis. We reviewed demographic, treatment and discharge data from each encounter along with 30-day returns, defined as ED revisits and readmissions within 30 days of discharge. Between-groups comparisons for continuous variables were performed using the Mann-Whitney U test and categorical variables using the Chi-Square or Fisher's Exact test where appropriate. Independent predictors of 30-day returns were evaluated using multivariable logistic regression (IBM, SPSS v22).Results: We reviewed a total of 290 encounters (n=110, ED discharge; n=180, hospital discharge) in 97 patients (51% male, median 11.9 years old) during the 5-year period. Patients had hemoglobin SS or S/ß0 thalassemia in 209/290 (72%) encounters and were on hydroxyurea in 104/290 (36%). For hospitalizations (median length of stay 4 days), patients were treated with parenteral opioids in 159/180 (88%) encounters, most commonly by patient-controlled analgesia. Patients were prescribed opioids at the time of discharge in 259/290 (89%) encounters, more commonly at discharge from the hospital versus ED (96 vs. 79%, p < 0.01). The remaining patients were either prescribed non-steroidal anti-inflammatory drugs (NSAIDs) or a prescription was not given. Compared to as needed or no therapy, scheduled opioids were more frequently prescribed when discharged from the hospital versus ED (61 vs. 19%, p < 0.01). In total, 56/290 (19%) encounters resulted in 30-day ED revisits or readmissions after discharge from the hospital or ED. Compared to hospital discharges, discharge from the ED for acute pain was associated with a higher incidence of 30-day returns (OR = 2.7 [95% CI 1.5, 4.8], p < 0.01). Median number of days to return was also shorter for patients discharged from the ED versus hospital (4 vs. 11.5 days, p < 0.01). In general, we found no association between prescribed opioid frequency and incidence of 30-day returns. Prescription of scheduled opioids was similar between encounters that did or did not result in a 30-day ED revisit or readmission (46 vs. 48%, p = 0.8). Using multivariable logistic regression, we examined if other factors were associated with an increased incidence of 30-day returns. After discharge from the ED, the prescription of NSAIDs only, without opioids, was independently associated with a higher incidence of 30-day ED revisits but not readmissions. Neither 30-day ED revisits nor readmissions was affected by age, sex, genotype, or hydroxyurea use. After discharge from the hospital, none of these factors, including hospital length of stay or use of patient-controlled analgesia, were independently associated with 30-day ED revisits or readmissions.Conclusions: Variability exists in opioid prescription practices after discharge from the ED or hospital in children with SCD and acute pain episodes. Prescribed opioid frequency did not impact overall 30-day returns after discharge from the ED or hospital. After discharge from the ED, however, prescription of NSAIDs only, without opioids, was an independent predictor of higher 30-day ED revisits. Formalized studies to better understand factors that influence 30-day returns in children with SCD and acute pain are needed. Standardized approaches to outpatient opioid management after discharge and their impact on 30-day returns are also warranted in this population. DisclosuresNo relevant conflicts of interest to declare.

(171) Relations among pain variables and vital signs in patients presenting to the emergency department for acute pain, exacerbations of chronic pain, and acute pain with concurrent chronic pain

Pain, both acute and chronic, is a common cause for visits to the emergency department (ED). Some ED clinicians believe vital signs can be used as a measure of pain, supporting patient-reported pain intensity, although research has failed to confirm any clinically meaningful relationships. No studies have examined associations among psychological factors, vital signs, and pain intensity in patients presenting to the ED with exacerbations of chronic pain or compared the relationships among these variables in patients with acute pain, patients with exacerbations of chronic pain, and patients with chronic pain experiencing unrelated acute pain.

Quality Improvement Goals for Sickle Cell Disease Pain Management in an Urban Pediatric Emergency Department: We Can Do Better!.

AbstractAbstract 2101▪▪This icon denotes a clinically relevant abstract Background.Vaso-occlusive painful episodes (VOE) are the leading cause of hospitalizations and emergency department (ED) visits in sickle cell disease (SCD), and are associated with increased mortality. Although disparities specific to pain management practices in the ED for children with SCD have not been identified, ethnic disparities in ED care have been reported, & adults with SCD experience longer delays in the initiation of analgesics compared to other patients with pain. However, initiation of treatment in the ED is often delayed as a result of random events that are beyond anyone’s control, such as high patient volumes & acuity of other patients in the ED, even when policies are in place for immediate triage of patients with SCD & pain. In a recent study of children with SCD, median time from arrival to analgesia administration was 90 minutes, with high ED census as the biggest culprit for delays. Barriers to rapid care in the ED are common across the country, including overcrowding, nursing ratios, insufficient staff coverage, inadequate funding, & slow flow of patients from the ED to the wards in addition to patient acuity. Methods.As part of a quality improvement (QI) project to improve management of SCD pain in the ED at Children’s Hospital & Research Center Oakland, we are reviewing quality indicators to determine areas that can be targeted for improvement. ED-based data was collected and analyzed from a sample of 47 patients initially evaluated in the ED and enrolled in a randomized, placebo-control trial of argininetherapy for children with SCD hospitalized for VOE between years 2000–2008, and compared to recent data in 2012 of 55 ED visits for VOE (66% admissions) to identify trends in practice in our ED. Results.See Table 1. Conclusions.To these authors' surprise, children with SCD commonly experienced delays in pain management in the ED. These trends have not changed dramatically over a decade, and are not likely to be unique to our facility. Areas to target for improvement include time of arrival to parenteral pioid administration, in particular, time from ED room placement to placement of intravenous catheter. Utilizing intranasal fentanyl in the ED for acute pain is one novel intervention that should significantly decrease time to initial pain management. These reported data will be used as baseline quality measures for comparison to determine the success of QI initiatives such as a refined pain management algorithm on ED-based clinical outcomes.Table 1Arginine study (N=47) 2000-2008QI review (N=55) 2012Age (SD)13.9±414.5±6Gender, N (%)Male23 (49%)18 (33%)Female24 (51%)37 (67%)Diagnosis, N (%)Hb-SS33 (70%)41 (74.5%)Hb-SC9 (19%)14 (25.5%)Hb-Sickle β-thalassemia5 (11%)0 (0%)HU Use N (%)11 (23%)21 (38%)Triage to 1st Opioid dose ±SD (min)111±11496±41Triage to Room21±4812±13Room to IV Placement77±10273±46IV Placement to 1st Opioid Dose29±4217±261st Narcotic Dose to 2nd Opioid Dose124±8677±62ED Length of Stay±SD (hrs)5.4±2.75.6±2.25% Admissions100%65.5%Total Length of Hospital Stay±SD (days)4.5±2.53.4±2.3% IV Opioid given in < 30 min15%3%% 30–60 min11%13%% 60–120 min28%55%% IV Opioid given > 2 hours23%24%No IV Opioid (oral only/IV ketorolac)23%5% Disclosures:No relevant conflicts of interest to declare.

Physician ethnicity predicts successful ED analgesia

Management of acute pain in emergency departments (EDs) is highly variable and often inadequate. Some patient characteristics predict receipt of analgesics, including age and race, but understanding of the effect of provider characteristics on the ED pain experience is very limited. Our objective was to investigate the association of patient and provider characteristics, especially racial concordance of patient and provider, and reduction of pain intensity. We conducted a prospective, multicenter cohort study of patients presenting to one of 20 US or Canadian EDs with moderate to severe pain, and subsequently discharged after treatment.

Factors influencing pain management by nurses in emergency departments in Central Africa

Objective: To observe pain management practices by nurses in emergency departments (EDs) in Central Africa and to study the various factors influencing these practices. Methods: Time to first analgesic treatment was recorded in 53 patients presenting to the ED of a Central African hospital in February 2005. A survey was simultaneously conducted on the attitudes and commitment of nurses towards the management of pain. All 28 nurses assigned to the ED agreed to participate in the survey. Results: Severity of pain was the factor most influencing the time to first analgesia following admission to the ED. Severe pain was assessed as a score of ⩾7 on a 1–10 visual analogue scale. The median time to first analgesia in patients with severe pain was 150 min, which was considerably longer than in patients without severe pain (p = 0.003). A quarter of the 28 nurses had no official training in pain management and most (>80%) were unable to carry out a formal assessment of pain. The majority (>90%) were confident of their ability to treat pain. Thirteen (48%) were of the opinion that cultural factors influenced their management of pain and 67% admitted that they had some fears about administering morphine to patients in the ED. Conclusion: Pain management by nurses in the ED in Central Africa is inadequate. Cultural factors greatly influence how nurses manage pain in the emergency room. Patients would benefit considerably if nurses received additional education about the diagnosis and management of acute pain in EDs in Central Africa.