Evaluation Of Emergency Department Patients Research Articles

142 Derivation and Validation of a Clinical Risk Score to Predict Need for Intensive Care Unit Utilization After Initial Emergency Department Evaluation of Patients With Acute Traumatic Injuries

142 Derivation and Validation of a Clinical Risk Score to Predict Need for Intensive Care Unit Utilization After Initial Emergency Department Evaluation of Patients With Acute Traumatic Injuries

Multi-slice CT Angiography “Triple Rule Out technique” in the Evaluation of Emergency Department Patients with Acute Chest Pain Having Low to Intermediate Risk for Acute Coronary Syndrome

Multi-slice CT Angiography “Triple Rule Out technique” in the Evaluation of Emergency Department Patients with Acute Chest Pain Having Low to Intermediate Risk for Acute Coronary Syndrome

Direct ophthalmoscopy in the evaluation of emergency department patients with headache: Time to rethink?

Direct ophthalmoscopy in the evaluation of emergency department patients with headache: Time to rethink?

A Novel Ocular Tonometry Task Trainer.

The measurement of intraocular pressure via ocular tonometry is a skill necessary for the evaluation of emergency department patients with ocular complaints. Accurate results inform the use of time-sensitive medications or invasive procedures. We sought to develop and evaluate an affordable, realistic, and reproducible task trainer to allow Emergency Medicine residents and medical students to practice tonometry. We placed an angiocatheter into the vitreous chamber of a swine eye through the optic nerve stump and sealed it with a purse string suture and cyanoacrylate glue. This allowed us to connect intravenous extension tubing and use a saline-filled syringe to repeatedly adjust intraocular pressure in real time. Optionally, this model can be mounted in a polystyrene foam mannequin head to enhance realism and facilitate practice. The task trainer was implemented in medical student and Emergency Medicine resident education at Vanderbilt University Medical Center. Thirty-six learners participated in the study, all of whom completed pre-course and post-course surveys. Among all learners, the mean comfort with performing tonometry improved significantly (3.26 to 7.64 {Z = -4.95, p < 0.005}). The mean confidence in the accuracy of measurements also increased (3.11 to 7.56 {Z = -4.8, p < 0.005}). On a 10-point scale, learners felt this task trainer was highly helpful in increasing their comfort with and the ability to perform tonometry (mean 9.19 {SD 1.19}). We have developed a low-cost and easily constructed ocular tonometry task trainer that resulted in significant improvement in learner comfort and confidence.

Direct cost analysis of rapid MRI in the emergency department evaluation of patients suspected of having acute ischemic stroke*.

Abbreviated "rapid MRI" protocols have become more common for the evaluation of acute ischemic stroke (AIS). Prior research has not evaluated the effect of rapid MRIs on cost or hospital length of stay in AIS patients. We retrospectively identified AIS patients who presented within 6h of acute neurologic symptom onset to an emergency department (ED) and activated a "brain attack" code. We included sequential patients from January 2012 to September 2015, before rapid MRI was available, who had CT perfusion (CTP) and compared them to patients from October 2015 to May 2018 who had a rapid MRI. We used inverse-probability-weighting (IPW) to balance the cohorts. The primary outcomes were direct cost to our healthcare system and total hospital length of stay (LOS). We included 408 brain attack activations (mean ± SD age 62.1 ± 17.6years, 47.8% male): 257 in the CTP cohort and 151 in the MRI cohort. Discharge diagnosis was ischemic stroke in 193/408 (47.3%). After patient matching, we found significant reductions for the MRI cohort in total cost (-18.7%, 95% CI -35.0, -2.4, p = 0.02) and hospital LOS (-17.0%, 95% CI -31.2, -2.8, p = 0.02), with no difference in ED LOS (p = 0.74) as compared to the CTP cohort. Although these results are preliminary and hypothesis-generating, we found that the use of a rapid MRI protocol in emergency department brain attacks was associated with a 18.7% reduction in total direct cost and 17% reduction in hospital length of stay.

Documentation of neurovascular assessment in fracture patients in a tertiary care hospital: A retrospective review

IntroductionNeurovascular problems are common in acute fracture. In the emergency room, a thorough clinical evaluation is required, when examined by an orthopedic specialist or emergency doctors. Materials and methodswe registered our project with the audit department. In the first cycle, we looked at notes from 77 patients from November–December 2020, emphasis to neurovascular documentation from both ED and orthopedic Clerking notes. We submitted our findings at our audit meeting and implemented modifications. Two months later, we re-audited, this time with 82 patients as the sample size. Results77 patient notes were reviewed in the first cycle, 51% male and 49% female. In ED clerking notes, 22% patients had no neurovascular documentation, compared to 3.8% of patients in orthopedic clerking. 39% ED notes had acronyms written for the neurovascular status, such as NVI, to 20.7% of orthopedic notes. 82 notes were reviewed in the second cycle,44% male and 56% female.7% of ED clerking notes lacked any neurovascular comments, compared to 0% of orthopedic admission sheets. 10% of the ED sheets contained NVI abbreviation, while 4% of ortho notes had the same. There were specific notes on neurovascular state on 68 of the ED admission sheets evaluated, and 74 of the orthopedic notes did the same. ConclusionIn fracture patients, documentation of neurovascular condition was lacking. The documentation of the details of the neurovascular assessment was poor. Increased recording of neurovascular assessment and improved emergency department evaluation of patients presenting with upper and lower limb injuries were aided by the introduction of teachings.

Emergency Department Evaluation of Patients with Vertigo: HINTS and Neuroimaging (2650)

Emergency Department Evaluation of Patients with Vertigo: HINTS and Neuroimaging (2650)

Evaluation, Treatment, and Outcomes of Patients With Suspected Acute Coronary Syndrome in the Prehospital and Emergency Department: Findings From a Prospective Multicenter Registry in China

Background: Early evaluation and treatment of patients with suspected acute coronary syndrome (ACS) poses a huge challenge to the emergency care system worldwide, but little is known about the contemporary prehospital and emergency department management of these patients. We aimed to investigate the early evaluation, treatment, and outcome of suspected ACS in a representative population of China. Methods: We did a prospective registry study involving a network of 23 emergency departments in China. Each participating site consecutively enrolled adult patients presenting with symptoms suggestive of ACS for at least 12 months between August 2015 and September 2017. All findings were weighted by sampling ratio and variation among EDs in enrollment period. Findings: A total of 13 919 patients were screened. Of those included in the analysis, mean age was 63·8±13·6 years, 57·9% were men. After symptom onset, 40·5% of the patients arrived at emergency department within two hours, and 17·9% were transported by ambulance. Upon arrival to the emergency department, 75·6% had their first ECG completed within ten minutes. Among patients without ST-segment elevation, 10·3% had serial ECGs, 56·6% had serum cardiac biomarkers measured, and 6·4% had serial cardiac biomarkers. Stress test and computed tomography angiography were rarely performed for evaluation. Among patients with ST-segment elevation, 57·3% underwent reperfusion therapy, with 51·3% receiving primary percutaneous coronary intervention and 6·3% receiving fibrinolysis. Post-hoc adjudication showed that over 60% of patients could be attributed to ACS, of which 10·2% received antiplatelet therapy prior to presentation, and by the time of emergency department disposition, 51·1% received antiplatelet therapy. Overall, the emergency department mortality rate was 0·5%, and the 30-day mortality and major adverse cardiac event rates were 3·8% and 6·8%, respectively. Interpretation: The pre-hospital and emergency department evaluation of patients with suspected ACS is insufficient in China. For those with ACS, gaps existed in the early medication and reperfusion therapy as per guidelines. These findings suggest opportunities to improve the quality of early management for suspected ACS and further reduce adverse cardiac events in China. Clinical Trial Registration Details: This study was registered at URL: https://www.clinicaltrials.gov (Unique identifier: NCT02536677). Funding Information: This work was supported by National S&T Fundamental Resources Investigation Project [2018FY100600, 2018FY100602], Shandong Provincial Natural Science Foundation [ZR2017PH070], Taishan Pandeng Scholar Program of Shandong Province [tspd20181220], Taishan Young Scholar Program of Shandong Province [tsqn20161065, tsqn201812129], Key R&D Program of Shandong Province [2020SFXGFY03, 2019GSF108073] and Qilu Young Scholar Program. Declaration of Interests: All authors declare no competing interests. Ethics Approval Statement: The study complies with the Declaration of Helsinki and was approved by the ethical committees of all participating sites. Informed consent was required from each patient to participate in the study.

A Standardized Patient Experience: Elevating Interns to Expected Level of Clinical Competency.

IntroductionMedical students transition to intern year with significant variability in prior clinical experience depending on their medical school education. This leads to notable differences in the interns’ ability to perform focused histories and physical exams, develop reasoned differentials, and maximize care plans. Providing a foundational experience for these essential skills will help to establish standardized expectations despite variable medical school experiences.MethodsDuring an orientation block, interns participated in a standardized patient experience. Interns were presented with three common chief complaints: abdominal pain; chest pain; and headache. Faculty observed the three patient encounters and provided immediate verbal and written feedback to the interns based on a standardized grading rubric.ResultsAll residents that participated “agreed” or “strongly agreed” that the experience was a meaningful educational experience. 90% of the interns reported the experience would change their clinical practice. Additionally, 75% of residents survyed one year after the experience felt the experience changed their clinical practice. Faculty felt the learning experience allowed them to address knowledge gaps early and provide early guidance where needed.ConclusionThis article describes an emergency medicine residency program’s effort to provide a foundational experience for interns in evaluating emergency department patients. The intent was to “level the playing field” and establish “good habits” early in intern year with the realization that prior experiences vary significantly in July of intern year.

Abstract 13670: Single versus Serial Measurements of Cardiac Troponin in the Evaluation of Emergency Department Patients With Suspected Acute Myocardial Infarction

Introduction: Chest pain is among the most common reasons for emergency department (ED) presentations. However, most patients are low risk for acute coronary syndrome (ACS) with low cardiac adverse outcomes. Biomarker testing with troponins is the mainstay of initial assessment for ACS. Although serial troponin testing can improve diagnosis of ACS, in clinical practice, some patients deemed to be low risk are discharged after a single negative troponin measurement. Our study evaluated the safety of single-troponin rule-out strategy using a conventional troponin assay. Hypothesis: We assessed the hypothesis that there is no significant difference in the clinical outcomes of patients deemed low-risk and discharged after a single negative troponin compared to patients discharged after serial troponin measurements. Methods: This is a retrospective study of ED encounters from January 2015 to December 2017 across 13 community emergency departments within an integrated healthcare system in Southern California. The study cohort includes adult ED encounters evaluated for suspected ACS with a HEART score and an initial conventional troponin-I below the level of detection (&lt;0.02). Multivariate logistic regression model was performed to evaluate the association between testing strategies and clinical outcomes. Results: Among 27,918 patients with an initial troponin measurement below the level of detection, 14,459 (51.8%) were discharged after a single measurement, and 13,459 patients (48.2%) had serial troponin orders. After adjusting for cardiac risk factors and comorbidities, there was no statistically significant difference in the primary outcome of AMI or cardiac mortality within 30 days between the two groups (single troponin 0.4% vs. serial troponin 0.4%, OR 1.41, 95% CI (0.96-2.07)). Single troponin was associated with a lower rate of CABG (OR 0.24, 95% CI: 0.11-0.48) and invasive coronary angiogram (OR 0.46, 95% CI: 0.38-0.56). Conclusions: When compared to serial troponin testing, discharge after a single negative troponin is routinely done among ED patients, and appears safe based on current physician decision making with no difference in rates of 30-day cardiac mortality and AMI.

Identifying patients with symptoms suspicious for COVID-19 at elevated risk of adverse events: The COVAS score.

ObjectiveDevelop and validate a risk score using variables available during an Emergency Department (ED) encounter to predict adverse events among patients with suspected COVID-19.MethodsA retrospective cohort study of adult visits for suspected COVID-19 between March 1 – April 30, 2020 at 15 EDs in Southern California. The primary outcomes were death or respiratory decompensation within 7-days. We used least absolute shrinkage and selection operator (LASSO) models and logistic regression to derive a risk score. We report metrics for derivation and validation cohorts, and subgroups with pneumonia or COVID-19 diagnoses.Results26,600 ED encounters were included and 1079 experienced an adverse event. Five categories (comorbidities, obesity/BMI ≥ 40, vital signs, age and sex) were included in the final score. The area under the curve (AUC) in the derivation cohort was 0.891 (95% CI, 0.880–0.901); similar performance was observed in the validation cohort (AUC = 0.895, 95% CI, 0.874–0.916). Sensitivity ranging from 100% (Score 0) to 41.7% (Score of ≥15) and specificity from 13.9% (score 0) to 96.8% (score ≥ 15). In the subgroups with pneumonia (n = 3252) the AUCs were 0.780 (derivation, 95% CI 0.759–0.801) and 0.832 (validation, 95% CI 0.794–0.870), while for COVID-19 diagnoses (n = 2059) the AUCs were 0.867 (95% CI 0.843–0.892) and 0.837 (95% CI 0.774–0.899) respectively.ConclusionPhysicians evaluating ED patients with pneumonia, COVID-19, or symptoms suspicious for COVID-19 can apply the COVAS score to assist with decisions to hospitalize or discharge patients during the SARS CoV-2 pandemic.

Point-of-care Lung Ultrasound Is Useful to Evaluate Emergency Department Patients for COVID-19.

IntroductionCoronavirus disease 2019 (COVID-19) can be a life-threatening lung disease or a trivial upper respiratory infection depending on whether the alveoli are involved. Emergency department (ED) evaluation of symptomatic patients with normal vital signs is frequently limited to chest auscultation and oro-nasopharyngeal swabs. We tested the null hypothesis that patients being screened for COVID-19 in the ED with normal vital signs and without hypoxia would have a point-of-care lung ultrasound (LUS) consistent with COVID-19 less than 2% of the time.MethodsWe performed a retrospective, structured, blinded ultrasound review and chart review in patients 14 years or older with symptoms prompting ED evaluation for COVID-19. We excluded those with known congestive heart failure or other chronic lung conditions likely to cause excessive B-lines on LUS. We used a two-sided exact hypothesis test for binomial random variables. We measured LUS diagnostic performance using computed tomography as the gold standard.ResultsWe reviewed 77 charts; 49 met inclusion criteria. Vital signs were normal in 30/49 patients; 10 (33%) of these patients had LUS consistent with viral pneumonitis. We rejected the null hypothesis (p-value <0.001). The treating physicians’ interpretations of their own point-of-care LUS had a sensitivity of 100% (95% confidence interval (CI), 74%, 100%), specificity 88% (95% CI, 47%, 100%), likelihood ratio (LR) positive of 5.8 (95% CI, 1.3, 25), and LR negative of 0.05 (95% CI, 0.03, 0.71) when compared to CT findings.ConclusionLUS had a meaningful detection rate for pneumonitis in symptomatic ED patients with normal vital signs who were being evaluated for COVID-19. We recommend at least LUS be used in addition to polymerase chain reaction testing when evaluating symptomatic ED patients for COVID-19.

An evaluation of emergency department patients referred for urgent lumbar magnetic resonance imaging with suspected cauda equina syndrome

An evaluation of emergency department patients referred for urgent lumbar magnetic resonance imaging with suspected cauda equina syndrome

Clinical evaluation of Ortho Clinical Diagnostics high-sensitivity cardiac Troponin I assay in patients with symptoms suggestive of acute coronary syndrome

BackgroundAs more companies obtain regulatory approval for high-sensitivity cardiac troponin (hs-cTn) assays there is an urgent need for independent analytical and clinical evaluations. To this end, we have evaluated Ortho Clinical Diagnostics’ hs-cTnI assay and compared it to their contemporary cTnI-ES assay in emergency department (ED) patients with suspected acute coronary syndrome (ACS). MethodsThe study cohort consisted of ED patients (n = 906) with symptoms suggestive of ACS who had Ortho hs-cTnI and cTnI-ES results at presentation and 3 h (with calculated delta (0–3 h) defined as the absolute concentration difference between paired results). The primary composite outcome was 7-day myocardial infarction (MI) or cardiovascular death, with secondary analyses performed for 7-day MI and index-MI. Analytical imprecision testing (i.e., coefficient of variation; CV), receiver-operating characteristic (ROC) curve analyses with area under the curve (AUC), and diagnostic parameters (sensitivity/specificity/predictive values) were calculated. ResultsThe hs-cTnI assay had superior precision compared to the cTnI-ES assay below 5 ng/L in EDTA plasma (hs-cTnI CV ≤ 15% versus cTnI-ES CV ≥ 85%). The AUCs were higher for hs-cTnI as compared to cTnI-ES at 0 h (0.88 vs. 0.85), 3 h (0.94 vs. 0.92), and the delta (0–3 h) value (0.91 vs. 0.85) for the primary composite outcome (p < 0.05). At 3 h, the sensitivity/specificity for index-MI was ≥97%/≥82%, for 7-day MI was ≥89%/≥84%, and for the primary composite outcome was ≥90%/≥85% using the manufacturer’s sex-specific 99th-percentile cutoffs. ConclusionThe Ortho hs-cTnI assay has superior analytical and clinical performance over their contemporary cTnI-ES assay in evaluating ED patients with symptoms suggestive of ACS.

Tricuspid Annular Plane of Systolic Excursion (TAPSE) for the Evaluation of Patients with Severe Sepsis and Septic Shock.

IntroductionSepsis is a systemic infection that can rapidly progress into multi organ failure and shock if left untreated. Previous studies have demonstrated the utility of point of care ultrasound (POCUS) in the evaluation of patients with sepsis. However, limited data exists on the evaluation of the tricuspid annular plane of systolic excursion (TAPSE) in patients with sepsis.MethodsWe prospectively enrolled patients who presented to the emergency department (ED) with concern for severe sepsis or septic shock in a pilot study. In patients that screened positive, the treating physician then performed POCUS to measure the TAPSE value. We compared the intensive care unit (ICU) admission rate, hospital length of stay, and morbidity with their respective TAPSE values.ResultsWe enrolled 24 patients in the study. Eight patients had TAPSE values less than 16 millimeters (mm), two patients had TAPSE values between 16mm–20mm, and fourteen patients had TAPSE values greater than 20mm. There was no statistically significant association between TAPSE levels and ICU admission (p=0.16), or death (p=0.14). The difference of length of stay (LOS) was not statistically significant in case of hospital LOS (p= 0.72) or ICU LOS.ConclusionOur pilot data did not demonstrate a correlation between severe sepsis or septic shock and TAPSE values. This may be due to several factors including patient comorbidities, strict definitions of sepsis and septic shock, as well as the absence of septic cardiomyopathy (SCM) in patients with sepsis and septic shock. Future large-scale studies are needed to determine if TAPSE can be beneficial in the ED evaluation of patients with concern for SCM.

Emergency department evaluation of patients with angiotensin converting enzyme inhibitor associated angioedema.

Angiotensin converting enzyme inhibitor (ACEi) associated angioedema is frequently encountered in the emergency department. Airway management is the primary treatment, but published evidence supporting the decision to intubate patients with this condition is extremely limited. We performed a retrospective study of all cases of ACEi associated angioedema encountered in a large, urban, tertiary referral emergency department. We classified demographics, duration of symptoms before presentation, physical exam findings and nasopharyngoscopy findings in patients that did and did not require intubation. We identified a total of 190 separate encounters from 183 unique patients who presented during the 3-year period of the study. Eighteen (9.5%) of these patients required intubation. Patients requiring intubation were more likely to present within 6h of the onset of angioedema symptoms. Anterior tongue swelling, vocal changes, drooling, and dyspnea were significantly more common in patients requiring intubation. Isolated lip swelling was present in 54% of all patients and was the only finding significantly more common in the group that did not require intubation. Rapid progression of symptoms within the first 6h of angioedema onset, anterior tongue swelling, vocal changes, drooling and dyspnea are associated with intubation for ACEi associated angioedema. Isolated lip swelling is significantly more common in patients that do not require intubation. Our data provide risk stratification guidance for providers treating patients with suspected ACEi associated angioedema in the emergency department.

Abstract TP280: Triage and Outpatient Evaluation of Emergency Department Patients With TIA and Minor Stroke: Rapid Access Vascular Evaluation-Neurology (RAVEN)

Introduction: The timely evaluation of TIA and minor stroke (TIAMS) is important, but whether TIAMS patients with no debilitating deficits should be admitted or not remains unsettled. We piloted a clinical protocol to assess the feasibility and safety of discharging selected TIAMS patients without disabling deficits from the Emergency Department (ED) to a rapid outpatient stroke clinic: Rapid Access Vascular Evaluation-Neurology (RAVEN). Methods: RAVEN was created as a specialized outpatient neurology clinic for TIAMS patients discharged within 24 hours from the ED at an urban quaternary academic medical center. Patients were first screened in the ED by a neurologist and selected using a decision tool identifying presumed low-risk TIAMS seen in the ED. Criteria included medical (e.g. National Institute of Health Stroke Scale of 5 or less, no disabling deficit, no fluctuating or recurrent symptoms over past month, no thrombolytic agent given, negative CT for hemorrhagic stroke, no new onset atrial fibrillation, blood pressure not over 180/110), as well as social criteria (e.g. patient ability to follow-up within 24 hours). Doppler ultrasound to exclude intracranial and extracranial stenosis, along with neurology re-evaluation was performed as part of RAVEN follow-up. Sample population was evaluated for rates of noncompliance with post-ED follow-up and need for hospitalization from clinic. Final diagnosis was also tabulated. Results: Between December 2016 and June 2018, 162 TIAMS patients seen in the ED were recommended for RAVEN utilizing the decision tool. Of these patients, 153 (94.4%) were evaluated within 24 hours of ED discharge. Two patients (1.3%) who received outpatient evaluation required hospitalization; 101 (66%) of these patients had a final diagnosis of TIAMS. Other common diagnoses included peripheral neuropathy (15%), migraine (12.5%) and seizure/recrudescence (4%). Conclusions: Our pilot data suggests that for a subset of TIAMS patients, rapid outpatient evaluation may be a feasible and safe strategy for TIAMS management. Future work exploring such strategies may improve TIAMS outcomes, reduce ED and inpatient crowding, and offer reductions in healthcare costs associated with TIAMS care.

Thyroid stimulating hormone testing in ED evaluation of patients with atrial fibrillation and various psychiatric diagnoses

BackgroundPrevious studies of thyroid stimulating hormone (TSH) levels in Emergency Department (ED) patients largely have centered on patients with atrial fibrillation (AF). In our ED patients with AF as well as patients with Psychiatric diagnoses (psych) are screened. The purpose of the present study was to compare TSH levels in the 2 groups. Our hypotheses were that an abnormal TSH and/or AF predicted the need for hospital admission and that TSH is more likely decreased in AF and increased in psych patients. MethodsOur goal in the study was to compare the use of TSH testing in two ED populations, AF vs. psych patients. The study was a cross sectional cohort of AF vs. psych patients who had TSH levels drawn in the ED over a two year period. Our laboratory ranges were used to determine high vs. low TSH. Two chart examiners collected data after a training process. Charts were reviewed extracting demographic data, TSH levels, outcome (admit vs. discharge), history of AF, thyroid disease, psych diagnoses, presence of CHF, diabetes, hypertension. We compared AF vs. Psych groups using chi square and t-tests for parametric data. Odds ratios were calculated for comparisons between the 2 groups. For non-parametric data Mann Whitney U was used. A logistic regression was performed with the outcome of admission vs. discharge to find predictors of hospital admission. Kappa was calculated for inter-rater agreement. An a priori power analysis showed 80% power with 2 groups of 100 with an absolute difference of 20% between the 2 groups. Results252 patients were included, 101 with AF and 152 Psych. Demographics differed in age only with AF patients being older. Mean TSH for AF vs. 2.4 for AF, 2.9 for psych (NS) with no differences in percentages with high or low TSH in the 2 groups. Fifty-three patients had abnormal TSH levels (21%), 27% of AF and 17% of Psych patients (NS). There were significant differences in incidence of CHF, DM, HTN, and tachycardia with more in the AF group (P < 0.001). Significantly more of the psych patients had a history of hypothyroidism (OR 2.28). Our logistic regression showed that taking into account demographics including age, the only predictors of admission were the presence of CHF (aOR 18.6) and having a diagnosis of AF (aOR 4.0). ConclusionThere were no differences in TSH levels between the 2 groups. Twenty-one percent had an abnormal level. CHF and AF predicted hospital admission on regression analysis. Many with these AF or Psych diagnoses had abnormal ED TSH levels that could be useful in diagnosis, maintenance, or continuous treatment for their conditions diagnoses.

Peripheral neuropathic mimics of visceral abdominal pain: Can physical examination limit diagnostic testing?

BackgroundThe emergency department evaluation of patients with abdominal pain is most appropriately directed at identifying acute inflammation, infection, obstruction, or surgical disease. Doing so commonly involves “routine” (and often extensive) diagnostic imaging and laboratory testing. Benign mimics of serious visceral abdominal pain that can be diagnosed by physical exam and confirmed with local anesthetic injections have been identified over the last century. These syndromes derive from painful irritation of the intercostal nerves by a mobile rib below, or from impingement of the cutaneous branches of those same intercostal nerves as they penetrate the abdominal wall. These peripheral neuropathic mimics of visceral abdominal pain continue to go unrecognized and underdiagnosed. MethodsOur purpose is to review the affirmative diagnosis of non-visceral abdominal pain by physical examination. ResultsThe consequences of failure to identify these conditions are considerable. In the search for a diagnosis that is literally at the provider's fingertips, patients frequently undergo months to years of fruitless and often invasive diagnostic tests, not uncommonly including unsuccessful surgeries. ConclusionsWith proper consideration of and appropriate testing for visceral etiologies, a carefully directed physical examination may yield an affirmative diagnosis in a percentage of these common emergency department patients.

Intravenous subdissociative-dose ketamine versus morphine for acute geriatric pain in the Emergency Department: A randomized controlled trial

Study objectiveWe compare the analgesic efficacy and safety of subdissociative intravenous-dose ketamine (SDK) versus morphine in geriatric Emergency Department (ED) patients. MethodsThis was a prospective, randomized, double-blind trial evaluating ED patients aged 65 and older experiencing moderate to severe acute abdominal, flank, musculoskeletal, or malignant pain. Patients were randomized to receive SDK at 0.3 mg/kg or morphine at 0.1 mg/kg by short intravenous infusion over 15 min. Evaluations occurred at 15, 30, 60, 90, and 120 min. Primary outcome was reduction in pain at 30 min. Secondary outcomes included overall rates of adverse effects and incidence of rescue analgesia. ResultsThirty patients per group were enrolled in the study. The primary change in mean pain scores was not significantly different in the ketamine and morphine groups: 9.0 versus 8.4 at baseline (mean difference 0.6; 95% CI −0.30 to 1.43) and 4.2 versus 4.4 at 30 min (mean difference −0.2; 95% CI −1.93 to1.46). Patients in the SDK group reported higher rates of psychoperceptual adverse effects at 15, 30, and 60 min post drug administration. Two patients in the ketamine group and one in the morphine group experienced brief desaturation episodes. There were no statistically significant differences with respect to changes in vital signs and need for rescue medication. ConclusionSDK administered at 0.3 mg/kg over 15 min provides analgesic efficacy comparable to morphine for short-term treatment of acute pain in the geriatric ED patients but results in higher rates of psychoperceptual adverse effects.ClinicalTrials.gov Registration #: NCT02673372.