Treatment Of Emergency Department Patients Research Articles

Effect of Out-Of-Hour Admission on Fluid Treatment of Emergency Department Patients with Suspected Infection; a Multicenter Post-Hoc Analysis.

Sepsis is a life-threatening and common cause of Emergency department (ED) referrals. Out-of-hour staffing is limited in ED, which may potentially affect fluid administration. This study aimed to investigate fluid volume variation in out-of-hour vs. routine-hour admissions. The present study is a post-hoc analysis of a multicentre, prospective, observational study investigating fluid administration in ED patients with suspected infection, from Jan 20th - March 2nd, 2020. Patient groups were "routine-hours" (RH): weekdays 07:00-18:59 or "out-of-hours" (OOH): weekdays 19:00-06:59 or Friday 19:00-Monday 06:59. Primary outcome was 24-hour total fluid volumes (oral + intravenous (IV)). Secondary outcomes were total fluids 0-6 hours, oral fluids 0-6 and 0-24 hours, and IV fluids 0-6 and 0-24 hours. Linear regression adjusted for site and illness severity was used. 734 patients had suspected infection; 449 were admitted during RH and 287 during OOH. Mean (95% CI) total 24-hour fluid volumes were equal in simple infection and sepsis regardless of admission time: Simple infection RH: 3640 (3410 - 3871) ml and OOH: 3681 (3451 - 3913) ml. Sepsis RH: 3671 (3443;3898) ml and OOH: 3896 (3542;4250) ml. Oral fluids 0-6h were reduced in simple infection and sepsis among OOH vs. RH. Sepsis patients received more 0-6-hour IV fluid when admitted OOH vs. RH. There were no associations between admission time and 0-24-hour oral or IV volumes in simple infection or sepsis. Admission time did not have an association with 24-hour total fluid volumes. Sepsis patients admitted during OOH received more 0-6-hour IV fluids than RH patients, and simple infection and sepsis patients received less oral fluid in 0-6 hours if admitted during OOH vs. RH.

A clinical decision framework to guide the outpatient treatment of emergency department patients diagnosed with acute pulmonary embolism or deep vein thrombosis: Results from a multidisciplinary consensus panel.

The outpatient treatment of select emergency department patients with acute pulmonary embolism (PE) or deep vein thrombosis (DVT) has been shown to be safe, cost effective and associated with high patient satisfaction. Despite this, outpatient PE and DVT treatment remains uncommon. To address this, the American College of Emergency Physicians assembled a multidisciplinary team of content experts to provide evidence‐based recommendations and practical advice to help clinicians safely treat patients with low‐risk PE and DVT without hospitalization. The emergency clinician must stratify the patient's risk of clinical decompensation due to their PE or DVT as well as their risk of bleeding due to anticoagulation. The clinician must also select and start an anticoagulant and ensure that the patient has access to the medication in a timely manner. Reliable follow‐up is critical, and the patient must also be educated about signs or symptoms that should prompt a return to the emergency department. To facilitate access to these recommendations, the consensus panel also created 2 web‐based “point‐of‐care tools.”

239 Evaluating the Role of Recovery Capital on Willingness to Enter Treatment for Emergency Department Patients With Opioid Use Disorders

The opioid epidemic in the United States remains a pressing public health concern. For many individuals with opioid use disorder (OUD), the emergency department (ED) may be their only contact point with the healthcare system. Opioid-related ED visits may be a critical time for interventions to prevent negative health consequences (eg, overdose) and also to increase engagement with OUD treatment services. We aimed to assess the relationship between greater resources and support—"recovery capital”—and willingness to enter OUD treatment among ED patients. The Navigator Trial is a multisite RCT comparing peer navigation with licensed clinical social workers on treatment engagement, recurrent overdose, and recovery for patients at risk of opioid overdose attending two EDs in Rhode Island. Participants completed the Brief Assessment of Recovery Capital-10 (BARC-10) before the behavioral intervention, and reported willingness to enter treatment after. The relationship between recovery capital (BARC-10 ≥47) and willingness to enter treatment was assessed using logistic regression, adjusting for sociodemographic characteristics and current engagement in some form of SUD treatment. Among 354 participants—64% male, 31% non-White, 30% currently in treatment, median age 35 years—the median BARC-10 score was 42, with 31% having high recovery capital. Following the intervention, willingness to enter treatment during the ED visit was endorsed by 40% of participants. In adjusted analysis, participants with lower recovery capital were more likely to report treatment willingness (adjusted OR: 1.35; 95% CI: 1.05, 1.72) compared to those with high recovery capital. Counterintuitively, higher recovery capital was not associated with willingness to enter OUD treatment. In the emergency department setting, screening, brief intervention, and referral efforts should seek to engage all patients who may benefit from OUD treatment, not just those who have high recovery capital.

Implementation of Oral and Extended-Release Naltrexone for the Treatment of Emergency Department Patients With Moderate to Severe Alcohol Use Disorder: Feasibility and Initial Outcomes

Despite evidence supporting naltrexone as an effective treatment for alcohol use disorder, its use in emergency department (ED) patients has not been described. We implemented a protocol that combined substance use navigation with either oral naltrexone or extended-release intramuscular naltrexone for patients with alcohol use disorder as a strategy to improve follow-up in addiction treatment after ED discharge. In this descriptive study, we analyzed the results from adult patients discharged from the ED with moderate to severe alcohol use disorder who received either oral naltrexone or extended-release intramuscular naltrexone between May 1, 2020, and October 31, 2020, and assessed their engagement in formal addiction treatment within 30 days after discharge from the ED. Among 59 patients with moderate to severe alcohol use disorder who accepted naltrexone treatment, 41 received oral naltrexone and 18 received extended-release intramuscular naltrexone. The mean (SD) age of the patients was 45.2 (13.4) years; 22 patients (37.3%) were Latinx, 18 (30.5%) were Black, and 16 (27.1%) were White. Among all patients, 9 (15.3%) attended follow-up formal addiction treatment within 30 days after discharge; 5 patients (27.8%) who received extended-release intramuscular naltrexone and 4 patients (9.8%) who received oral naltrexone attended follow-up treatment within 30 days. We implemented a clinical protocol for ED patients with moderate to severe alcohol use disorder using oral naltrexone and extended-release intramuscular naltrexone together with substance use navigation. Identification of alcohol use disorder, a brief intervention, and initiation of naltrexone resulted in a 15% follow-up rate in formal addiction treatment. Future work should prospectively examine the effectiveness of naltrexone as well as the effect of substance use navigation for ED patients with alcohol use disorder.

Predicting waiting time to treatment for emergency department patients

BackgroundThe current systems of reporting waiting time to patients in public emergency departments (EDs) has largely relied on rolling average or median estimators which have limited accuracy. This study proposes to use machine learning (ML) algorithms that significantly improve waiting time forecasts. MethodsBy implementing ML algorithms and using a large set of queueing and service flow variables, we provide evidence of the improvement in waiting time predictions for low acuity ED patients assigned to the waiting room. In addition to the mean squared prediction error (MSPE) and mean absolute prediction error (MAPE), we advocate to use the percentage of underpredicted observations. The use of ML algorithms is motivated by their advantages in exploring data connections in flexible ways, identifying relevant predictors, and preventing overfitting of the data. We also use quantile regression to generate time forecasts which may better address the patient’s asymmetric perception of underpredicted and overpredicted ED waiting times. ResultsUsing queueing and service flow variables together with information on diurnal fluctuations, ML models outperform the best rolling average by over 20 % with respect to MSPE and quantile regression reduces the number of patients with large underpredicted waiting times by 42 %. ConclusionWe find robust evidence that the proposed estimators generate more accurate ED waiting time predictions than the rolling average. We also show that to increase the predictive accuracy further, a hospital ED may decide to provide predictions to patients registered only during the daytime when the ED operates at full capacity, thus translating to more predictive service rates and the demand for treatments.

Non-invasive assessment of haemodynamic parameters in an Emergency Department

Introduction: Hospital Emergency Departments are places where fractions of a second decide about human life and every possibility of quickly and reliably obtaining additional information about the patient’s condition is extremely important. Therefore, an attempt was made to determine the usefulness of non-invasive assessment of haemodynamic parameters in patients in Emergency Departments. Material and methods: The research was conducted in June and July 2019 in the Emergency Room of the Bielanski Hospital, Jerzy Popieluszko in Warsaw. Non-invasive measurement of haemodynamic parameters was performed with the ICON (Osypka Medical, GmbH) Heart Rate Monitor. The study was conducted among patients of the green part of the Emergency Department. P < 0.05 was adopted as the significance level. Results: One-way non-parametric ANOVA confirmed the existence of statistically significant differences (all p for trend 0.05) between age (p = 0.418), SV (p = 0.161), TFC (p = 0.142), and STR (p = 0.094) and for the four groups according to the reason for reporting to the Emergency Department. In simple linear regression analysis (Spearman), BMI was negatively correlated with CO, ICON, SV, and TFC (all p for trend < 0.05). Age was negatively correlated with CO, ICON, and SV. Conclusions: Due to the diversity of patients and their conditions, non-invasive assessment of haemodynamic parameters can become an invaluable help during the diagnosis and subsequent treatment of Emergency Department patients.

Use of Physician-Estimated and Patient Self-Reported Weights to Guide Initial Fluid Resuscitation in Emergency Department Patients With Suspected Sepsis.

Knowledge of patient weight is required to guide initial intravenous fluid therapy for patients with sepsis-associated hypotension or elevated lactate. Previous studies have shown patients are better estimators of their weight than medical providers are; critically ill patients, however, may be unable to provide this information. This study compares the accuracy of physician-estimated and patient self-reported weights to subsequent inpatient bed/stretcher scale weights for guiding initial protocol-based intravenous fluid therapy in the treatment of emergency department patients with suspected sepsis. Adult patients presenting with a suspected diagnosis of severe sepsis to a large, urban, academic emergency department had either physician-estimated or patient self-reported weights recorded on presentation. All patients had subsequent inpatient bed/stretcher scale weights recorded on the first day of hospitalization. Physician-estimated and patient self-reported weights linearly correlated (P < .001) with inpatient bed/stretcher scale weights. Median accuracy error for physicians (5.4% [2.0-10.1]) and patients (3.9% [1.6-6.4]) was not significantly different (P = .28). Physician-estimated and patient self-reported weights accuracy was determined at multiple levels: within 5% (46%, 57%, respectively), 10% (75%, 90%), 15% (90%, 95%), and 20% (100%, 95%) error tolerances, as well accurate estimates within 5 kg (69.2%, 70.0%). Both physician-estimated and patient self-reported weights are reliable when calculating initial protocol-based intravenous fluid resuscitation for emergency department patients with sepsis.

16 Procainamide vs Ibutilide in the Cardioversion of Recent-Onset Atrial Fibrillation and Flutter in the Emergency Department: A Retrospective Cohort Study

Intravenous (IV) procainamide and ibutilide are two commonly used medications for the cardioversion of emergency department (ED) patients with recent-onset (<48h) atrial fibrillation (AF) and atrial flutter (AFL; either = AF/AFL) across North America. It is unclear which medication is preferable. No trials have compared these agents for this indication and North American society guidelines offer contradictory recommendations: procainamide is the drug of choice in the Canadian guideline, where ibutilide is not recommended; the converse is true in U.S. guidelines. Issues of effectiveness, safety, and ease of use may contribute to drug selection. Ibutilide carries a black-box warning for the risk for torsade de pointes (polymorphic ventricular tachycardia [VT]) and requires at least 4h of monitoring, making it riskier and more cumbersome to administer than procainamide. We compare patient selection, effectiveness, and side-effect profiles of IV procainamide and ibutilide in the treatment of ED patients with recent-onset AF/FL. This retrospective cohort study included all adults who received IV procainamide or ibutilide for recent-onset AF/FL from 01/2009 to 06/2015 in 21 community EDs within a large U.S. integrated health care delivery system. We gathered demographic and clinical variables from the electronic health record and structured manual chart review. Our effectiveness outcome was cardioversion at 90m, sustained to ED discharge. Safety outcomes were the 60m incidence of hypotension (defined as more than one systolic blood pressure <100 mmHg) and VT, at least three beats in duration. We describe patient characteristics and compare outcomes using Fisher’s exact test (two-tailed) with significance noted when p<0.05. Among 730 unique ED adults, 376 received procainamide (51.5%) and 354 (48.5%) ibutilide. The two cohorts were comparable in demographics, symptom duration, and cardiac history, but ibutilide was preferred for patients with AFL (Table). The two agents had similar 90m rates of cardioversion for AF. For AFL, however, ibutilide was more effective. Hypotension occurred in 34 procainamide recipients (9.0%), only 17 of whom (4.5%) required any treatment (IV fluids or procainamide discontinuation or both) and resolved without sequelae in all 34 cases. Non-sustained monomorphic VT was uncommon. One ibutilide patient developed torsade, which resolved with treatment. More ibutilide-recipients received observation or hospitalization (Table). ED patients selected for treatment with procainamide or ibutilide for the cardioversion of recent-onset AF/FL appear similar in demographics, cardiac history, and symptom duration. The two agents demonstrate comparable 90m effectiveness for AF, but ibutilide is more effective for AFL. Until randomized trials are conducted on patients with recent-onset AF/FL, our findings suggest that IV ibutilide may be preferable for AFL based on effectiveness, whereas procainamide may be preferable for AF based on ease of use and safety.

Intravenous Fluid for the Treatment of Emergency Department Patients With Migraine Headache: A Randomized Controlled Trial

The objective of this pilot study is to assess the feasibility and necessity of performing a large-scale trial to measure the effect of intravenous fluid therapy on migraine headache pain. This was a single-center, pilot randomized controlled trial. We randomized adult emergency department migraine headache patients to receive 1 L of normal saline solution during 1 hour (fluid group) or saline solution at 10 mL/hour for 1 hour (control group). All patients received intravenous prochlorperazine and diphenhydramine at the start of fluid administration. Participants and outcome assessors were blinded; nurses administering the intervention were not. Outcomes were assessed at 60 and 120 minutes, and 48hours. The primary outcome was the difference in the verbal pain rating (on a scale of 0 to 10) between 0 and 60 minutes. Key secondary outcomes included additional clinical endpoints, the rate of protocol completion, and the effectiveness of blinding. Fifty patients consented to participate; one withdrew, leaving 25 patients randomized to the fluid group and 24 in the no fluid group. The mean improvement in 0- to 60-minute pain score was 4.5 (95% confidence interval 3.7 to 5.3) in the fluid group and 4.9 (95% confidence interval 3.5 to 6.2) in the control group. Primary outcome data were collected for 49 of 50 enrolled patients, and only one participant correctly identified the group assignment. This pilot study showed no statistically significant treatment effect from fluid administration, but does not exclude the possibility of a clinically important treatment effect. The study protocol and approach to blinding are both feasible and effective.

The American Psychiatric Association Practice Guideline for the Pharmacological Treatment of Patients With Alcohol Use Disorder.

The American Psychiatric Association Practice Guideline for the Pharmacological Treatment of Patients With Alcohol Use Disorder.

384 Interim Analysis: Benefits of a Standardized Exercise Program in Treatment of Emergency Department Patients Experiencing Acute or Acute-on-Chronic Musculoskeletal Back Pain

384 Interim Analysis: Benefits of a Standardized Exercise Program in Treatment of Emergency Department Patients Experiencing Acute or Acute-on-Chronic Musculoskeletal Back Pain

61 Utility of a Nurse-Initiated Screening Protocol in Triage on Early Identification and Treatment of Emergency Department Patients Diagnosed With Sepsis

Sepsis carries a mortality burden of around 30% (Hayden et al 2015). Additionally, Rivers et al (2001), in a landmark trial, showed that early, goal-directed therapy significantly reduces morbidity and mortality in individuals with severe sepsis or septic shock compared to standard of care. Concurrently, CMS has also implemented a new sepsis measure which requires the completion of a 3-hour and 6-hour bundle for patients diagnosed with severe sepsis or septic shock. The goal of this study was to determine whether utilization of a nurse-initiated sepsis protocol would identify emergency department patients at risk of sepsis and improve compliance with the 3-hour sepsis bundle. A multidisciplinary team collaborated to create (a) an order set “bundle” to be initiated at triage for patients with suspected sepsis and (b) a screening protocol that emergency medicine nursing staff would utilize to identify patients as high-risk candidates for sepsis. Study objectives were to: (1) Determine sensitivity of the screening protocol in the identification of patients with sepsis in the emergency department; (2) Determine whether a nurse-initiated protocol would impact completion of the components of the 3-hour bundle both pre- and post-intervention. Prior to implementation of the screening and treatment protocols, 296 patient records identified as having been admitted from the emergency department with a diagnosis of sepsis within the prior 6 months were reviewed for completion of the 3-hour bundle components by two physicians. Following implementation of the protocol, all patients who were screened in the ED for sepsis or eventually diagnosed with sepsis were reviewed on a weekly basis by an emergency physician and nurse. Feedback was sent to all ED providers and nurses that were involved in each patient’s care. Data compared for the 296 patients pre-intervention and 91 patients post-intervention identified as having sepsis reveals the following: Percentage of 3-hour bundle completed: 13.9% pre-intervention vs 38.5% post-intervention Antibiotic administration within 3 hours: 44.9% pre-intervention vs 73.6% post-intervention At least 30 mL/kg fluids given in ED: 35.14% pre-intervention vs 53.9% post-intervention Lactate obtained within 3 hours of entry to ED: 49.7% vs 92.3% post intervention Blood cultures obtained in ED: 84.1% pre-intervention vs 85.7% post-intervention Overall sensitivity of the protocol in early identification of patients diagnosed with sepsis: 76.5% (95% CI: 65.8%-85.25%) Compliance with 3-hour bundle components in the ED has been 100% on cases selected for review by CMS. The reviewed data demonstrates an increased compliance with recommended sepsis screening and treatment with implementation of nurse-initiated sepsis screening and treatment protocol. Sensitivity continues to improve since implementation due to increasing adoption of the protocol. Overall fluid administration of 30mL/kg was only 53.9% as this study did not delineate whether patients diagnosed with sepsis were eventually diagnosed with severe sepsis/septic shock. It follows that the intervention also decreases overall morbidity and mortality of sepsis patients, although this has yet to be measured and indicates potential for future studies.

Improvement of the Trauma Care Process by Implementation of a Computerized Physician Order Entry-Based Trauma Team Approach

AbstractOriginal Article Improvement of the Trauma Care Process by Implementation of a Computerized Physician Order Entry-Based Trauma Team Approach1Purpose: The need for the rapid evaluation and treatment of emergency depart-ment patients with major trauma is essential. A computerized physician order entry (CPOE) system can improve communication and provide immediate access to in-formation with the goal of reducing ED time delays. The aim of this study was to report on the operation of a trauma CPOE program and demonstrate its usefulness by comparing time intervals from ED arrival to various evaluation steps before and after implementation of the program.Methods: This was a before-and-after observational study from a single emergen-cy department at an academic center. The CPOE program was implemented for 6 months and compared with the data collected from the pre-CPOE implementation period. The efficacy of the program was assessed by comparing the time difference before and after CPOE implementation based on the following factors: total board-ing time in ED, door-to-disposition decision time, door-to-blood-test report time, door-to-X-ray time, door-to-CT time, and door-to-transfusion time.Results: Over a period of 6 months, the CPOE was activated for a total of 17 pa-tients. Total boarding time was reduced significantly after implementation [medi-an, 641.5 minutes (IQR, 367.3-859.3) versus289.0 minutes (IQR, 140.0-508.0) for pre-CPOE vs. post-CPOE, respectively, p< 0.05). Time intervals for all evaluation steps were reduced after implementation of the program. The improvements in the door-to-blood-test and door-to-CT times were both statistically significant.Conclusion: This study demonstrated that a standard CPOE system can be success-fully implemented and can reduce ED time delays in managing trauma patients. Key wordsEmergency department, Computerized physician order entry, Trauma

General characteristics of patients with electrolyte imbalance admitted to emergency department.

BACKGROUND:Fluid and electrolyte balance is a key concept to understand for maintaining homeostasis, and for a successful treatment of many metabolic disorders. There are various regulating mechanisms for the equilibrium of electrolytes in organisms. Disorders of these mechanisms result in electrolyte imbalances that may be life-threatening clinical conditions. In this study we defined the electrolyte imbalance characteristics of patients admitted to our emergency department.METHODS:This study was conducted in the Emergency Department (ED) of Uludag University Faculty of Medicine, and included 996 patients over 18 years of age. All patients had electrolyte imbalance, with various etiologies other than traumatic origin. Demographic and clinical parameters were collected after obtaining informed consent from the patients. The ethical committee of the university approved this study.RESULTS:The mean age of the patients was 59.28±16.79, and 55% of the patients were male. The common symptoms of the patients were dyspnea (14.7%), fever (13.7%), and systemic deterioration (11.9%); but the most and least frequent electrolyte imbalances were hyponatremia and hypermagnesemia, respectively. Most frequent findings in physical examination were confusion (14%), edema (10%) and rales (9%); and most frequent pathological findings in ECG were tachycardia in 24%, and atrial fibrillation in 7% of the patients. Most frequent comorbidity was malignancy (39%). Most frequent diagnoses in the patients were sepsis (11%), pneumonia (9%), and acute renal failure (7%).CONCLUSIONS:Electrolyte imbalances are of particular importance in the treatment of ED patients. Therefore, ED physicians must be acknowledged of their fluid-electrolyte balance dynamics and general characteristics.

Letter to the Editor and Reply: Sedation-assisted Orthopedic Reduction in Emergency Medicine: The Safety and Success of a One Physician/ One Nurse Model

To the Editor: We applaud Vinson and Hoehn for eloquently demonstrating that the performance of sedation assisted procedures in the emergency department (ED) does not necessarily require a 2 physician team. From a Canadian perspective, where single physician coverage in smaller EDs is common, this has important implications in terms of efficiency of patient care, reduction in the need for patient transfer and decreasing the time to definitive treatment for ED patients. We would like to draw attention to a model of care practiced in Halifax, Nova Scotia for over 15 years, using a team consisting of an advanced care paramedic (ACP) and a single physician, the former to conduct the sedation, and the latter to do the procedure.1 The skills of ACPs complement specific supplementary training in Procedural Sedation and Analgesia (PSA) to produce, in our opinion, expert ED sedationists, and our database of over 4000 safely conducted PSAs attest to this. Although performing PSA is primary role of ACPs in our ED, success with this has expanded our use of paramedics to a number of other ED tasks, freeing up other staff to perform what they do best.2

Gender Disparity in Analgesic Treatment of Emergency Department Patients with Acute Abdominal Pain

Oligoanalgesia for acute abdominal pain historically has been attributed to the provider's fear of masking serious underlying pathology. The authors assessed whether a gender disparity exists in the administration of analgesia for acute abdominal pain. This was a prospective cohort study of consecutive nonpregnant adults with acute nontraumatic abdominal pain of less than 72 hours' duration who presented to an urban emergency department (ED) from April 5, 2004, to January 4, 2005. The main outcome measures were analgesia administration and time to analgesic treatment. Standard comparative statistics were used. Of the 981 patients enrolled (mean age +/- standard deviation [SD] 41 +/- 17 years; 65% female), 62% received any analgesic treatment. Men and women had similar mean pain scores, but women were less likely to receive any analgesia (60% vs. 67%, difference 7%, 95% confidence interval [CI] = 1.1% to 13.6%) and less likely to receive opiates (45% vs. 56%, difference 11%, 95% CI = 4.1% to 17.1%). These differences persisted when gender-specific diagnoses were excluded (47% vs. 56%, difference 9%, 95% CI = 2.5% to 16.2%). After controlling for age, race, triage class, and pain score, women were still 13% to 25% less likely than men to receive opioid analgesia. There was no gender difference in the receipt of nonopioid analgesia. Women waited longer to receive their analgesia (median time 65 minutes vs. 49 minutes, difference 16 minutes, 95% CI = 3.5 to 33 minutes). Gender bias is a possible explanation for oligoanalgesia in women who present to the ED with acute abdominal pain. Standardized protocols for analgesic administration may ameliorate this discrepancy.

Changing Opioid Use for Right Lower Quadrant Abdominal Pain in the Emergency Department

To compare the use of opioid analgesia in the treatment of emergency department patients with acute right lower quadrant (RLQ) abdominal pain between 1998 and 2003 and to explore the relationship between opioid use and abdominal computed tomography (CT) scanning. This was a retrospective cohort study of patients presenting in 1998 and 2003 to an urban emergency department with a triage complaint of RLQ pain. The authors abstracted use and timing of abdominal CT scanning and opioid analgesia. Other predictor variables were patient demographics. Risk ratio for receiving opioids with CT scan versus without CT scan, stratifying by year, were calculated. Proportional-hazards analysis was used to control for time in the emergency department. Of the 187 patients seen in 1998, 38 (20%) underwent CT scanning and 43 (23%) received opioids. Of the 137 patients seen in 2003, 77 (56%) underwent CT scanning and 72 (53%) received opioids. In 1998, the risk ratio for receiving opioids in patients who underwent CT scanning (vs. without) was 3.7 (95% confidence interval [CI] = 2.3 to 6.1); in 2003, it was 1.5 (95% CI = 1.0 to 2.1). Opioids were overwhelmingly given before CT scanning in those patients who received both (81% in 1998 and 98% in 2003). The mean time to administration of the first opioid dose in 1998 was 155 minutes and in 2003 was 94 minutes. The proportional-hazards analysis confirmed a strong association between CT scanning and opioid administration in 1998 (relative hazard, 2.7; 95% CI = 1.5 to 5.1) and substantial attenuation of the association in 2003 (relative hazard, 1.3; 95% CI = 0.8 to 2.1). The hospitalization rate was not significantly different in 2003 (33%) versus 1998 (27%) (p = 0.28). The risk ratio of receiving opioids in admitted patients was 2.8 (95% CI = 1.7 to 4.6) in 1998 and 2.0 (95% CI = 1.5 to 2.7) in 2003. Opioid administration to patients with RLQ pain has dramatically increased between 1998 and 2003. During these five years, the number of patients receiving opioids more than doubled and the time to first administration of opioids decreased by one hour. The authors show that this cannot be attributed to an increased use of CT scanning.

Characteristics of patients presenting to the emergency department with headache

Study objectives: To better understand headache patients presenting to the emergency department (ED), we attempt to determine the characteristics of patients presenting with headache to the ED with respect to current prescription medication use. Methods: This was a prospective, observational, anonymous survey done as a pilot study in a university ED. A continuous sample of patients older than 12 years and presenting with headache were enrolled during a 6-month period. Patients were evaluated for use of prescription medications for headaches, previous headache diagnosis, age, income, number of ED visits, race, sex, education, insurance, primary care provider, headache specialist provider, employment, number of ED visits for headache, and Migraine Disability Assessment (MIDAS) score (previously validated headache disability score). Statistical analyses were performed with relative risk with 95% confidence intervals (CIs) calculated. The MIDAS score was evaluated for significance with a <i>t</i> test; <i>P</i> values were determined. Results: Ninety-nine patients were enrolled. Patients were more likely to be taking a prescription headache medication if they used a headache specialist (relative risk 1.9, 95% CI 1.4 to 2.5), if they had medical insurance (relative risk 2.7, 95% CI 1.1 to 7.5), or if they were in the upper income quartile of our cohort (relative risk 1.5, 95% CI 1.1 to 1.9). MIDAS scores were not found to be different between the patients with and without prescriptions (<i>P</i>=.09). Conclusion: Patients with headaches and receiving prescription medications were more likely to have a headache specialist, to be medically insured, and to have a higher income. This study illustrates the disparity of care for lower-income uninsured headache patients and identifies an area for further consideration in treatment of ED patients.

Intramuscular Droperidol versus Intramuscular Dimenhydrinate for the Treatment of Acute Peripheral Vertigo in the Emergency Department: A Randomized Clinical Trial

Objective: The emergency department (ED) treatment of acute peripheral vertigo (APV) has not been well studied. The purpose of this study was to determine the efficacy of intramuscular (IM) droperidol vs IM dimenhydrinate, in the treatment of ED patients with APV. Methods: The study was a randomized, double‐blinded clinical trial, performed at a suburban, teaching ED. A convenience sample of adult patients with symptoms and signs consistent with rigid diagnostic criteria for APV were randomized to one of two treatment groups. Patients more than 65 years of age were excluded to reduce the likelihood of diagnostic misclassification. Demographic and historical features were recorded on a standardized data form. Patients recorded their initial level (t0) of discomfort on a 10‐centimeter (cm) visual analog scale (VAS). Treatment group 1 received 2.5 mg droperidol IM, while treatment group 2 received 50 mg dimenhydrinate IM. After 30 minutes (t30), patients again recorded the severity of their symptoms on the VAS. Chi‐square, t‐tests, and Mann‐Whitney were used for statistical comparison as appropriate. All tests were two‐tailed, with alpha set at 0.05. Primary outcome parameters were the mean change in VAS score from t0 to t30, and the percentage of patients in each treatment group who felt well enough to go home after t30 without further ED intervention. Results: There were 20 patients in the droperidol group and 20 in the dimenhydrinate group. The two groups were similar with respect to mean age (40 ± 13 years droperidol vs. 42 ± 13 years dimenhydrinate; p = 0.6), female sex (60% vs. 50%; p = 0.7), and mean median duration of symptoms [3 (interquartile range 2‐12) vs 9 (interquartile range 2‐30) hours; p = 0.2]. Mean initial t0 VAS scores were 7.2 ± 2.3 and 7.8 ± 1.9 (p = 0.47). Both treatment groups had mean reductions in VAS scores at t30 of 3.3 [95% confidence interval (95% CI) = 2.3 to 4.3]. At t30, 42% of patients in the droperidol group and 45% of patients in the dimenhydrinate group felt well enough to go home without further ED intervention. Conclusions: The authors found no difference between the therapeutic efficacies of IM droperidol and dimenhydrinate for the treatment of acute peripheral vertigo.

Successful conversion of unstable supraventricular tachycardia to sinus rhythm with adenosine

To evaluate the efficacy of adenosine in the treatment of emergency department patients with unstable paroxysmal supraventricular tachycardia (PSVT). A retrospective chart review conducted over two years. A university-affiliated hospital ED. Patients with unstable PSVT (systolic blood pressure of less than 90 mm Hg, chest pain, pulmonary edema, and/or altered mental status) who were treated with adenosine. Patients' preadenosine and postadenosine heart rates, symptoms, and blood pressure were recorded, as were complications and recurrence of PSVT. PSVT was diagnosed by surface ECG. Twelve patients were identified (three men and nine women with a mean age of 47.6 years). Nine patients presented with hypotension (mean systolic blood pressure, 79 mm Hg), ten with chest pain, and six with both chest pain and hypotension. There were no patients with altered mental status or pulmonary edema. Eight patients converted to sinus rhythm with a single 6-mg bolus of adenosine; the remaining four required an additional 12-mg bolus. In all cases, chest pain and hypotension resolved within minutes of conversion to sinus rhythm. There were no clinically significant adverse effects or recurrence of PSVT during ED observation (mean, 1.8 hours). All patients responded to adenosine; none required electrical cardioversion. In the unstable patient with PSVT, adenosine appears to be a safe and effective alternative to current advanced cardiac life support-recommended immediate electrical cardioversion.