Comparative Effectiveness of Patient-Controlled Analgesia for Treating Acute Pain in the Emergency Department.

STUDY OBJECTIVE: We assess the effectiveness of patient-controlled analgesia in the emergency department (ED). We hypothesized that decline in pain intensity from 30 to 120 minutes after initial intravenous opioid administration is greater in patients receiving morphine by patient-controlled analgesia compared with usual care and would differ by a clinically significant amount. METHOD: This was a pragmatic randomized controlled trial of patient-controlled analgesia and usual care (opioid and dose at physician's discretion) in 4 EDs. Entry criteria included age 18 to 65 years and acute pain requiring intravenous opioids. The primary outcome was decline in numeric rating scale pain score 30 to 120 minutes postbaseline. Secondary outcomes included satisfaction, time to analgesia, adverse events, and patient-controlled analgesia pump-related problems. We used a mixed-effects linear model to compare rate of decline in pain (slope) between groups. A clinically significant difference between groups was defined as a difference in slopes equivalent to 1.3 numeric rating scale units. RESULTS: Six hundred thirty-six patients were enrolled. The rate of decline in pain from 30 to 120 minutes was greater for patients receiving patient-controlled analgesia than usual care (difference=1.0 numeric rating scale unit; 95% confidence interval [CI] 0.6 to 1.5; P<.001) but did not reach the threshold for clinical significance. More patients receiving patient-controlled analgesia were satisfied with pain management (difference=9.3%; 95% CI 3.3% to 15.1%). Median time to initial analgesia was 15 minutes longer for patient-controlled analgesia than usual care (95% CI 11.4 to 18.6 minutes). There were 7 adverse events in the patient-controlled analgesia group and 1 in the usual care group (difference=2.0%; 95% CI 0.04% to 3.9%), and 11 pump-programming errors. CONCLUSION: The findings of this study do not favor patient-controlled analgesia over usual ED care for acute pain management.

Exploratory study on association of single-nucleotide polymorphisms with hydromorphone analgesia in ED.

OBJECTIVES: The objective of this study is to provide information on distribution of important single-nucleotide polymorphisms (SNPs) and evaluate their associations with clinical response to intravenous hydromorphone in emergency department. METHODS: A prospective exploratory study was performed. A convenience sample of adult emergency department patients with acute pain deemed to require intravenous opioids received 1 mg of intravenous hydromorphone. Primary outcome was pain score (numeric rating scale, NRS) reduction between baseline and 30 minutes after medication administration. Secondary outcomes were pain relief, patient satisfaction with analgesia, desire for more analgesics, and side effects (nausea, vomiting, and pruritis). Single-nucleotide polymorphisms in OPRM1 gene (opioid receptor, A118G), ABCB1 gene (opioid transporter, C3435T), COMT gene (pain sensitivity, G1947A), and UGT2B7 gene (opioid metabolism, -G840A) were tested. We used Kruskal-Wallis test to compare the primary outcome and χ(2) test (or Fisher test) to compare the secondary outcomes among patients carrying different SNPs. RESULTS: One thousand four hundred thirty-eight patients were screened, and 163 patients were enrolled in the study. The mean age was 39 years. Sixty-three percent were female, 58% were Hispanic, and 67% had pain located in abdomen. The median pain NRS reduction at 30 minutes was 5 (interquartile range, 3-8). There was no difference in pain NRS reduction among patients carrying different SNPs. Secondary outcome analysis revealed statistically significant associations between patient satisfaction with treatment and OPRM1 and between nausea and UGT2B7. CONCLUSIONS: This exploratory study did not show a significant difference in pain NRS reduction among patients carrying different SNPs. Patient satisfaction with analgesia and nausea were statistically significantly associated with OPRM1 and UGT2B7, respectively.

Prehospital trauma arrival notification associated with more image studies in patients with minor head trauma discharged from ED.

OBJECTIVES: The objective of this study was to determine whether prehospital trauma arrival notification was associated with more head computed tomography (CT) scans and image studies performed in patients with minor head trauma and discharged from emergency department (ED). METHODS: A retrospective cross-sectional study based on hospital electronic medical record was performed. Patients with head trauma indicated by their diagnostic codes or chief complaints, presenting to and discharged from ED in a level I trauma center between January 1, 2010, and June 30, 2014, and triage Glasgow Coma Scale (GCS) score 14 or greater were selected from electronic medical record. Triage prehospital trauma arrival notification, number and types of image studies performed, and basic demographics were extracted. χ(2) Analysis (or Fisher test) was applied to compare the proportions of patients who received image studies between prehospital trauma arrival notification and non-notification groups. RESULTS: There were 3603 patients with head trauma, triage GCS score 14 or greater, and discharged from ED. Mean age was 43.8 years. Forty-six percent was female. Thirty-two point nine percent was Hispanic, and 28.6% was black. Numbers (proportions) of patients who received prehospital trauma arrival notification, head CT scan, or any image study (x-ray, CT, magnetic resonance imaging, or sonogram) were 287 (8.0%), 1621 (45.0%), and 2267 (63.0%), respectively. Compared with patients without prehospital trauma arrival notifications, patients with prehospital trauma arrival notifications were significantly more likely to receive a head CT scan as well as an image study. CONCLUSIONS: Prehospital trauma arrival notification was associated with significantly more head CT scans and more image studies in patients with minor head trauma and discharged from ED.

Does initial hydromorphone relieve pain best if dosing is fixed or weight based?

STUDY OBJECTIVE: It remains unknown whether initial opioid dosing should optimally be fixed or weight-based. We wish to determine whether pain response after an initial fixed dose of intravenous hydromorphone varied by total body weight. METHODS: We enrolled a convenience sample of emergency department adults aged 18 to 65 years with acute pain requiring intravenous opioids and administered 1 mg of hydromorphone. Our primary outcome was the correlation of total body weight with the reduction in pain at 30 minutes, as measured with a numeric rating scale. Our secondary outcomes contrasted total body weight by other measures of efficacy (numeric rating scale <3, pain relief, satisfaction, and desire for more analgesics) and adverse events (nausea, vomiting, and pruritus). We also performed a multivariate analysis to control for variables that might affect the relationship of pain response to total body weight. RESULTS: We enrolled 163 subjects with a range of weights from 45 to 157 kg, and their mean numeric rating scale pain reduction at 30 minutes was 5.3. Pain reduction did not correlate with weight in either univariate or multivariable models. Secondary outcomes were also similar, except greater pruritus in lower-weight subjects. CONCLUSION: Pain response to a fixed 1 mg intravenous dose of hydromorphone did not vary by total body weight in this sample of adults aged 18 to 65 years, suggesting no advantage to weight-based over fixed opioid dosing.

Exudative retinal detachment caused by metastatic choriocarcinoma to the choroid.

BACKGROUND: Choriocarcinoma is an aggressive malignant tumor. It commonly invades the uterus, causing necrosis and hemorrhage through vascular invasion. Metastasis is also common, with the main areas affected being the lung, brain, liver, pelvis, vagina, spleen, intestine, and kidney. OBJECTIVES: To illustrate the presentation of a rare disease, metastatic choriocarcinoma to the eye, causing a retinal detachment, and to elucidate the characteristics and treatment of that rare disease. CASE REPORT: A 23-year-old woman presented to our Emergency Department with a left painful red eye with decreased visual acuity and was subsequently diagnosed with choriocarcinoma with metastasis to the lungs, brain, and choroid, causing a left exudative retinal detachment. CONCLUSION: Gestational choriocarcinoma with metastasis to the eye is a rare disease and a rare cause of exudative retinal detachment. In general, metastatic choriocarcinoma is highly curable with chemotherapy. However, metastasis to the eye, regardless of the type of tumor, portends a poor prognosis.

Performance of the RAD-57 pulse CO-oximeter compared with standard laboratory carboxyhemoglobin measurement.

STUDY OBJECTIVE: We assess agreement between carboxyhemoglobin levels measured by the Rad-57 signal extraction pulse CO-oximeter (RAD), a Food and Drug Administration-approved device for noninvasive bedside measurement, and standard laboratory arterial or venous measurement in a sample of emergency department (ED) patients with suspected carbon monoxide poisoning. METHODS: The study was a cross-sectional cohort design using a convenience sample of adult and pediatric ED patients in a Level I trauma, burn, and hyperbaric oxygen referral center. Measurement of RAD carboxyhemoglobin was performed simultaneously with blood sampling for laboratory determination of carboxyhemoglobin level. The difference between the measures for each patient was calculated as laboratory carboxyhemoglobin minus carboxyhemoglobin from the carbon monoxide oximeter. The limits of agreement from a Bland-Altman analysis are calculated as the mean of the differences between methods ±1.96 SDs above and below the mean. RESULTS: Median laboratory percentage carboxyhemoglobin level was 2.3% (interquartile range 1 to 8.5; range 0% to 38%). The mean difference between laboratory carboxyhemoglobin values and RAD values was 1.4% carboxyhemoglobin (95% confidence interval [CI] 0.2% to 2.6%). The limits of agreement of differences of measurement made with the 2 devices were -11.6% and 14.4% carboxyhemoglobin. This range exceeded the value of ±5% carboxyhemoglobin defined a priori as clinically acceptable. RAD correctly identified 11 of 23 patients with laboratory values greater than 15% carboxyhemoglobin (sensitivity 48%; 95% CI 27% to 69%). There was one case of a laboratory carboxyhemoglobin level less than 15%, in which the RAD device gave a result greater than 15% (specificity of RAD 96/97=99%; 95% CI 94% to 100%). CONCLUSION: In the range of carboxyhemoglobin values measured in this sample, the level of agreement observed suggests RAD measurement may not be used interchangeably with standard laboratory measurement.

Response to morphine in male and female patients: analgesia and adverse events.

BACKGROUND: There is little agreement about a differential response of men and women to opioid analgesics. Some experimental and clinical studies have shown that women have a better response to opioids, others have found no difference, and still others have found opioids to be more effective analgesics for men than women. OBJECTIVES: To assess sex differences in analgesic response to morphine and incidence of adverse events in patients receiving a dose of 0.1 mg intravenous morphine/kg. METHODS: Secondary analysis of the control arms of 6 randomized clinical trials that compared 0.1 mg/kg intravenous morphine with other opioids or other doses of morphine in patients aged 21 to 65 with acute pain. The setting was an academic medical center Emergency Department serving primarily Latino and African-American patients. Change in self-reported pain intensity from baseline to 30 minutes postbaseline on a validated and reproducible 11-point numerical rating scale and count of adverse events were the primary outcomes. RESULTS: The sample consisted of 211 women and 144 men. The mean change in pain from baseline to 30 minutes postbaseline was 3.7 in women, 3.6 men (difference=0.04; 95% confidence interval: -0.52, 0.60). In women without nausea before administration of morphine, the incidence of adverse events was 18.3% versus 10.7% in men without initial nausea (difference=7.6%; 95% confidence interval: -2.0, 17.2). DISCUSSION: Men and women presenting to the Emergency Department did not have a differential response to a single weight-based dose of morphine for alleviation of acute pain. Women without baseline nausea had more adverse events than men.

Failure to validate the San Francisco Syncope Rule in an independent emergency department population.

STUDY OBJECTIVE: We conduct a prospective independent validation of the San Francisco Syncope Rule to identify emergency department (ED) syncope patients with short-term serious outcomes. METHODS: This was a prospective observational cohort study of adult patients presenting to a university hospital ED with acute syncope or near syncope. Patients meeting inclusion criteria as defined in the San Francisco Syncope Rule derivation were evaluated for 5 previously derived predictor variables: abnormal ECG result, shortness of breath, hematocrit level less than 30%, triage systolic blood pressure less than 90 mm Hg, and history of congestive heart failure. Hospital admission occurred at the discretion of the emergency physician, independent of the decision rule. Follow-up occurred through contact with the inpatient attending physician for admitted patients and by telephone contact with patients not hospitalized or those hospitalized and discharged before day 7. Predetermined outcome measures as defined by the San Francisco Syncope Rule were death, myocardial infarction, arrhythmia, pulmonary embolism, stroke, subarachnoid hemorrhage, significant hemorrhage, or any condition causing or likely to cause a return ED visit and hospitalization for a related event. RESULTS: Complete predictor and follow-up data were available for 713 of 743 (96%) enrolled patients. Sixty-one of 713 (9%) patients met predetermined criteria for serious outcome. Sixteen of 61 (26%; 95% confidence interval [CI] 16% to 39%) patients with a serious outcome were not identified as high risk by the rule. Rule performance to predict serious outcomes was sensitivity 74% (95% CI 61% to 84%), specificity 57% (95% CI 53% to 61%); negative likelihood ratio 0.5 (95% CI 0.3 to 0.7) and positive likelihood ratio 1.7 (95% CI 1.4 to 2.0). CONCLUSION: In this independent validation study, sensitivity and negative likelihood ratio of the San Francisco Syncope Rule were substantially lower than reported in the original studies and suggest that the rule has limited generalizability.

Randomized double-blind placebo-controlled trial of two intravenous morphine dosages (0.10 mg/kg and 0.15 mg/kg) in emergency department patients with moderate to severe acute pain.

STUDY OBJECTIVE: We compare pain relief and safety of morphine 0.10 mg/kg with 0.15 mg/kg in adult emergency department (ED) patients with acute pain. METHODS: This was a randomized double-blind placebo-controlled trial of intravenous morphine 0.10 mg/kg versus 0.15 mg/kg, (delivered in 2 divided doses) in adult ED patients with acute pain requiring opioid analgesia. Assessment was made at baseline, 30 minutes, and 60 minutes with a validated verbal numeric rating scale. Pain reduction and satisfaction scores were measured at 30 and 60 minutes. The primary outcome measure was the between-group difference in mean before-after change in numeric rating scale from baseline to 60 minutes. RESULTS: Two hundred eighty patients were enrolled. Between-group difference in numeric rating scale improvement from baseline to 60 minutes was 0.8 (95% confidence interval 0.1 to 1.5), favoring the 0.15 mg/kg group. Pain relief scores and adverse events were similar in the 2 groups. CONCLUSION: Although 0.15 mg/kg of morphine is safe and provides statistically superior analgesia compared with a dose of morphine at 0.10 mg/kg, this difference in pain reduction did not reach the threshold of greater than 1.3 numeric rating scale units required to declare the higher dose of morphine clinically superior.

Predictors of early progression to severe sepsis or shock among emergency department patients with nonsevere sepsis.

BACKGROUND: Progression from nonsevere sepsis-i.e., sepsis without organ failure or shock-to severe sepsis or shock among emergency department (ED) patients has been associated with significant mortality. Early recognition in the ED of those who progress to severe sepsis or shock during their hospital course may improve patient outcomes. We sought to identify clinical, demographic, and laboratory parameters that predict progression to severe sepsis, septic shock, or death within 96 h of ED triage among patients with initial presentation of nonsevere sepsis. METHODS: This is a retrospective cohort of patients presenting to a single urban academic ED from November 2008 to October 2010. Patients aged 18 years or older who met criteria for sepsis and had a lactate level measured in the ED were included. Patients were excluded if they had any combination of the following: a systolic blood pressure <90 mmHg upon triage, an initial whole blood lactate level ≥4 mmol/L, or one or more of a set of predefined signs of organ dysfunction upon initial assessment. Disease progression was defined as the development of any combination of the aforementioned conditions, initiation of vasopressors, or death within 96 h of ED presentation. Data on predefined potential predictors of disease progression and outcome measures of disease progression were collected by a query of the electronic medical record and via chart review. Logistic regression was used to assess associations of potential predictor variables with a composite outcome measure of sepsis progression to organ failure, hypotension, or death. RESULTS: In this cohort of 582 ED patients with nonsevere sepsis, 108 (18.6 %) experienced disease progression. Initial serum albumin <3.5 mg/dL (OR 4.82; 95 % CI 2.40-9.69; p < 0.01) and a diastolic blood pressure <52 mmHg at ED triage (OR 4.59; 95 % CI 1.57-13.39; p < 0.01) were independently associated with disease progression to severe sepsis or shock within 96 h of ED presentation. There were no deaths within 96 h of ED presentation. CONCLUSIONS: In our patient cohort, serum albumin <3.5 g/dL and an ED triage diastolic blood pressure <52 mmHg independently predict early progression to severe sepsis or shock among ED patients with presumed sepsis.

Faculty development: academic opportunities for emergency medicine faculty on education career tracks.

Medical school faculty members who specialize in the scholarship of teaching have unique requirements for academic advancement in universities with clinician-educator series. While excellence in teaching is the cornerstone of achievement, attention to traditional academic pursuits improves the likelihood of a favorable review by the institution's promotion and tenure committee. The teaching portfolio is an effective means to document performance. Ongoing faculty development and sound mentoring relationships facilitate the academic advancement of clinician-educators.

The virtual advisor program: linking students to mentors via the world wide web.

BACKGROUND: Emergency medicine (EM) is a popular specialty for medical students choosing a career. Many attend medical schools without an affiliated EM residency and lack both the formal mentorship and informal guidance provided by medical school advisors (or faculty) involved in an accredited EM training program. Others desire specialized advice based on geographic or specific academic interest. OBJECTIVE: The authors describe user characteristics of a Web-based virtual advisor program that paired medical students with EM faculty advisors. METHODS: Prospective users access the system from a link on the Society for Academic Emergency Medicine (SAEM) home page. On the initial visit, demographic information is collected. Faculty and student guidelines are provided. Students desiring individual advice may register for a virtual advisor who can assess career goals and qualifications. Volunteer faculty mentors are assigned on the basis of the student's geographic and demographic preferences and career aspirations. Encounters rely primarily on electronic and/or voice correspondence to suit the needs of the pair. A frequently asked question (FAQ) section provides answers to common questions and does not require registration. RESULTS: Two hundred sixty-four students (183 males, 75 females, 6 unspecified) from North American (87) and international (25) medical schools requested a virtual advisor. One hundred twenty-one faculty advisors from 56 U.S. medical schools participated (86 [71%] males; 35 [29%] females). Students indicated reasons they sought a virtual advisor. Qualitative feedback was generally positive from advisors and advisees. CONCLUSION: The implementation of the virtual advisor program enabled medical students to have access to experienced EM faculty career mentors.

Is single observer identification of wound infection a reliable endpoint?

The majority of wound studies over the past 20 years have relied on single observer determination of infection presence or absence as a study endpoint. Nevertheless, there are few data on the reliability of those determinations. If single observer determinations are not reliable, the validity of studies using this endpoint should be questioned. Two physicians independently evaluated wounds for presence or absence of the primary endpoint of infection and the secondary endpoints of purulence, tenderness, warmth, and erythema. Kappa values were calculated as measures of inter-observer agreement, which was used as a measure of reliability. Of 125 patients enrolled, 115 wounds were available for analysis. Kappa =.57 [95%CI.39 to.75] for the primary endpoint of infection,.84 for purulence,.72 for tenderness,.48 for warmth, and.48 for erythema. Agreement on two features of infection and overall agreement on the presence or absence of wound infection was only 'moderate.' Single observer determination of wound infection by inexperienced observers using imprecise definitions, though commonly used, is an unreliable measure for scientific study.

Efficacy of patient-controlled analgesia for patients with acute abdominal pain in the emergency department: a randomized trial.

OBJECTIVES: The objective was to assess the efficacy of patient-controlled analgesia (PCA) in the emergency department (ED) and to compare two PCA dosing regimens. METHODS: A randomized controlled trial with three treatment arms was performed in an urban ED. A convenience sample of ED patients ages 18 to 65 years with abdominal pain of 7 days or less duration requiring intravenous (IV) opioid analgesia was enrolled between April 2009 and June 2010. All patients received an initial dose of 0.1 mg/kg IV morphine followed by physician-managed analgesia as needed. Patients in the PCA arms also received IV morphine with on-demand doses of 1 or 1.5 mg, with a 6-minute lockout between doses. Pain intensity was rated by patients on an 11-point numeric rating scale (NRS). Satisfaction with pain treatment, desire for the same treatment in the future, and need for additional analgesia were assessed at study end. Adverse events (O(2) sat < 92%, respiratory rate [RR] < 10/min, systolic blood pressure [sBP] < 90 mm Hg, and naloxone use) were counted. One-way analysis of variance was used to test the difference among groups in short-term pain relief, as assessed by mean change in NRS pain intensity from baseline to 30 minutes and pain over the entire 2-hour study period measured by area under the curve (AUC) of NRS pain ratings. A post hoc hierarchical linear model was used to test the observed difference in NRS between the groups between 30 and 120 minutes. RESULTS: A total of 211 patients were enrolled. A sharp, nearly identical decline in mean NRS scores occurred from baseline to 30 minutes in the three groups (p = 0.82). Between 30 and 120 minutes, there was little further decline in the non-PCA NRS scores, while both PCA groups continued to decline (p = 0.004). The net treatment effect over the entire 2 hours was smallest in the non-PCA group and largest in the group receiving 1.5 mg of morphine (p = 0.06). The mean decline in pain from baseline to 120 minutes postbaseline in both PCA groups was 1.4 NRS units (95% confidence interval [CI] = 0.3 to 2.4) greater than the decline in patients treated without PCA. More patients in the PCA arms reported satisfaction, wanting the same pain management in the future, and not wanting further analgesics at 120 minutes than patients who did not receive PCA. There were no clinically or statistically significant differences in any outcomes between the two PCA groups. One PCA patient had a transient oxygen saturation of 88% after the initial bolus only, and one non-PCA patient had a brief drop in sBP to 87 mm Hg. CONCLUSIONS: This study provides support for efficacy of PCA when applied to the ED setting. Future studies designed to assess implementation of this modality in the context of conditions of actual ED staffing and competing patient demands are warranted.

Ability of CT to alter decision making in elderly patients with acute abdominal pain.

The study objective was to assess the ability of computerized tomography (CT) to alter clinical decision-making in the evaluation of elderly Emergency Department (ED) patients with abdominal pain. A prospective, observational cohort study of a convenience sample of ED patients, 65 years of age, with abdominal or flank pain of 1-week duration was conducted. ED attending physicians completed a structured data collection instrument recording 5 primary endpoints before and after CT. Change in frequency of each of these 5 endpoints from pre- to post-CT comprised the target outcome variables. Of 104 eligible patients, CT altered the admission decision in 26% (95%CI 18, 34%)]; need for surgery in 12% (95% CI 6%, 18%); need for antibiotics in 21% (95% CI 13%, 29%) and suspected diagnosis in 45% (95% CI 35%, 55%). The proportion of cases in which physicians reported a high degree of certainty in the suspected diagnosis increased from 36% pre-CT (95%CI 26,44%) to 77% post-CT (95% CI 69, 85%). Diagnosis and disposition were altered by CT in about one-half and one-quarter of patients, respectively, concurrent with a doubling in diagnostic certainty. CT has the ability to significantly alter clinically important decisions in elderly patients with abdominal pain.