Referral pathways for chronic pain patients from Canadian emergency departments: emergency physicians' practices, perspectives, and recommendations.

BACKGROUND: Patients with chronic pain account for 12-20% of total emergency department (ED) and was the primary presenting concern among 37% of patients who visited the ED > 12 times per year. Despite this, emergency physicians receive little focused training managing these patients, and there is a paucity of effective referral pathways from EDs, despite strong evidence that chronic pain is best treated longitudinally in multidisciplinary clinics. This study sought to explore the practices, perspectives, and recommendations of current Canadians emergency physicians in better serving the chronic pain patient (CPP) population in the ED. METHODS: An electronic cross-sectional survey was administered to members of the Canadian Association of Emergency Physicians (CAEP), consisting of 16 multiple choice and numerical response questions. Responses were summarized descriptively as percentages and as the median and inter-quartile range (IQR) for quantitative variables. RESULTS: The study was completed by 169/1635 respondents for a response rate of 10%. The most common presentations respondents saw were neuropathic pain and centrally mediated disorders (23% each) and low back pain (19%). 86% of respondents felt that chronic pain patients did not get appropriate referrals from the ED, and 70% of respondents were unaware of where they could even refer chronic pain patients from the ED. 96% of respondents felt that their ED did not have an effective referral pathway for chronic pain patients. Rapid access clinics for common conditions, reduced pain clinic wait times, and clear ED referral pathways were the commonest recommendations by respondents. CONCLUSION: There is a clear need to increase the accessibility to outpatient pain medicine clinics for chronic pain patients presenting to the ED. ED and pain medicine providers must collaborate to establish mutually beneficial referral pathways from EDs, and to advocate for increased funding for rapid access outpatient pain clinics.

RéSUMé: CONTEXTE: Les patients souffrant de douleur chronique représentent de 12 à 20% de l'ensemble du service d'urgence (SU) et constituaient la principale préoccupation chez 37% des patients qui ont visité le SU > 12 fois par année. Malgré cela, les urgentologues reçoivent peu de formation ciblée sur la gestion de ces patients, et il y a peu de voies d'aiguillage efficaces de la part des urgences, malgré de solides preuves que la douleur chronique est mieux traitée longitudinalement dans les cliniques multidisciplinaires. Cette étude visait à explorer les pratiques, les perspectives et les recommandations des médecins d'urgence canadiens actuels pour mieux servir la population de patients souffrant de douleur chronique (RPC) à l'urgence. MéTHODES: Un sondage transversal électronique a été administré aux membres de l'Association canadienne des médecins d'urgence (ACMU), comprenant seize questions à choix multiples et réponses numériques. Les réponses ont été résumées de façon descriptive sous forme de pourcentages et de fourchette médiane et inter quartile (IQR) pour les variables quantitatives. RéSULTATS: : L'étude a été complétée par 169/1635 répondants pour un taux de réponse de 10%. Les présentations les plus courantes que les répondants ont vues étaient des douleurs neuropathiques et des troubles médiés centraux (23% chacun) et des douleurs lombaires (19%). 86% des répondants estimaient que les patients souffrant de douleur chronique n'obtenaient pas de références appropriées de la part de l'urgence, et 70% des répondants ne savaient même pas où ils pouvaient référer les patients souffrant de douleur chronique de l'urgence. 96% des répondants estimaient que leur DE n'avait pas de voie d'aiguillage efficace pour les patients souffrant de douleur chronique. Les cliniques d'accès rapide pour les affections courantes, la réduction des temps d'attente dans les cliniques de traitement de la douleur et des voies d'aiguillage claires vers le service d'urgence étaient les recommandations les plus courantes des répondants. CONCLUSION: Il est clairement nécessaire d'accroître l'accessibilité aux cliniques de traitement de la douleur ambulatoire pour les patients souffrant de douleur chronique qui se présentent à l'urgence. Les fournisseurs de soins de l'urgence et de médicaments contre la douleur doivent collaborer pour établir des voies d'aiguillage mutuellement avantageuses à partir des urgences. et plaider en faveur d'un financement accru pour des cliniques de traitement de la douleur en consultation externe à accès rapide.

Test Characteristics of Point-of-care Ultrasound for the Diagnosis of Retinal Detachment in the Emergency Department.

BACKGROUND: Previous studies of point-of-care ultrasound (POCUS) have reported high sensitivities and specificities for retinal detachment (RD). Our primary objective was to assess the test characteristics of POCUS performed by a large heterogeneous group of emergency physicians (EPs) for the diagnosis of RD. METHODS: This was a prospective diagnostic test assessment of POCUS performed by EPs with varying ultrasound experience on a convenience sample of emergency department (ED) patients presenting with flashes or floaters in one or both eyes. After standard ED assessment, EPs performed an ocular POCUS scan targeted to detect the presence or absence of RD. After completing their ED visit, all patients were assessed by a retina specialist who was blinded to the results of the POCUS scan. We calculated sensitivity and specificity with associated exact binomial confidence intervals (CIs) using the retina specialist's final diagnosis as the reference standard. RESULTS: A total of 30 EPs enrolled 115 patients, with median age of 60 years and 64% female. The retina specialist diagnosed RD in 16 (14%) cases. The sensitivity and specificity of POCUS for detecting RD were 75% (95% CI = 48%-93%) and 94% (95% CI = 87%-98%), respectively. The positive likelihood ratio was 12.4 (95% CI = 5.4-28.3), and negative likelihood ratio was 0.27 (95% CI = 0.11-0.62). CONCLUSIONS: A large heterogeneous group of EPs can perform POCUS with high specificity but only intermediate sensitivity for RD. A negative POCUS scan in the ED performed by a heterogeneous group of providers after a 1-hour POCUS didactic is not sufficiently sensitive to rule out RD in a patient with new-onset flashes or floaters.

Diagnosis of a pericardial effusion with a thoracic aortic aneurysm by point-of-care ultrasound.

We present a rare case of a young patient with chest pain whose ascending thoracic aortic aneurysm (TAA) was detected by point-of-care ultrasound (POCUS) leading to a successful surgical repair. POCUS identified a moderate pericardial effusion and an associated severely dilated ascending aorta. In this context, it is important to rule out aortic rupture and aortic dissection. We also discuss the epidemiology, complications, and management of TAAs as well as the role of cardiac POCUS in the diagnosis of thoracic aneurysmal disease.

Reduction in sodium content of local anesthetics for peripheral nerve blocks: a comparative evaluation of saline with 5% dextrose--a randomized controlled double-blind study.

BACKGROUND: Commercially available local anesthetic drugs when diluted with normal saline have high sodium content. High perineural sodium concentration has been implicated in antagonizing the analgesic effects of local anesthetics by preventing and/or delaying neural blockade. Five percent dextrose is not known to cause any short- or long-term injury when injected around neural tissue. In this study, we prospectively compared and evaluated block characteristics when local anesthetic drug was diluted with these 2 different agents. METHODS: Patients scheduled for upper limb surgery were randomly assigned to receive axillary brachial plexus block with 0.5% ropivacaine (1% diluted with either 5% dextrose or normal saline). Motor and sensory block were tested every 5 minutes for 30 minutes. Postoperatively, a telephone interview was conducted after 24 hours and 7 days along with surgical follow-up at days 3, 10, and/or 14 to 28 days to document side effects, patient satisfaction, and time for block resolution. Any nerve deficits were followed until resolution. The primary outcome was time to onset of sensory nerve block. RESULTS: Five hundred fifty patients were recruited for this study. The mean time to complete sensory block was 18.3 ± 6.1 minutes in the dextrose group and 22.5 ± 6.4 minutes in the saline group (P < 0.001, 95% confidence interval for mean difference 3.0-5.4 minutes). There were 5 patients with clinical nerve deficits (no statistical difference between groups). CONCLUSIONS: Dilution with 5% dextrose provides earlier onset of axillary brachial plexus block with ropivacaine.