Perception of Treatment Success and Impact on Function with Antibiotics or Appendectomy for Appendicitis: A Randomized Clinical Trial with an Observational Cohort.

OBJECTIVE: To compare secondary patient reported outcomes of perceptions of treatment success and function for patients treated for appendicitis with appendectomy vs. antibiotics at 30 days. SUMMARY BACKGROUND DATA: The Comparison of Outcomes of antibiotic Drugs and Appendectomy trial found antibiotics noninferior to appendectomy based on 30-day health status. To address questions about outcomes among participants with lower socioeconomic status, we explored the relationship of sociodemographic and clinical factors and outcomes. METHODS: We focused on 4 patient reported outcomes at 30 days: high decisional regret, dissatisfaction with treatment, problems performing usual activities, and missing >10 days of work. The randomized (RCT) and observational cohorts were pooled for exploration of baseline factors. The RCT cohort alone was used for comparison of treatments. Logistic regression was used to assess associations. RESULTS: The pooled cohort contained 2062 participants; 1552 from the RCT. Overall, regret and dissatisfaction were low whereas problems with usual activities and prolonged missed work occurred more frequently. In the RCT, those assigned to antibiotics had more regret (Odd ratios (OR) 2.97, 95% Confidence intervals (CI) 2.05-4.31) and dissatisfaction (OR 1.98, 95%CI 1.25-3.12), and reported less missed work (OR 0.39, 95%CI 0.27-0.56). Factors associated with function outcomes included sociodemographic and clinical variables for both treatment arms. Fewer factors were associated with dissatisfaction and regret. CONCLUSIONS: Overall, participants reported high satisfaction, low regret, and were frequently able to resume usual activities and return to work. When comparing treatments for appendicitis, no single measure defines success or failure for all people. The reported data may inform discussions regarding the most appropriate treatment for individuals. TRIAL REGISTRATION: Clinicaltrials.gov Identifier: NCT02800785.

A Randomized Trial Comparing Antibiotics with Appendectomy for Appendicitis.

BACKGROUND: Antibiotic therapy has been proposed as an alternative to surgery for the treatment of appendicitis. METHODS: We conducted a pragmatic, nonblinded, noninferiority, randomized trial comparing antibiotic therapy (10-day course) with appendectomy in patients with appendicitis at 25 U.S. centers. The primary outcome was 30-day health status, as assessed with the European Quality of Life-5 Dimensions (EQ-5D) questionnaire (scores range from 0 to 1, with higher scores indicating better health status; noninferiority margin, 0.05 points). Secondary outcomes included appendectomy in the antibiotics group and complications through 90 days; analyses were prespecified in subgroups defined according to the presence or absence of an appendicolith. RESULTS: In total, 1552 adults (414 with an appendicolith) underwent randomization; 776 were assigned to receive antibiotics (47% of whom were not hospitalized for the index treatment) and 776 to undergo appendectomy (96% of whom underwent a laparoscopic procedure). Antibiotics were noninferior to appendectomy on the basis of 30-day EQ-5D scores (mean difference, 0.01 points; 95% confidence interval [CI], -0.001 to 0.03). In the antibiotics group, 29% had undergone appendectomy by 90 days, including 41% of those with an appendicolith and 25% of those without an appendicolith. Complications were more common in the antibiotics group than in the appendectomy group (8.1 vs. 3.5 per 100 participants; rate ratio, 2.28; 95% CI, 1.30 to 3.98); the higher rate in the antibiotics group could be attributed to those with an appendicolith (20.2 vs. 3.6 per 100 participants; rate ratio, 5.69; 95% CI, 2.11 to 15.38) and not to those without an appendicolith (3.7 vs. 3.5 per 100 participants; rate ratio, 1.05; 95% CI, 0.45 to 2.43). The rate of serious adverse events was 4.0 per 100 participants in the antibiotics group and 3.0 per 100 participants in the appendectomy group (rate ratio, 1.29; 95% CI, 0.67 to 2.50). CONCLUSIONS: For the treatment of appendicitis, antibiotics were noninferior to appendectomy on the basis of results of a standard health-status measure. In the antibiotics group, nearly 3 in 10 participants had undergone appendectomy by 90 days. Participants with an appendicolith were at a higher risk for appendectomy and for complications than those without an appendicolith. (Funded by the Patient-Centered Outcomes Research Institute; CODA ClinicalTrials.gov number, NCT02800785.).

Four- and three-year emergency medicine residency graduates perform similarly in their first year of practice compared to experienced physicians.

INTRODUCTION: United States emergency medicine (EM) post-graduate training programs vary in training length, either 4 or 3 years. However, it is unknown if clinical care by graduates from the two curricula differs in the early post-residency period. METHODS: We performed a retrospective observational study comparing measures of clinical care and practice patterns between new graduates from 4- and 3-year EM programs with experienced new physician hires as a reference group. We included emergency department (ED) encounters from a national EM group (2016-19) between newly hired physicians from 4- and 3- year programs and experienced new hires (>2 years' experience) during their first year of practice with the group. Primary outcomes were at the physician-shift level (patients per hour and relative value units [RVUs] per hour) and encounter-level (72-h return visits with admission/transfer and discharge length of stay [LOS]). Secondary outcomes included discharge opioid prescription rates, test ordering, computer tomography (CT) use, and admission/transfer rate. We compared outcomes using multivariable linear regression models that included patient, shift, and facility-day characteristics, and a facility fixed effect. We hypothesized that experienced new hires would be most efficient, followed by new 4-year graduates and then new 3-year graduates. RESULTS: We included 1,084,085 ED encounters by 4-year graduates (n = 39), 3-year graduates (n = 70), and experienced new hires (n = 476). There were no differences in physician-level and encounter-level primary outcomes except discharge LOS was 10.60 min (2.551, 18.554) longer for 4-year graduates compared to experienced new hires. Secondary outcomes were similar among the three groups except 4- and 3-year new graduates were less likely to prescribe opioids to discharged patients, -3.70% (-5.768, -1.624) and - 3.38% (-5.136, -1.617) compared to experienced new hires. CONCLUSIONS: In this sample, measures of clinical care and practice patterns related to efficiency, safety, and flow were largely similar between the physician groups; however, experienced new hires were more likely to prescribe opioids than new graduates. These results do not support recommending a specific length of residency training in EM.

Current status of robotic surgery in colorectal residency training programs.

BACKGROUND: Robotic surgery (RS) has been increasingly incorporated into colorectal surgery (CRS) training. The degree to which RS has been integrated into CRS residency training is not well described. METHODS: A web-based survey was sent to all 2019 accredited CRS residency programs within the United States and Canada. Program directors (PDs) were queried on how robotic surgery had been integrated into their program, specifics on RS curriculum and opinions on RS training during general surgery residency. We compared survey responses by program type (university-based, university-affiliated programs, or independent programs) and by geographic region. In addition, a chi-square test was used to evaluate differences in survey responses with respect to robotic curriculum components. RESULTS: Of 66 programs, 42 (64%) responded to the survey. Of the responding programs, 35 (83%) were university-based or university-affiliated, while 7 (17%) were independent. Most programs were in the Midwest (33%). Forty-one (98%) reported having a surgical robot in use at their institution, with 95% reporting active participation of CRS residents in RS. While 74% of programs have a formal RS training curriculum for CRS residents, there was considerable variability in the curriculum elements employed by each institution, and the differences in proportions of these elements were significant (χ2 99.8, p < 0.001). The median operative approach to abdominopelvic cases was estimated to be 33% robotic, 40% laparoscopic and 20% open. There were no significant differences in the survey responses between university/university-affiliated and independent programs (p > 0.05) or among the different regions (p > 0.05). CONCLUSIONS: This study demonstrated that almost all CRS residencies have integrated RS and have trainees operating at the robotic console. Most programs have a robotics curriculum and there are expanding indications for RS within CRS. This expansion calls for discussion on implementation of training standards such as curricular requisites, baseline competency assessments, and definitions of minimum case requirements to ensure adequate training.

A Standardized Formulary to Reduce Pediatric Medication Dosing Errors: A Mixed Methods Study.

Objective: We hypothesized that implementation of a Medical Control Guideline (MCG) with a standardized formulary (fixed medication concentrations) and pre-calculated medication dosages in a large emergency medical services (EMS) system would reduce pediatric dosing errors. To assess the effectiveness of the standardized formulary to reduce errors, we chose to evaluate midazolam administration for seizures, because it is the most frequently dosed medication by EMS for children, and seizures are a time-sensitive condition. The objective of this study was to compare: 1) frequency of midazolam dosing errors during the field treatment of pediatric seizures and 2) paramedic anxiety and confidence in dosing midazolam for pediatric seizures, before and after implementation of the MCG.Methods: In this mixed-methods study, we utilized the Los Angeles County EMS data registry to identify pediatric patients ≤14 years-old treated with midazolam for seizure. We defined a dosing error as outside the dose directed by the color code on the length-based resuscitation tape, or ±20% the weight-based midazolam dose when color code was absent. We compared dosing errors during a two-year period before and after implementation of the MCG with the standardized formulary in February 2017. We surveyed paramedics to assess their level of anxiety and confidence in dosing midazolam and conducted semi-structured interviews with 20 respondents to further explore its impact on paramedic practice.Results: There were 80 dosing errors in 569 patients treated post-formulary (14.1%) compared with 92 dosing errors in 497 patients treated pre-formulary (18.5%), risk difference -4.5% (95% CI -8.9 to 0.0), p = 0.049. Among 304 paramedic survey respondents who had experience with the formulary, anxiety decreased (p < 0.001) and confidence increased (p < 0.001) post-formulary. Paramedics expressed the challenges of pediatric calls, the benefits of the MCG with the standardized formulary, and the ongoing challenges of pediatric medication dosing. Benefits included simplifying paramedic tasks, increasing paramedic self-efficacy, facilitating provider communication, and improving patient care.Conclusion: Implementation of a MCG with standardized formulary and pre-calculated medication dosing by weight reduced pediatric medication dosing errors and increased paramedic confidence in pediatric medication dosing. It may have the potential to facilitate patient care through improved communications and task simplification.

The Effectiveness of Intranasal Midazolam for the Treatment of Prehospital Pediatric Seizures: A Non-inferiority Study.

Background: Intranasal (IN) midazolam allows for rapid, painless treatment of pediatric seizures in the prehospital setting and may be a preferred administration route if determined to be non-inferior to intravenous (IV) or intramuscular (IM) routes. We sought to evaluate the effectiveness of IN midazolam for terminating prehospital pediatric seizures compared to midazolam administered by alternate routes. Methods: We performed a retrospective, non-inferiority analysis using data from a regional Emergency Medical Services (EMS) database. We included pediatric patients ≤ 14 years treated with midazolam (0.1 mg/kg) by EMS for non-traumatic seizures. The primary outcome was the proportion of patients requiring redosing of midazolam after initial treatment with IN midazolam compared to those that received IV or IM midazolam. We established a priori a risk difference of 6.5% as the non-inferiority margin. Results: We evaluated outcomes from 2,034 patients (median age 6 years [interquartile range 3 - 10 years], 55% male). Initial administration routes were 461 (23%) IN, 547 (27%) IM, 1024 (50%) IV, and 2 (0.1%) intraosseous (IO). Midazolam redosing occurred in 116 patients (25%) who received IN midazolam versus 222 patients (14%) treated initially with midazolam via alternate routes (risk difference 11% [95%CI 7 - 15%]). The age-adjusted odds ratio for redosing midazolam after intranasal administration compared to alternate route administration was 2.0 (95% CI 1.6 - 2.6). Conclusion: Prehospital treatment of pediatric seizure with intranasal midazolam was associated with increased frequency of redosing compared to midazolam administered by other routes, suggesting that 0.1 mg/kg is a subtherapeutic dose for intranasal midazolam administration.

Impact of video laryngoscope shape on first-attempt success during non-supine emergency department intubations.

INTRODUCTION: Laryngoscope blade shape may differentially facilitate first-attempt success in patients intubated in non-supine positions in the emergency department (ED). Therefore, we analyzed first-attempt success in ramped and upright positions stratified by hyperangulated or standard geometry video laryngoscopes (VL). METHODS: We performed a secondary analysis of the National Emergency Airway Registry (NEAR) on ED intubations from January 1, 2016 to December 31, 2018. Our primary outcome was first-attempt success, and secondary outcomes included first-attempt success without adverse events and glottic view. We included all VL intubation attempts in the ramped and upright positions on medical patients >17-years-old. We calculated adjusted odds ratios (aOR) using a multivariable logistic regression mixed-effects model with site as a random effect and blade type, obesity / morbid obesity, training level (i.e., post-graduate year), operator-perceived difficult airway, and presence of an objective difficult airway finding as fixed effects. RESULTS: Our analysis included 266 attempts with hyperangulated blades and 370 attempts with standard geometry blades in the ramped cohort, and 116 attempts with hyperangulated attempts and 55 attempts with standard geometry blades in the upright cohort. In the ramped cohort, 244 (91.7%) of hyperangulated first attempts were successful, and 341 (92.2%) of standard geometry first attempts were successful (aOR 1.02 [95% confidence interval 0.56, 1.84]). In the upright cohort, 107 (92.2%) of hyperangulated first attempts were successful, and 50 (90.9%) of standard geometry first attempts were successful (aOR 1.04 [0.28, 3.86]). There was no difference across the secondary outcomes, including first-attempt success without adverse events. CONCLUSION: Hyperangulated and standard geometry VL had similar first-attempt success in ramped and upright position intubations in the ED.

Video Laryngoscopy Is Associated With First-Pass Success in Emergency Department Intubations for Trauma Patients: A Propensity Score Matched Analysis of the National Emergency Airway Registry.

STUDY OBJECTIVE: We sought to (1) characterize emergency department (ED) intubations in trauma patients and estimate (2) first-pass success and (3) the association between patient and intubation characteristics and first-pass success. METHODS: We performed a secondary analysis of a multicenter prospective observational cohort of ED intubations from the National Emergency Airway Registry (NEAR). Descriptive statistics were calculated for all patients who were intubated for trauma at 23 NEAR EDs between 2016 and 2018. We evaluated first-pass success in patients intubated by (1) emergency or pediatric emergency physicians, (2) using rapid sequence intubation or no medications, and (3) either direct laryngoscopy or video laryngoscopy. We used propensity score matching with a generalized linear mixed-effects model to estimate the associations between patient and intubation characteristics and first-pass success. RESULTS: Of the 19,071 intubations in NEAR, 4,449 (23%) were for trauma, and nearly all (88%) had at least one difficult airway characteristic. Prevalence of first-pass success was 86.8% (95% confidence interval [CI]: 83.3% to 90.3%). Most patients were intubated with video laryngoscopy, and patients were more likely to be intubated on first-pass with video laryngoscopy as compared to direct laryngoscopy (90% versus 79%). After propensity score matching, video laryngoscopy remained associated with first-pass success (adjusted risk difference 11%, 95% CI: 8% to 14%; and OR 2.2, 95% CI: 1.6 to 2.9). Additionally, an initial impression of difficult airway, blood/vomit in the airway, and use of external laryngeal manipulation were all associated with decreased odds of first-pass success. CONCLUSION: Emergency physicians are successful at intubating patients in the setting of trauma, and video laryngoscopy is associated with twice the odds of first-pass success when compared to direct laryngoscopy.

Clinical Policy: Critical Issues in the Management of Adult Patients Presenting to the Emergency Department With Community-Acquired Pneumonia.

This clinical policy from the American College of Emergency Physicians is a revision of the 2009 "Clinical Policy: Critical Issues in the Management of Adult Patients Presenting to the Emergency Department With Community-Acquired Pneumonia." A writing subcommittee conducted a systematic review of the literature to derive evidence-based recommendations to answer the following clinical questions: (1) In the adult emergency department patient diagnosed with community-acquired pneumonia, what clinical decision aids can inform the determination of patient disposition? (2) In the adult emergency department patient with community-acquired pneumonia, what biomarkers can be used to direct initial antimicrobial therapy? (3) In the adult emergency department patient diagnosed with community-acquired pneumonia, does a single dose of parenteral antibiotics in the emergency department followed by oral treatment versus oral treatment alone improve outcomes? Evidence was graded and recommendations were made based on the strength of the available data.

Awake intubations in the emergency department: A report from the National Emergency Airway Registry.

OBJECTIVE: To describe awake intubation practices in the emergency department (ED) and report success, complications, devices used, and rescue techniques using multicenter surveillance. METHODS: We analyzed data from the National Emergency Airway Registry (NEAR). Patients with an awake intubation attempt between January 1, 2016 and December 31, 2018 were included. We report univariate descriptive data as proportions with cluster-adjusted 95% confidence intervals (CIs). RESULTS: Of 19,071 discrete patient encounters, an awake technique was used on the first attempt in 82 (0.4%) patients. The majority (91%) of first attempts were performed by emergency medicine physicians. Angioedema (32%) and non-angioedema airway obstruction (31%) were the most common indications for an awake intubation attempt. The most common initial device used was a flexible endoscope (78%). Among all awake intubations first-attempt success was achieved in 85% (95% CI [76%-95%]), and peri-intubation complications occurred in 16% (95% CI [9%-26%]). CONCLUSION: Awake intubation in this multicenter cohort of emergency department patients was rare and was performed most often in patients with airway edema or obstruction. Emergency physicians performed the majority of first intubation attempts with high first-attempt success. Further studies are needed to determine optimal emergency airway management in this patient population.

Emergency Department Intubations in Patients With Angioedema: A Report from the National Emergency Airway Registry.

BACKGROUND: Angioedema, a localized swelling of subcutaneous and submucosal tissues, may involve the upper airway. A subset of patients presenting for emergent evaluation of angioedema will require intubation. Little is known about airway management practices in patients with angioedema requiring intubation in the emergency department (ED). OBJECTIVE: To describe airway management practices in patients intubated for angioedema in the ED. METHODS: We analyzed data from the National Emergency Airway Registry. All patients with an intubation attempt for angioedema between January 1, 2016 and December 31, 2018 were included. We report univariate descriptive data as proportions with cluster-adjusted 95% confidence intervals. RESULTS: Of 19,071 patient encounters, intubation was performed for angioedema in 98 (0.5%). First-attempt success was achieved in 81%, with emergency physicians performing the procedure in 94% of encounters. The most common device used was a flexible endoscope (49%), and 42% of attempts were via a nasal route. Pharmacologic methods included sedation with paralysis (61%), topical anesthesia with or without sedation (13% and 13%, respectively), and sedation only (10%). Among 19 (19%) patients requiring additional attempts, intubation was achieved on second attempt in 10 (53%). The most common adverse events were hypotension (13%) and hypoxemia (12%). Cricothyrotomy occurred in 2 patients (2%). No deaths were observed. CONCLUSIONS: Angioedema was a rare indication for intubation in the ED setting. Emergency physicians achieved first-attempt success in 81% of encounters and used a broad range of intubation devices and methods, including flexible endoscopic techniques. Cricothyrotomy was rare, and no ED deaths were reported. © 2021 Elsevier Inc.

Can Oncotype DX testing be omitted in invasive breast cancer patients with clinicopathologic factors predicting very high pretest probability of a concordant result?

OBJECTIVE: To determine if clinicopathologic (CP) factors could identify patients at "very low" and/or "very high" pretest probability of a high Oncotype DX (ODX) score. METHODS: A retrospective analysis of all patients that had ODX testing 2008-2018 at a single institution. RESULTS: Of 215 patients, all 16 (7.4%) with "all high" risk CP factors had high ODX scores, and all 45 (20.9%) over age 50 with "all low" risk CP factors had ODX recommendations for no chemotherapy. CONCLUSIONS: Oncotype DX results did not change chemotherapy recommendations in those with "very low" or "very high" pretest probability of high ODX scores.

Careful Patient Selection Achieves High Radiocephalic Arteriovenous Fistula Patency in Diabetic and Female Patients.

BACKGROUND: The radiocephalic arteriovenous fistula (rcAVF) is considered the first-choice site for hemodialysis access; however, it has been associated with decreased rates of patency and maturation in women and diabetic patients in some studies. We hypothesized that careful preoperative selection of patients for an rcAVF fistula would result in a high 1-year patency rate and that external factors, such as female gender and diabetes mellitus (DM), would not adversely affect fistula patency. METHODS: This is a retrospective study of all patients who underwent rcAVF creation at a single institution from January 2011 to June 2016. Patients were carefully selected based on clinical examination and preoperative, B-mode, ultrasound findings. Primary patency and primary assisted patency at 1 year were calculated. Survival analysis was also conducted to evaluate for factors associated with rcAVF patency. RESULTS: There were 158 patients identified who underwent rcAVF fistula creation and were seen in follow-up. The 1-year primary and primary assisted patency rates were 62% and 81%, respectively. On Kaplan-Meier survival analysis, there was no difference in rcAVF patency with respect to gender, Hispanic race, anesthesia type, DM, and smoking status. Patients with a prior AVF, most often received in the nondominant arm and now receiving an rcAVF in the dominant arm, had a significantly higher risk of fistula failure, in both primary and primary assisted patency survival (hazard ratio 5.1, 95% confidence interval 1.6-16.2, P = 0.06). Patients without a history of hypertension (HTN), as noted in the electronic medical records, trended toward a higher risk of primary assisted patency rcAVF failure, compared to those who had a history of HTN (hazard ratio 3.0, 95% confidence interval 1.1-7.9, P = 0.03). CONCLUSIONS: With careful patient selection, the rcAVF can achieve a high 1-year primary assisted patency rate. Female gender and DM were not significantly associated with an increase in rcAVF failure and should not be heavily relied on in-patient selection. First-time AVF patients and patients with a history of HTN may be associated with increased rcAVF patency.

Evaluation of Trauma Triage Criteria Performance in a Regional Trauma System.

Objective: We evaluated the performance of individual trauma triage criteria using data from a regional trauma registry. Methods: Los Angeles County (LAC) paramedics use triage criteria adapted from the 2011 Center for Disease Control (CDC) guidelines to triage injured patients to Trauma Centers (TCs). TCs report outcomes to a LAC EMS registry. We abstracted data for patients 15 years or older from 2013 to 2015 and identified all trauma triage criteria that were met for each encounter. Study outcomes were: (1) "clear need" for a TC, defined as receiving a non-orthopedic operative intervention within 6 hours of arrival, injury severity score (ISS) > 15, or surgical ICU admission; or (2) "no need" for a TC, defined as discharge home from the emergency department (ED). We also defined "possible need" as those patients not discharged home from the ED, inclusive of "clear need" and all other admitted patients. For each individual triage criteria, we calculated the positive likelihood ratios and positive predictive values for TC need. Results: There were 71,536 adult patients in the registry transported by EMS to a LAC TC during the study. Median age was 38 years (IQR 25-55) with 73% male. There were 23,628 (33%) who met "no need" criteria for a TC, leaving 47,908 (67%) patients with "possible need" for a TC, of whom 13,343 patients (19% of total) met "clear need" for a TC. No individual trauma criterion met the a priori likelihood ratio threshold of 10 for predicting "clear need" for a TC. Cardiopulmonary arrest with penetrating torso trauma and flail chest met this threshold for "possible need." Conclusion: In this retrospective analysis, no individual triage criterion definitively identified patients who benefit from transport to a TC. Yet, the majority of patients demonstrated potential benefit for nearly all criteria, supporting CDC recommendations that trauma triage criteria be considered in their entirety, not as individual criterion.

Safety and Effectiveness of Field Nitroglycerin in Patients with Suspected ST Elevation Myocardial Infarction.

Objective: While widely used in the treatment of cardiac conditions, only limited data characterize out-of-hospital nitroglycerin (NTG) use. We sought to determine the safety of out-of-hospital sublingual NTG administered for suspected ST-segment elevation myocardial infarction (STEMI) and its effect on the patient's pain score. Methods: We prospectively identified adult patients with suspected STEMI transported by paramedics to three percutaneous Coronary Intervention PCI-capable hospitals in a large urban-suburban emergency medical services (EMS) system. We compared patients who received field NTG to those who did not. The primary outcome was the change in systolic blood pressure (SBP) between initial EMS measurement and emergency department (ED) triage vital signs. Secondary outcomes included the frequency of hypotension (SBP < 100 mmHg) and bradycardia (HR < 60) on ED arrival, drop in SBP ≥ 30 mmHg, out-of-hospital cardiac arrest (OHCA), and the change in pain score compared to an a priori threshold of -1.39. Results: Among 940 EMS transports for suspected STEMI, we excluded 160 for initial SBP < 100 mmHg, leaving 780 subjects for the analysis. Median age was 67 with 61% male. NTG was administered to 340 (44%) patients. The median change in SBP was -10 mmHg (IQR -27, 2) and -3 mmHg (IQR -20, 9) in patients treated with and without NTG, respectively. The median difference in the decrease in SBP was 6 mmHg (95% CI 3, 9 mmHg). The frequencies of ED hypotension and bradycardia, the drop in SBP ≥ 30 mmHg, and the OHCA did not differ between groups. For patients with an initial pain score > 0, the average change in pain score for patients treated with NTG was -2.6 (95% CI -3.0, -2.2), while patients who did not receive NTG had a change in pain score of -1.4 (95% CI -1.8, -1.0). Conclusion: In this cohort, field NTG did not result in a clinically significant decrease in blood pressure when compared with patients who did not receive NTG. However, NTG did cause a clinically significant reduction in pain.