Comparison of droperidol and haloperidol for use by paramedics: assessment of safety and effectiveness.

BACKGROUND: Since the 2001 "black box" warning on droperidol, its use in the prehospital setting has decreased substantially in favor of haloperidol. There are no studies comparing the prehospital use of either drug. The goal of this study was to compare QTc prolongation, adverse events, and effectiveness of droperidol and haloperidol among a cohort of agitated patients in the prehospital setting. METHODS: In this institutional review board-approved before and after study, we collected data on 532 patients receiving haloperidol (n = 314) or droperidol (n = 218) between 2007 and 2010. We reviewed emergency department (ED) electrocardiograms when available (haloperidol, n = 78, 25%; droperidol, n = 178, 76%) for QTc length (in milliseconds), medical records for clinically relevant adverse events (defined a priori as systolic blood pressure (SBP) <90 mmHg, seizure, administration of anti-dysrhythmic medications, cardioversion or defibrillation, bag-valve-mask ventilation, intubation, cardiopulmonary arrest, and prehospital or in-hospital death). We also compared effectiveness of the medications, using administration of additional sedating medications within 30 minutes of ED arrival as a proxy for effectiveness. RESULTS: The mean haloperidol dose was 7.9 mg (median 10 mg, range 4-20 mg). The mean droperidol dose was 2.9 mg (median 2.5 mg, range 1.25-10 mg.) Haloperidol was given i.m. in 289 cases (92%), and droperidol was given i.m. in 132 cases (61%); in all other cases, the medication was given i.v.. There was no statistically significant difference in median QTc after medication administration (haloperidol 447 ms, 95% CI: 440-454 ms; droperidol 454 ms, 95% CI: 450-457). There were no statistically significant differences in adverse events in the droperidol group as compared to the haloperidol group. One patient in the droperidol group with a history of congenital heart disease suffered a cardiopulmonary arrest and was resuscitated with neurologically intact survival. There was no significant difference in the use of additional sedating medications within 30 minutes of ED arrival after receiving droperidol (2.9%, 95% CI: -2.5-8.4%). CONCLUSIONS: In this cohort of agitated patients treated with haloperidol or droperidol in the prehospital setting, there was no significant difference found in QTc prolongation, adverse events, or need for repeat sedation between haloperidol and droperidol.

Post-traumatic stress disorder in an emergency department population one year after Hurricane Katrina.

BACKGROUND: Hurricane Katrina resulted in a significant amount of injury, death, and destruction. STUDY OBJECTIVES: To determine the prevalence of, and risk factors for, symptoms of post-traumatic stress disorder (PTSD) in an emergency department (ED) population, 1 year after hurricane Katrina. METHODS: Survey data including the Primary Care PTSD (PC-PTSD) screening instrument, demographic data, and questions regarding health care needs and personal loss were collected and analyzed. RESULTS: Seven hundred forty-seven subjects completed the survey. The PC-PTSD screen was positive in 38%. In the single variate analysis, there was a correlation with a positive PC-PTSD screen and the following: staying in New Orleans during the storm (odds ratio [OR] 1.73, 95% confidence interval [CI] 1.28-2.34), having material losses (OR 1.64, 95% CI 1.03-2.60), experiencing the death of a loved one (OR 1.96, 95% CI 1.35-1.87), needing health care during the storm (OR 2.01, 95% CI 1.48-2.73), and not having health care needs met during the storm (OR 2.00, 95% CI 1.26-3.18) or after returning to New Orleans (OR 2.29, 95% CI 1.40-3.73). In the multivariate analysis, the death of a loved one (OR 1.87, 95% CI 1.26-2.78), being in New Orleans during the storm (OR 1.69, 95% CI 1.22-2.33), and seeking health care during the storm (OR 1.69, 95% CI 1.22-2.35) were associated with positive PC-PTSD screens. CONCLUSIONS: There was a high prevalence of PTSD in this ED population surveyed 1 year after hurricane Katrina. By targeting high-risk patients, disaster relief teams may be able to reduce the impact of PTSD in similar populations.

Interhospital transfers from U.S. emergency departments: implications for resource utilization, patient safety, and regionalization.

OBJECTIVES: The authors sought to describe the demographic and clinical characteristics of interhospital transfers from U.S. emergency departments (EDs) along with the primary reasons for transfers. METHODS: This was a retrospective, cross-sectional analysis of the 1997 through 2009 National Hospital Ambulatory Medical Care Survey (NHAMCS). Visit-level characteristics were compared for patients who were transferred, admitted, or discharged. Additionally, data on primary reason for transfer for available years (2005 through 2008) were reviewed. Weighted analyses produced nationally representative estimates. RESULTS: During this time period, 1.8% (95% confidence interval [CI] = 1.7% to 2.0%) of ED patients were transferred to other hospitals. Compared to visits resulting in admission, those resulting in transfer were more likely to involve patients who were <18 years old (18% vs. 7.9%), male (53% vs. 46%), with Medicaid (22% vs. 16%) or self-payment (15% vs. 8.2%) as a primary expected source of payment, having a visit related to injury (40% vs. 19%), and from a nonurban ED (29% vs. 15%). Among transferred patients, 28% (95% CI = 27% to 30%) received four to six diagnostic tests, and 31% (95% CI = 29% to 34%) received more than six diagnostic tests prior to transfer; 52% (95% CI = 50% to 54%) had diagnostic imaging, and 17% (95% CI = 16% to 19%) had cross-sectional imaging. Of the patients transferred from 2005 through 2008, 47% (95% CI = 43% to 53%) were transferred for a higher level of care, and 29% (95% CI = 26% to 35%) were transferred for psychiatric care. CONCLUSIONS: Transfer of ED patients was relatively rare, but was more common among specific, potentially high-risk populations. Diagnostic testing, including advanced imaging, was common prior to transfer. A majority of transfers were for reasons indicating limited resources or expertise at the referring facility.

Rural clinical experiences for emergency medicine residents: a curriculum template.

Rural emergency departments (EDs) in the United States are less likely to be staffed with emergency medicine (EM) residency-trained and American Board of Emergency Medicine (ABEM)-certified physicians than urban EDs. Rural EM clinical experiences during residency training have been suggested as a strategy to encourage future rural practice, but past Accreditation Council for Graduate Medical Education (ACGME) Residency Review Committee for Emergency Medicine program requirements and a lack of familiarity with rural rotations in the EM graduate medical education (GME) community have limited their availability. To provide a template for the development and implementation of a rural EM clinical experience, Kern's six-step approach was followed.

An argument for the conservative management of small traumatic pneumathoraces in populations with high prevalence of HIV and tuberculosis: an evidence-based review of the literature.

BACKGROUND: Traumatic pneumothoraces are common. Many are managed with tube thoracostomy. However, there is a high complication rate from chest tube placement, particularly in patients with HIV, TB, or both. AIMS: We sought to investigate the literature on the conservative management of traumatic pneumothorax in patients with HIV and/or TB. METHODS: The literature search was broken into two parts. In the first part, we searched for articles comparing tube thoracostomy versus conservative management in traumatic pneumothorax. In the second part, we sought articles describing the incidence and outcome of pneumothoraces in patients with pre-existing HIV or tuberculosis. In both, relevant articles were reviewed, and citations were hand-searched. RESULTS: For the first portion, we identified 384 papers. From these, six studies were relevant. For the second portion, we identified 327 articles. A total of four unique articles were selected. The heterogeneity of the studies did not allow any pooled analysis. The studies of conservative management demonstrated a low percentage of patients with small pneumothoraces (most often <1.5 cm or less than 10%) later required tube thoracostomy for clinical deterioration (range 6-25%). No studies focused exclusively on pneumothoraces in patients with TB. In patients with HIV, there were no prospective trials of conservative management. Mortality for all HIV-infected patients with pneumothorax was high (25-50%), and the rate of complications from tube thoracostomy was also high. Pneumocystits carinii pneumonia (PCP) independently increased mortality. CONCLUSIONS: A review of the literature suggests that selected small pneumothoraces may be managed conservatively and that there is a high rate of complications related to tube thoracostomy in HIV patients. We propose a trial of the safety of conservative management of traumatic pneumothoraces in an area with a high prevalence of HIV and TB.

Treatment of suspected cardiac ischemia with aspirin by paramedics in an urban emergency medical services system.

BACKGROUND: Aspirin (ASA) has unquestioned benefit to patients with cardiac ischemia. Previous studies indicate health care providers may not adequately treat patients experiencing cardiac ischemia with ASA. OBJECTIVE: To determine the rate of ASA use for patients being treated for chest pain suggestive of cardiac ischemia in the prehospital setting. METHODS: This was a retrospective study of paramedic encounters identified through billing records for all patients receiving the combination of an intravenous catheter, supplemental oxygen, and cardiac monitoring from November 2001 to January 2002. Prehospital medical records were reviewed in order to determine the proportion of patients with suspected cardiac ischemia who received ASA. The setting was a single prehospital emergency medical services system serving an urban population. RESULTS: A total of 2,457 paramedic encounters were reviewed over a three-month period. Two hundred thirty-two patients were assessed as having cardiac ischemia, of whom 169 (73%) had no absolute or relative contraindication to ASA. Of the 169 patients, only 92 (54%) received ASA. Of the 99 patients, who received nitroglycerin for presumed cardiac ischemia and had no contraindication to receiving ASA, only 78 (79%) received ASA. Of the 453 patients complaining of nontraumatic chest pain and without a contraindication, 157 (35%) received ASA. CONCLUSIONS: Paramedics do not use ASA optimally and may choose therapies with less proven benefit.