A rapid host-protein test for differentiating bacterial from viral infection: Apollo diagnostic accuracy study.

Objectives: To determine the diagnostic accuracy of a rapid host-protein test for differentiating bacterial from viral infections in patients who presented to the emergency department (ED) or urgent care center (UCC). Methods: This was a prospective multicenter, blinded study. MeMed BV (MMBV), a test based on tumor necrosis factor-related apoptosis-inducing ligand (TRAIL), interferon gamma-inducible protein-10 (IP-10), and C-reactive protein (CRP), was measured using a rapid measurement platform. Patients were enrolled from 9 EDs and 3 UCCs in the United States and Israel. Patients >3 months of age presenting with fever and clinical suspicion of acute infection were considered eligible. MMBV results were not provided to the treating clinician. MMBV results (bacterial/viral/equivocal) were compared against a reference standard method for classification of infection etiology determined by expert panel adjudication. Experts were blinded to MMBV results. They were provided with comprehensive patient data, including laboratory, microbiological, radiological and follow-up. Results: Of 563 adults and children enrolled, 476 comprised the study population (314 adults, 162 children). The predominant clinical syndrome was respiratory tract infection (60.5% upper, 11.3% lower). MMBV demonstrated sensitivity of 90.0% (95% confidence interval [CI]: 80.3-99.7), specificity of 92.8% (90.0%-95.5%), and negative predictive value of 98.8% (96.8%-99.6%) for bacterial infections. Only 7.2% of cases yielded equivocal MMBV scores. Area under the curve for MMBV was 0.95 (0.90-0.99). Conclusions: MMBV had a high sensitivity and specificity relative to reference standard for differentiating bacterial from viral infections. Future implementation of MMBV for patients with suspected acute infections could potentially aid with appropriate antibiotic decision-making.

Efficacy and tolerability of oral morphine versus oxycodone/acetaminophen for analgesia in the emergency department.

OBJECTIVE: Oxycodone/acetaminophen is one of the most commonly prescribed medications for pain management in the emergency department (ED) despite its high abuse liability. Our objective was to determine whether oral immediate-release morphine is as effective and well tolerated as oral oxycodone/acetaminophen for pain relief in stable ED patients. DESIGN: This is a prospective comparative study in which stable adult patients with acute painful conditions who had either oral morphine (15 or 30 mg) or oxycodone/acetaminophen (5/325 mg or 10/650 mg) ordered for them at the discretion of a triage physician were recruited. SETTING: This study took place in an urban, academic ED from 2016 to 2019. PARTICIPANTS: Seventy-three percent of the subjects were between the ages of 18 and 59, 57 percent were female, and 85 percent were African American. Most presented with abdominal, extremity, or back pain. Patient characteristics were similar between treatment groups. INTERVENTIONS: Of the 364 enrolled patients, 182 were given oral morphine and 182 were given oxycodone/acetaminophen at the discretion of the triage provider. They were asked to rate their pain score prior to receiving analgesia and at 60 and 90 minutes after administration. MAIN OUTCOME MEASURES: We examined pain scores, adverse effects, overall satisfaction, willingness to accept the same treatment again, and the need for additional analgesia. RESULTS: There was no difference in satisfaction reported by patients who received morphine versus oxycodone/acetaminophen: 15.9 percent vs 16.5 percent were very satisfied, 31.9 percent vs 26.4 percent were somewhat satisfied, and 23.6 percent vs 22.5 percent were not satisfied, p = 0.56. Secondary outcomes also showed no significant difference: net change in pain score -2 vs -2 at 60 and 90 minutes, p = 0.91 and p = 0.72, respectively; adverse effects 20.9 percent vs 19.2 percent, p = 0.69; need for further analgesia 9.3 percent vs 7.1 percent, p = 0.44; willingness to accept analgesic again 73.1 percent vs 78.6 percent, p = 0.22. CONCLUSIONS: Oral morphine is a feasible alternative to oxycodone/acetaminophen for analgesia in the ED.

Droperidol Use in the Emergency Department: A Clinical Review.

BACKGROUND: Droperidol is a butyrophenone, with antiemetic, sedative, anxiolytic, and analgesic properties. Although droperidol was once widely used in both emergency and perioperative settings, use of the medication declined rapidly after a 2001 U.S. Food and Drug Administration (FDA) boxed warning called the medication's safety into question. OBJECTIVE: The purpose of this clinical review was to provide evidence-based answers to questions about droperidol's safety and to examine its efficacy in its various clinical indications. DISCUSSION: Droperidol is an effective sedative, anxiolytic, analgesic, and antiemetic medication. As a sedative, when compared with haloperidol, droperidol has faster onset, as well as greater efficacy, in patients experiencing acute psychosis, with no increase in adverse events. As an antiemetic, droperidol has been found to have equal or greater efficacy in reducing nausea and vomiting than ondansetron and metoclopramide, with similar adverse effects and the added effect of reducing the need for rescue analgesia in these patients. As an analgesic, droperidol is effective for migraines and has opioid-sparing effects when used to treat abdominal pain. Droperidol is a particularly useful adjunct in patients who are opioid-tolerant, whose pain is often difficulty to manage adequately. CONCLUSIONS: Droperidol seems to be effective and safe, despite the boxed warning issued by the FDA. Droperidol is a powerful antiemetic, sedative, anxiolytic, antimigraine, and adjuvant to opioid analgesia and does not require routine screening with electrocardiography when used in low doses in otherwise healthy patients before administration in the emergency department.

Subdissociative-dose ketamine for sickle cell vaso-occlusive crisis: a narrative review for the emergency physician.

Vaso-occlusive crisis (VOC) in sickle cell disease can cause severe pain and requires a thoughtful approach to analgesia. Considering the heightened awareness of the harm associated with opioids, an exploration of safer and more effective alternatives is overdue. Ketamine may play a role in supplementing or replacing opioid analgesia for patients in VOC. Studies on the use of ketamine for VOC are sparse, though increasing. In this review, we summarize the literature on subdissociative ketamine use for VOC to offer providers insight into the most effective and safe dosing regimens for sickle cell disease patients. Overall, the studies discussed in this review show decreased opioid use when subdissociative ketamine is provided as an adjunct and resolution of pain for most patients when subdissociative ketamine is used as the sole form of analgesia in VOC. Most studies examined intravenous delivery, and successful outcomes were established for both adult and pediatric patients in multiple clinical settings, including in the emergency department. Although more research is needed, it is clear from the published data that subdissociative ketamine may provide an efficacious addition to the clinician's toolbox for managing VOC.

Novel uses of ketamine in the emergency department.

INTRODUCTION: Ketamine is gaining renewed interest among healthcare providers in the emergency department (ED) setting due to its novel clinical applications. AREAS COVERED: This article provides a comprehensive discussion of ketamine's pharmacological properties, safety profile, and an overview of current evidence for ketamine in the management of ED patients with acute agitation, pain, depression/suicide ideation. EXPERT OPINION: Ketamine is an effective adjunct to opioids, providing greater pain relief than morphine alone. Ketamine (0.1-0.3 mg/kg IV) alone can provide analgesia similar to that of morphine in patients with acute visceral and musculoskeletal pain, as well as for chronic painful conditions (cancer, vaso-occlusive pain crisis associated with sickle cell disease, and in patients with high opioid tolerance and/or opioid dependency). Available literature shows that ketamine (1-2 mg/kg IV or 4-5 mg/kg IM) is a safe, rapid (<5 minutes) and effective tranquilization agent for ED patients with acute agitation. Finally, there is growing evidence that suggests ketamine may have potential utility in the management of patients with self-harm ideation or acute depressive episodes. Intravenous infusion of ketamine (0.5 mg/kg over 40 mins) has been shown to produce an antidepressant effect and decrease in suicidal ideation within 4 hours with effects lasting up to one week.

Analgesia and Sedation for Tactical Combat Casualty Care: TCCC Proposed Change 21-02.

Analgesia in the military prehospital setting is one of the most essential elements of caring for casualties wounded in combat. The goals of casualty care is to expedite the delivery of life-saving interventions, preserve tactical conditions, and prevent morbidity and mortality. The Tactical Combat Casualty Care (TCCC) Triple Option Analgesia guideline provided a simplified approach to analgesia in the prehospital combat setting using the options of combat medication pack, oral transmucosal fentanyl, or ketamine. This review will address the following issues related to analgesia on the battlefield: 1. The development of additional pain management strategies. 2. Recommended changes to dosing strategies of medications such as ketamine. 3. Recognition of the tiers within TCCC and guidelines for higher-level providers to use a wider range of analgesia and sedation techniques. 4. An option for sedation in casualties that require procedures. This review also acknowledges the next step of care: Prolonged Casualty Care (PCC). Specific questions addressed in this update include: 1) What additional analgesic options are appropriate for combat casualties? 2) What is the optimal dose of ketamine? 3) What sedation regimen is appropriate for combat casualties?

Nebulized ketamine for managing acute pain in the pediatric emergency department: A case series.

Administration of sub-dissociative doses of ketamine is used via intranasal (IN) and intravenous routes in the pediatric emergency department for managing acute pain. Due to difficulties in both obtaining intravenous access and compliance with IN medications in children, administration of ketamine via breath-actuated nebulizer can serve as a valuable modality for timely analgesia in children where dosing titration is patient controlled. We describe five pediatric patients who received ketamine via breath-actuated nebulizer at 0.75 mg/kg, 1 mg/kg, and 1.5 mg/kg, with all patients experiencing a decrease in pain score. This case series introduces ketamine inhalation as a modality for managing pain in children.

Pain management in the emergency department: a clinical review.

Pain is one of the most common reasons for patients to visit the emergency department. The ever-growing research on emergency department analgesia has challenged the current practices with respect to the optimal analgesic regimen for acute musculoskeletal pain, safe and judicious opioid prescribing, appropriate utilization of non-opioid therapeutics, and non-pharmacological treatment modalities. This clinical review is set to provide evidence-based answers to these challenging questions.

Should Antiemetics be Given Prophylactically with Intravenous Opioids While Treating Acute Pain in the Emergency Department?: Clinical Practice Paper Approved by American Academy of Emergency Medicine Clinical Guidelines Committee.

BACKGROUND: It is common practice for emergency physicians to give parenteral opioids for acute pain, however, some treating physicians have concerns that using parenteral opioids can lead to nausea and vomiting when used alone. Therefore, antiemetics are often given prophylactically with opioids for nausea and vomiting in the emergency department (ED). This systematic review evaluates the use of prophylactic antiemetics with parenteral opioids for the treatment of acute pain in the ED. METHODS: A 10-year literature search using keywords was performed in PubMed for English-language human studies. Abstracts were screened to identify high-quality studies, which then underwent a more rigorous structured review. The recommendations are made based on the literature review. RESULTS: Eight articles met criteria for structured review and citation in this article. These include one review article, two randomized controlled trials, three prospective observational trials, one retrospective study, and one pre- and post-intervention trial. CONCLUSIONS: Based on the literature review, routine use of prophylactic antiemetics are not indicated with administration of parenteral opioids for treatment of acute pain in the ED, as nausea and vomiting are infrequent side effects. The recent literature clearly demonstrates that there are potential undesirable side effects from the use of antiemetics when using opioids. However, one subgroup of patients, those with a known history of nausea and vomiting after opioid use or a history of travel sickness, may benefit from the use of prophylactic antiemetic when being treated with parenteral opioids.

Comparing Nonopioids Versus Opioids for Acute Pain in the Emergency Department: A Literature Review.

BACKGROUND: Pain is the most common reason for patient visits in the emergency department (ED). Opioids have been long considered the standard of care for acute pain in the ED. Because of the opioid crisis, investigation and implementation of novel practices to manage pain is needed. The use of various nonopioids has been suggested as a plausible alternative to opioids, with emerging literature to support its use for acute pain in the ED. STUDY QUESTION: To evaluate the safety, efficacy, opioid-sparing effects of nonopioids in patients who present with acute pain in the ED. DATA SOURCES: We systematically searched PubMed and EMBASE (July 1970 to January 2019). STUDY DESIGN: Randomized controlled trials that evaluated nonopioids versus opioids in the ED were eligible. The clinical outcomes measured were change in pain scores compared with baseline, the incidence of adverse events, and use of rescue analgesia. RESULTS: Twenty-five randomized controlled trials that evaluated the use of nonopioids in 2323 patients [acetaminophen (APAP) (n = 651), diclofenac (n = 547), ketamine (n = 272), ketorolac (n = 225), lidocaine (n = 219), ibuprofen (n = 162), ibuprofen & APAP (n = 162), hydroxyzine & dihydroergotamine (n = 85)] met inclusion criteria. Four trials found significant greater reductions in pain scores, favoring nonopioids. In all trials, the duration of pain relief provided by nonopioids was not sustained over an extended period. Eighteen trials reported no significant differences in reduction of pain scores. Two trials reported improved pain reduction with opioids and one trial reported noninferiority. CONCLUSIONS: Evidence from primary literature suggests that nonopioids could be a feasible alternative to opioids for management of acute pain in the ED as it is effective, safe, and decreases the need for rescue analgesia.

Essential pharmacologic options for acute pain management in the emergency setting.

Pain is the root cause for the overwhelming majority of emergency department (ED) visits worldwide. However, pain is often undertreated due to inappropriate analgesic dosing and ineffective utilization of available analgesics. It is essential for emergency providers to understand the analgesic armamentarium at their disposal and how it can be used safely and effectively to treat pain of every proportion within the emergency setting. A 'balanced analgesia' regimen may be used to treat pain while reducing the overall pharmacologic side effect profile of the combined analgesics. Channels-Enzymes-Receptors Targeted Analgesia (CERTA) is a multimodal analgesic strategy incorporating balanced analgesia by shifting from a system-based to a mechanistic-based approach to pain management that targets the physiologic pathways involved in pain signaling transmission. Targeting individual pain pathways allows for a variety of reduced-dose pharmacologic options - both opioid and non-opioid - to be used in a stepwise progression of analgesic strength as pain advances up the severity scale. By developing a familiarity with the various analgesic options at their disposal, emergency providers may formulate safe, effective, balanced analgesic combinations unique to each emergency pain presentation.

The use of intranasal analgesia for acute pain control in the emergency department: A literature review.

BACKGROUND: Traditional routes for administration of pain medications include oral (PO), intravenous (IV), or intramuscular routes (IM). When these routes are not feasible, the intranasal (IN) route may be considered. The objectives of this evidence-based review were: to review the literature which compared the safety and efficacy of IN analgesia to traditional routes and to determine if IN analgesia should be considered over traditional routes for acute pain control in the ED. METHODS: The MEDLINE and EMBASE databases from July 1970 to July 2017 were searched. Randomized controlled trials (RCT) that evaluated the use of IN analgesia for acute pain in the ED were included. Methodological quality of the trials was assessed using the Grading of Recommendations Assessment, Development, and Evaluation criteria. RESULTS: Eleven randomized controlled trials (RCT) met the inclusion criteria. Four trials found significant reductions in pain scores, favoring IN analgesia. However, in all of the trials, pain relief was not sustained. Three trials reported superior pain reduction with comparators and three trials reported no statistical significance. One trial described effective pain relief with IN analgesia but did not provide data on statistical analysis. CONCLUSION: Eleven randomized controlled trials with various methodological flaws revealed conflicting conclusions. There is limited evidence to support the use of the IN analgesia over traditional routes for acute pain in the ED. The IN route may be a good alternative in scenarios where IV access is not feasible, patients are refusing injectable medications, or a fast onset of pain relief is needed.

Something for pain: Responsible opioid use in emergency medicine.

The United States is currently experiencing a public health crisis of opioid addiction, which has its genesis in an industry marketing effort that successfully encouraged clinicians to prescribe opioids liberally, and asserted the safety of prescribing opioids for chronic non-cancer pain, despite a preponderance of evidence demonstrating the risks of dependence and misuse. The resulting rise in opioid use has pushed drug overdose deaths in front of motor vehicle collisions to become the leading cause of accidental death in the country. Emergency providers frequently treat patients for complications of opioid abuse, and also manage patients with acute and chronic pain, for which opioids are routinely prescribed. Emergency providers are therefore well positioned to both prevent new cases of opioid misuse and initiate appropriate treatment of existing opioid addicts. In opioid-naive patients, this is accomplished by a careful consideration of the likelihood of benefit and harm of an opioid prescription for acute pain. If opioids are prescribed, the chance of harm is reduced by matching the number of pills prescribed to the expected duration of pain and selecting an opioid preparation with low abuse liability. Patients who present to acute care with exacerbations of chronic pain or painful conditions associated with opioid misuse are best managed by treating symptoms with opioid alternatives and encouraging treatment for opioid addiction.

Consensus-Based Recommendations for an Emergency Medicine Pain Management Curriculum.

BACKGROUND: Increased prescribing of opioid pain medications has paralleled the subsequent rise of prescription medication-related overdoses and deaths. We sought to define key aspects of a pain management curriculum for emergency medicine (EM) residents that achieve the balance between adequate pain control, limiting side effects, and not contributing to the current public health opioid crisis. METHODS: We convened a symposium to discuss pain management education in EM and define the needs and objectives of an EM-specific pain management curriculum. Multiple pertinent topics were identified a priori and presented before consensus work. Subgroups then sought to define perceived gaps and needs, to set a future direction for development of a focused curriculum, and to prioritize the research needed to evaluate and measure the impact of a new curriculum. RESULTS: The group determined that an EM pain management curriculum should include education on both opioid and nonopioid analgesics as well as nonpharmacologic pain strategies. A broad survey is needed to better define current knowledge gaps and needs. To optimize the impact of any curriculum, a modular, multimodal, and primarily case-based approach linked to achieving milestones is best. Subsequent research should focus on the impact of curricular reform on learner knowledge and patient outcomes, not just prescribing changes. CONCLUSIONS: This consensus group offers a path forward to enhance the evidence, knowledge, and practice transformation needed to improve emergency analgesia.

Advanced Concepts and Controversies in Emergency Department Pain Management.

Pain is the most common complaint for which patients come to the emergency department (ED). Emergency physicians are responsible for pain relief in a timely, efficient, and safe manner in the ED. The improvement in our understanding of the neurobiology of pain has balanced the utilization of nonopioid and opioid analgesia, and simultaneously has led to more rational and safer opioid prescribing practices. This article reviews advances in pain management in the ED for patients with acute and chronic pain as well as describes several newer strategies and controversies.

The Use of Intravenous Acetaminophen for Acute Pain in the Emergency Department.

OBJECTIVES: Acetaminophen (APAP) is a mainstay for pain management worldwide. The intravenous (IV) formulation has been widely used in Europe for more than 20 years in adults and children. In the United States, IV APAP obtained full approval from the Food and Drug Administration in 2010. There is emerging literature to suggest the use of IV APAP for pain reduction in the emergency department (ED). This evidence-based review examines the evidence pertaining to the use of IV APAP for acute pain control in the ED. METHODS: The MEDLINE and EMBASE databases were searched. Randomized controlled trials (RCTs) that described or evaluated the use of IV APAP for acute pain in the ED were included. Duplicate articles, unpublished reports, abstracts, review articles, and non-English literature were excluded. The primary outcome of interest in this review was the difference in pain score between IV APAP and active comparator or placebo from baseline to a cutoff time specified in the original trials. Secondary outcome measures were the incidence of adverse events and reduction in the amount of adjuvant analgesics consumed by patients who received IV APAP. Methodologic quality of the trials was assessed using the Grading of Recommendations Assessment, Development, and Evaluation criteria. RESULTS: Fourteen RCTs with various methodologic flaws, which enrolled a total of 1,472 patients, met the inclusion criteria. The level of evidence for the individual trials ranged from very low to moderate. In three of the 14 trials, a significant reduction in pain scores was observed in patients who received IV APAP. The first trial found a significant reduction in mean pain scores when IV APAP was compared to IV morphine at 30 minutes after drug administration (4.7 ± 2.3 vs. 2.9 ± 2.2). In the second trial, patients who received IV APAP reported of lower pain scores (31.7 ± 18 mm, 95% confidence interval [CI] = 8.2 to 25.2 mm) compared to those who received IV morphine (48.3 ± 14.1 mm, 95% CI = 8.2 to 25.2 mm), 15 minutes after drug administration. A third trial found a significant reduction (p = 0.005) in the mean pain scores when IV APAP was compared to intramuscular piroxicam at 90 minutes after drug administration. In the remaining eight trials, pain scores were not statistically different when IV APAP was compared to other pain medications. The incidence of side effects associated with IV APAP was very low. CONCLUSIONS: Fourteen RCTs with various methodologic flaws provided limited evidence to support the use of IV APAP as the primary analgesic for acute pain control in patients who present to the ED.

The use of subdissociative-dose ketamine for acute pain in the emergency department.

OBJECTIVES: Ketamine is a well-known anesthetic with its use trailing back to the 1960s. It has antagonistic effects at the N-methyl-d-aspartate receptor. There is emerging literature to suggest the use of subdissociative-dose ketamine (SDDK) for pain reduction. This evidence-based review evaluates the evidence regarding the use of SDDK for acute pain control in the emergency department (ED). METHODS: The MEDLINE and EMBASE databases were searched. Randomized controlled trials (RCTs) that described or evaluated the use of SDDK for acute pain in the ED were included. Literature was excluded if it was not published in English. Duplicate articles, unpublished reports, abstracts, and review articles were also excluded. Quality assessment and evaluation of literature were evaluated based on the GRADE criteria. The primary outcome of interest in this review was the difference in pain score from baseline to cutoff time as specified in the studies. Secondary outcome measures were the incidence of adverse events and reduction in the amount of adjuvant opioids consumed by patients who received SDDK. RESULTS: Four RCTs met the inclusion criteria, which enrolled a total of 428 patients. Three adult trials and one pediatric trial were identified. The level of evidence for the individual trials ranged from low to moderate. A significant reduction in pain scores was only found in two of the four trials. One trial found a significant reduction in mean pain scores when ketamine was compared to morphine (p < 0.05). Another trial reported a significant decrease in mean distress scores, favoring SDDK over fentanyl (1.0 vs. 2.7, p < 0.05). One trial found a significant reduction in the amount of morphine consumed, favoring ketamine over placebo (0.14 mg/kg, 95% confidence interval [CI] = 0.13 to 0.16 mg/kg vs. 0.2 mg/kg, 95% CI = 0.18 to 0.22 mg/kg; p < 0.001). An emergence phenomenon was reported in one trial. CONCLUSIONS: Four RCTs with methodologic limitations failed to provide convincing evidence to either support or refute the use of SDDK for acute pain control in the ED.

Acute pain management curriculum for emergency medicine residency programs.

Pain is the most common reason people visit emergency departments (EDs); this implies that emergency physicians (EPs) should be experts in managing acute painful conditions. The current trend in the literature, however, demonstrates that EPs possess inadequate knowledge and lack formal training in acute pain management. The purpose of this article is to create a formal educational curriculum that would assist emergency medicine (EM) residents in proper assessment and treatment of acute pain, as well as in providing a solid theoretical and practical knowledge base for managing acute pain in the ED. The authors propose a series of lectures, case-oriented study groups, practical small group sessions, and class-specific didactics with the goal of enhancing the theoretical and practical knowledge of acute pain management in the ED.

Problems and barriers of pain management in the emergency department: Are we ever going to get better?

Pain is the most common reason people visit emergency rooms. Pain does not discriminate on the basis of gender, race or age. The state of pain management in the emergency department (ED) is disturbing. ED physicians often do not provide adequate analgesia to their patients, do not meet patients' expectations in treating their pain, and struggle to change their practice regarding analgesia. A review of multiple publications has identified the following causes of poor management of painful conditions in the ED: failure to acknowledge pain, failure to assess initial pain, failure to have pain management guidelines in ED, failure to document pain and to assess treatment adequacy, and failure to meet patient's expectations. The barriers that preclude emergency physicians from proper pain management include ethnic and racial bias, gender bias, age bias, inadequate knowledge and formal training in acute pain management, opiophobia, the ED, and the ED culture. ED physicians must realize that pain is a true emergency and treat it as such.