The Optimal Initial Dose and Route of Naloxone Administration for Successful Opioid Reversal: A Systematic Literature Review.

This systematic literature review aims to determine the optimal initial dose of naloxone for successful opioid overdose reversal across different administration routes. Types of participants included adults who have opioid overdoses and adults who are suspected to have opioid overdoses. Pregnant women, children, animals, and populations outside the US were excluded. The interventions included were intranasal (IN), intramuscular (IM), and intravenous (IV) naloxone administration. The data collected for this systematic review were studies from PubMed, CINAHL, PsyINFO, and Cochrane Central Register of Controlled Trials registers between January 2015 and July 2021. The risk of bias was assessed via the Review Manager application. Six studies met the inclusion criteria. A meaningful statistical analysis was unable to be conducted with such few studies. The studies reveal 2 mg IN as the most popular dosing for initial naloxone for successful opioid reversal. The most common route of naloxone administration for successful reversal could not be studied but most studies revealed successful initial naloxone dosing in IN equivalents. With minimal studies emerging from our review, further research is warranted in naloxone dosing for optimal opioid reversal in order to fully treat patients. Healthcare workers must be vigilant of potential withdrawal from high naloxone dosing as well as the inefficiency of lower naloxone dosing for adequate opioid overdose reversal in order to treat patients with opioid overdoses properly.

Emergency department usage by uninsured patients in Galveston County, Texas.

The number of uninsured Texas residents who rely on the medical emergency department as their primary health care provider continues to increase. Unfortunately, little information about the characteristics of this group of emergency department users is available. Using an administrative billing database, we conducted a descriptive study to examine the demographic and clinical features of 17,110 consecutive patients without medical insurance who presented to the emergency department of the University of Texas Medical Branch in Galveston over a 12-month period. We also analyzed the risk of multiple emergency department visits or hospitalization according to demographic characteristics. Twenty percent of the study population made two or more emergency department visits during the study period; 19% of the population was admitted to the hospital via the emergency department. The risk of multiple emergency department visits was significantly elevated among African Americans and increased in a stepwise fashion according to age. The risk of being hospitalized was significantly reduced among females, African Americans, and Hispanics. There was an age-related monotonic increase in the risk of hospitalization. Abdominal pain, cellulitis, and spinal disorders were the most common primary diagnoses in patients who made multiple emergency department visits. Hospitalization occurred most frequently in patients with a primary diagnosis of chest pain, nonischemic heart disease, or an affective disorder. Additional studies of emergency department usage by uninsured patients from other regions of Texas are warranted. Such data may prove helpful in developing effective community-based alternatives to the emergency department for this growing segment of our population. Local policymakers who are responsible for the development of safety net programs throughout the state should find this information particularly useful.

Evaluation of the fast track unit of a university emergency department.

INTRODUCTION: The purpose of this study was to evaluate the efficacy of the newly developed fast track (FT) area in a University-affiliated emergency department. The goals of the FT unit included reducing patients' length of stay, improving patients' satisfaction, and decreasing ED overcrowding. METHODS: An exploratory descriptive design used to investigate length of stay in the emergency department, the rate of patients who left without being seen, unscheduled return visits to the emergency department within 72 hours of being seen, and patient satisfaction. RESULTS: During the evaluation period, 5995 patients were seen in the ED fast track area. The average time patients spent in the emergency department was 4.36 hours. The average time in room for the FT area was 1.97 hours. The left-without-being-seen rate for this time period for the main emergency department was 7%; the rate for the FT area was 4%. Additionally, 100% of respondents who completed a patient satisfaction survey in the FT area rated the care received by the nurse practitioner (NP) as good or excellent. CONCLUSIONS: Although the average time in room and overall length of stay did not meet expectations, patients did move more quickly through the department after the addition of the FT unit. Patient satisfaction data suggested that the FT staffed by NPs is a welcome addition to the emergency department. The findings provide direction for the future study of NP utilization in the emergency department.

Management of the violent patient.

Emergency medical services (EMS) providers must often manage violent or combative patients. The data regarding violence against EMS personnel are poor, but according to studies conducted thus far, between 0.8% and 5.0% of incidents to which EMS personnel respond involve violence or the threat of violence. Physical or chemical restraint is usually the only option available to emergency care providers to control violent patients. Physical restraint, however, can lead to sudden death in otherwise healthy patients, possibly as a result of positional asphyxia, severe acidosis, or a patient's excited delirium. Chemical restraint has traditionally consisted of either neuroleptics or benzodiazepines, but those drugs also have drawbacks. Haloperidol and droperidol, the neuroleptics most frequently used for restraint, can cause serious side effects such as extrapyramidal symptoms or QTc (QT interval corrected for heart rate) prolongation. The Food and Drug Administration recently issued a black box warning regarding the use of droperidol, because the QTc prolongation associated with the drug has led to fatal torsades de pointes in some patients. Benzodiazepines are also associated with adverse effects, such as sedation and respiratory depression, especially when the drugs are mixed with alcohol. The atypical antipsychotics, a new option that may be available soon, are less likely to cause such effects and therefore may be preferred over the neuroleptics. Liquid and injectable formulations of various atypical antipsychotics are currently in clinical trials. Because few options are currently available to EMS personnel for managing violent patients outside of the hospital, more research regarding violence against emergency care providers is necessary.

Managing the post-resuscitation patient in the field.

The principal goal after successful resuscitation of a cardiac arrest patient is to maintain the patient's pulse and avoid a pulseless state. Of equal importance in the post-resuscitation patient are efforts to prevent myocardial dysfunction and increase the likelihood of a good neurologic outcome. To optimize cardiac and hemodynamic resuscitation, paramedics should obtain good background information, which could provide clues to factors contributing to the cardiac arrest, such as the use of certain drugs or being overdue for dialysis, and could aid in customizing therapy for rhythm disturbances and hemodynamic aberrations. Treatment of rhythm disturbances depends on the type of arrhythmia identified, the history of present illness, and the resuscitation efforts provided. Common post-resuscitation dysrhythmias are wide-complex tachycardia, narrow-complex tachycardia, and bradycardia. Optimizing neurologic resuscitation is difficult, but evidence suggests that hypertensive reperfusion, hemodilution, and mild hypothermia may be of benefit in improving neurologic outcome after resuscitation. Unfortunately, to date, no proven therapies are available to improve neurologic outcome after resuscitation from cardiac arrest.