Adrienne Birnbaum

Failure to Validate the San Francisco Syncope Rule in an Independent Emergency Department Population

STUDY OBJECTIVE We conduct a prospective independent validation of the San Francisco Syncope Rule to identify emergency department (ED) syncope patients with short-term serious outcomes. METHODS This was a prospective observational cohort study of adult patients presenting to a university hospital ED with acute syncope or near syncope. Patients meeting inclusion criteria as defined in the San Francisco Syncope Rule derivation were evaluated for 5 previously derived predictor variables: abnormal ECG result, shortness of breath, hematocrit level less than 30%, triage systolic blood pressure less than 90 mm Hg, and history of congestive heart failure. Hospital admission occurred at the discretion of the emergency physician, independent of the decision rule. Follow-up occurred through contact with the inpatient attending physician for admitted patients and by telephone contact with patients not hospitalized or those hospitalized and discharged before day 7. Predetermined outcome measures as defined by the San Francisco Syncope Rule were death, myocardial infarction, arrhythmia, pulmonary embolism, stroke, subarachnoid hemorrhage, significant hemorrhage, or any condition causing or likely to cause a return ED visit and hospitalization for a related event. RESULTS Complete predictor and follow-up data were available for 713 of 743 (96%) enrolled patients. Sixty-one of 713 (9%) patients met predetermined criteria for serious outcome. Sixteen of 61 (26%; 95% confidence interval [CI] 16% to 39%) patients with a serious outcome were not identified as high risk by the rule. Rule performance to predict serious outcomes was sensitivity 74% (95% CI 61% to 84%), specificity 57% (95% CI 53% to 61%); negative likelihood ratio 0.5 (95% CI 0.3 to 0.7) and positive likelihood ratio 1.7 (95% CI 1.4 to 2.0). CONCLUSION In this independent validation study, sensitivity and negative likelihood ratio of the San Francisco Syncope Rule were substantially lower than reported in the original studies and suggest that the rule has limited generalizability.

Performance of the RAD-57 Pulse Co-Oximeter Compared With Standard Laboratory Carboxyhemoglobin Measurement

STUDY OBJECTIVE We assess agreement between carboxyhemoglobin levels measured by the Rad-57 signal extraction pulse CO-oximeter (RAD), a Food and Drug Administration-approved device for noninvasive bedside measurement, and standard laboratory arterial or venous measurement in a sample of emergency department (ED) patients with suspected carbon monoxide poisoning. METHODS The study was a cross-sectional cohort design using a convenience sample of adult and pediatric ED patients in a Level I trauma, burn, and hyperbaric oxygen referral center. Measurement of RAD carboxyhemoglobin was performed simultaneously with blood sampling for laboratory determination of carboxyhemoglobin level. The difference between the measures for each patient was calculated as laboratory carboxyhemoglobin minus carboxyhemoglobin from the carbon monoxide oximeter. The limits of agreement from a Bland-Altman analysis are calculated as the mean of the differences between methods ±1.96 SDs above and below the mean. RESULTS Median laboratory percentage carboxyhemoglobin level was 2.3% (interquartile range 1 to 8.5; range 0% to 38%). The mean difference between laboratory carboxyhemoglobin values and RAD values was 1.4% carboxyhemoglobin (95% confidence interval [CI] 0.2% to 2.6%). The limits of agreement of differences of measurement made with the 2 devices were -11.6% and 14.4% carboxyhemoglobin. This range exceeded the value of ±5% carboxyhemoglobin defined a priori as clinically acceptable. RAD correctly identified 11 of 23 patients with laboratory values greater than 15% carboxyhemoglobin (sensitivity 48%; 95% CI 27% to 69%). There was one case of a laboratory carboxyhemoglobin level less than 15%, in which the RAD device gave a result greater than 15% (specificity of RAD 96/97=99%; 95% CI 94% to 100%). CONCLUSION In the range of carboxyhemoglobin values measured in this sample, the level of agreement observed suggests RAD measurement may not be used interchangeably with standard laboratory measurement.

Response to morphine in male and female patients: Analgesia and adverse events

BackgroundThere is little agreement about a differential response of men and women to opioid analgesics. Some experimental and clinical studies have shown that women have a better response to opioids, others have found no difference, and still others have found opioids to be more effective analgesics for men than women. ObjectivesTo assess sex differences in analgesic response to morphine and incidence of adverse events in patients receiving a dose of 0.1 mg intravenous morphine/kg. MethodsSecondary analysis of the control arms of 6 randomized clinical trials that compared 0.1 mg/kg intravenous morphine with other opioids or other doses of morphine in patients aged 21 to 65 with acute pain. The setting was an academic medical center Emergency Department serving primarily Latino and African-American patients. Change in self-reported pain intensity from baseline to 30 minutes postbaseline on a validated and reproducible 11-point numerical rating scale and count of adverse events were the primary outcomes. ResultsThe sample consisted of 211 women and 144 men. The mean change in pain from baseline to 30 minutes postbaseline was 3.7 in women, 3.6 men (difference=0.04; 95% confidence interval: −0.52, 0.60). In women without nausea before administration of morphine, the incidence of adverse events was 18.3% versus 10.7% in men without initial nausea (difference=7.6%; 95% confidence interval: −2.0, 17.2). DiscussionMen and women presenting to the Emergency Department did not have a differential response to a single weight-based dose of morphine for alleviation of acute pain. Women without baseline nausea had more adverse events than men.

Faculty development: academic opportunities for emergency medicine faculty on education career tracks.

Medical school faculty members who specialize in the scholarship of teaching have unique requirements for academic advancement in universities with clinician-educator series. While excellence in teaching is the cornerstone of achievement, attention to traditional academic pursuits improves the likelihood of a favorable review by the institutions promotion and tenure committee. The teaching portfolio is an effective means to document performance. Ongoing faculty development and sound mentoring relationships facilitate the academic advancement of clinician-educators.

Efficacy of patient-controlled analgesia for patients with acute abdominal pain in the emergency department: a randomized trial.

OBJECTIVES The objective was to assess the efficacy of patient-controlled analgesia (PCA) in the emergency department (ED) and to compare two PCA dosing regimens. METHODS A randomized controlled trial with three treatment arms was performed in an urban ED. A convenience sample of ED patients ages 18 to 65 years with abdominal pain of 7 days or less duration requiring intravenous (IV) opioid analgesia was enrolled between April 2009 and June 2010. All patients received an initial dose of 0.1 mg/kg IV morphine followed by physician-managed analgesia as needed. Patients in the PCA arms also received IV morphine with on-demand doses of 1 or 1.5 mg, with a 6-minute lockout between doses. Pain intensity was rated by patients on an 11-point numeric rating scale (NRS). Satisfaction with pain treatment, desire for the same treatment in the future, and need for additional analgesia were assessed at study end. Adverse events (O(2) sat < 92%, respiratory rate [RR] < 10/min, systolic blood pressure [sBP] < 90 mm Hg, and naloxone use) were counted. One-way analysis of variance was used to test the difference among groups in short-term pain relief, as assessed by mean change in NRS pain intensity from baseline to 30 minutes and pain over the entire 2-hour study period measured by area under the curve (AUC) of NRS pain ratings. A post hoc hierarchical linear model was used to test the observed difference in NRS between the groups between 30 and 120 minutes. RESULTS A total of 211 patients were enrolled. A sharp, nearly identical decline in mean NRS scores occurred from baseline to 30 minutes in the three groups (p = 0.82). Between 30 and 120 minutes, there was little further decline in the non-PCA NRS scores, while both PCA groups continued to decline (p = 0.004). The net treatment effect over the entire 2 hours was smallest in the non-PCA group and largest in the group receiving 1.5 mg of morphine (p = 0.06). The mean decline in pain from baseline to 120 minutes postbaseline in both PCA groups was 1.4 NRS units (95% confidence interval [CI] = 0.3 to 2.4) greater than the decline in patients treated without PCA. More patients in the PCA arms reported satisfaction, wanting the same pain management in the future, and not wanting further analgesics at 120 minutes than patients who did not receive PCA. There were no clinically or statistically significant differences in any outcomes between the two PCA groups. One PCA patient had a transient oxygen saturation of 88% after the initial bolus only, and one non-PCA patient had a brief drop in sBP to 87 mm Hg. CONCLUSIONS This study provides support for efficacy of PCA when applied to the ED setting. Future studies designed to assess implementation of this modality in the context of conditions of actual ED staffing and competing patient demands are warranted.

Does Initial Hydromorphone Relieve Pain Best if Dosing Is Fixed or Weight Based

STUDY OBJECTIVE It remains unknown whether initial opioid dosing should optimally be fixed or weight-based. We wish to determine whether pain response after an initial fixed dose of intravenous hydromorphone varied by total body weight. METHODS We enrolled a convenience sample of emergency department adults aged 18 to 65 years with acute pain requiring intravenous opioids and administered 1 mg of hydromorphone. Our primary outcome was the correlation of total body weight with the reduction in pain at 30 minutes, as measured with a numeric rating scale. Our secondary outcomes contrasted total body weight by other measures of efficacy (numeric rating scale <3, pain relief, satisfaction, and desire for more analgesics) and adverse events (nausea, vomiting, and pruritus). We also performed a multivariate analysis to control for variables that might affect the relationship of pain response to total body weight. RESULTS We enrolled 163 subjects with a range of weights from 45 to 157 kg, and their mean numeric rating scale pain reduction at 30 minutes was 5.3. Pain reduction did not correlate with weight in either univariate or multivariable models. Secondary outcomes were also similar, except greater pruritus in lower-weight subjects. CONCLUSION Pain response to a fixed 1 mg intravenous dose of hydromorphone did not vary by total body weight in this sample of adults aged 18 to 65 years, suggesting no advantage to weight-based over fixed opioid dosing.

Brief ReportExploratory study on Association of Single-Nucleotide Polymorphisms with Hydromorphone Analgesia in ED☆☆☆

OBJECTIVES The objective of this study is to provide information on distribution of important single-nucleotide polymorphisms (SNPs) and evaluate their associations with clinical response to intravenous hydromorphone in emergency department. METHODS A prospective exploratory study was performed. A convenience sample of adult emergency department patients with acute pain deemed to require intravenous opioids received 1 mg of intravenous hydromorphone. Primary outcome was pain score (numeric rating scale, NRS) reduction between baseline and 30 minutes after medication administration. Secondary outcomes were pain relief, patient satisfaction with analgesia, desire for more analgesics, and side effects (nausea, vomiting, and pruritis). Single-nucleotide polymorphisms in OPRM1 gene (opioid receptor, A118G), ABCB1 gene (opioid transporter, C3435T), COMT gene (pain sensitivity, G1947A), and UGT2B7 gene (opioid metabolism, -G840A) were tested. We used Kruskal-Wallis test to compare the primary outcome and χ(2) test (or Fisher test) to compare the secondary outcomes among patients carrying different SNPs. RESULTS One thousand four hundred thirty-eight patients were screened, and 163 patients were enrolled in the study. The mean age was 39 years. Sixty-three percent were female, 58% were Hispanic, and 67% had pain located in abdomen. The median pain NRS reduction at 30 minutes was 5 (interquartile range, 3-8). There was no difference in pain NRS reduction among patients carrying different SNPs. Secondary outcome analysis revealed statistically significant associations between patient satisfaction with treatment and OPRM1 and between nausea and UGT2B7. CONCLUSIONS This exploratory study did not show a significant difference in pain NRS reduction among patients carrying different SNPs. Patient satisfaction with analgesia and nausea were statistically significantly associated with OPRM1 and UGT2B7, respectively.

Exploratory study on Association of Single-Nucleotide Polymorphisms with Hydromorphone Analgesia in ED

OBJECTIVES The objective of this study is to provide information on distribution of important single-nucleotide polymorphisms (SNPs) and evaluate their associations with clinical response to intravenous hydromorphone in emergency department. METHODS A prospective exploratory study was performed. A convenience sample of adult emergency department patients with acute pain deemed to require intravenous opioids received 1 mg of intravenous hydromorphone. Primary outcome was pain score (numeric rating scale, NRS) reduction between baseline and 30 minutes after medication administration. Secondary outcomes were pain relief, patient satisfaction with analgesia, desire for more analgesics, and side effects (nausea, vomiting, and pruritis). Single-nucleotide polymorphisms in OPRM1 gene (opioid receptor, A118G), ABCB1 gene (opioid transporter, C3435T), COMT gene (pain sensitivity, G1947A), and UGT2B7 gene (opioid metabolism, -G840A) were tested. We used Kruskal-Wallis test to compare the primary outcome and χ(2) test (or Fisher test) to compare the secondary outcomes among patients carrying different SNPs. RESULTS One thousand four hundred thirty-eight patients were screened, and 163 patients were enrolled in the study. The mean age was 39 years. Sixty-three percent were female, 58% were Hispanic, and 67% had pain located in abdomen. The median pain NRS reduction at 30 minutes was 5 (interquartile range, 3-8). There was no difference in pain NRS reduction among patients carrying different SNPs. Secondary outcome analysis revealed statistically significant associations between patient satisfaction with treatment and OPRM1 and between nausea and UGT2B7. CONCLUSIONS This exploratory study did not show a significant difference in pain NRS reduction among patients carrying different SNPs. Patient satisfaction with analgesia and nausea were statistically significantly associated with OPRM1 and UGT2B7, respectively.

Comparative Effectiveness of Patient-Controlled Analgesia for Treating Acute Pain in the Emergency Department

Study objective We assess the effectiveness of patient‐controlled analgesia in the emergency department (ED). We hypothesized that decline in pain intensity from 30 to 120 minutes after initial intravenous opioid administration is greater in patients receiving morphine by patient‐controlled analgesia compared with usual care and would differ by a clinically significant amount. Method This was a pragmatic randomized controlled trial of patient‐controlled analgesia and usual care (opioid and dose at physician’s discretion) in 4 EDs. Entry criteria included age 18 to 65 years and acute pain requiring intravenous opioids. The primary outcome was decline in numeric rating scale pain score 30 to 120 minutes postbaseline. Secondary outcomes included satisfaction, time to analgesia, adverse events, and patient‐controlled analgesia pump‐related problems. We used a mixed‐effects linear model to compare rate of decline in pain (slope) between groups. A clinically significant difference between groups was defined as a difference in slopes equivalent to 1.3 numeric rating scale units. Results Six hundred thirty‐six patients were enrolled. The rate of decline in pain from 30 to 120 minutes was greater for patients receiving patient‐controlled analgesia than usual care (difference=1.0 numeric rating scale unit; 95% confidence interval [CI] 0.6 to 1.5; P<.001) but did not reach the threshold for clinical significance. More patients receiving patient‐controlled analgesia were satisfied with pain management (difference=9.3%; 95% CI 3.3% to 15.1%). Median time to initial analgesia was 15 minutes longer for patient‐controlled analgesia than usual care (95% CI 11.4 to 18.6 minutes). There were 7 adverse events in the patient‐controlled analgesia group and 1 in the usual care group (difference=2.0%; 95% CI 0.04% to 3.9%), and 11 pump‐programming errors. Conclusion The findings of this study do not favor patient‐controlled analgesia over usual ED care for acute pain management.

Prehospital trauma arrival notification associated with more image studies in patients with minor head trauma discharged from ED

OBJECTIVES The objective of this study was to determine whether prehospital trauma arrival notification was associated with more head computed tomography (CT) scans and image studies performed in patients with minor head trauma and discharged from emergency department (ED). METHODS A retrospective cross-sectional study based on hospital electronic medical record was performed. Patients with head trauma indicated by their diagnostic codes or chief complaints, presenting to and discharged from ED in a level I trauma center between January 1, 2010, and June 30, 2014, and triage Glasgow Coma Scale (GCS) score 14 or greater were selected from electronic medical record. Triage prehospital trauma arrival notification, number and types of image studies performed, and basic demographics were extracted. χ(2) Analysis (or Fisher test) was applied to compare the proportions of patients who received image studies between prehospital trauma arrival notification and non-notification groups. RESULTS There were 3603 patients with head trauma, triage GCS score 14 or greater, and discharged from ED. Mean age was 43.8 years. Forty-six percent was female. Thirty-two point nine percent was Hispanic, and 28.6% was black. Numbers (proportions) of patients who received prehospital trauma arrival notification, head CT scan, or any image study (x-ray, CT, magnetic resonance imaging, or sonogram) were 287 (8.0%), 1621 (45.0%), and 2267 (63.0%), respectively. Compared with patients without prehospital trauma arrival notifications, patients with prehospital trauma arrival notifications were significantly more likely to receive a head CT scan as well as an image study. CONCLUSIONS Prehospital trauma arrival notification was associated with significantly more head CT scans and more image studies in patients with minor head trauma and discharged from ED.