Andrew K. Chang

The influence of triage systems and triage scores on timeliness of ED analgesic administration

OBJECTIVES The aim of the study was to examine the association between triage scoring systems and triage priority scores on time to initial emergency department (ED) analgesic administration. METHODS An observational, multicenter, prospective, cohort study was conducted at 20 US and Canadian EDs. Centers from the United States used the Emergency Severity Index triage system or 1 of 3 unvalidated triage systems. Canadian centers used the Canadian Triage and Acuity Scale. Patients aged 8 years or older who presented to the ED with a chief complaint of moderate to severe pain (>3 on a 10-point numerical rating scale) and who were ultimately discharged home were eligible for study enrollment. Triage score, triage system, pain rating on arrival, and time of initial analgesic administration were recorded. RESULTS Among 842 enrolled subjects, 506 (60%) received an analgesic while in the ED. Lower-acuity patients consistently waited longer for analgesics. On multivariate modeling, presenting pain intensity, total time spent in the ED, white ethnicity, and triage system were associated with time to initial analgesic administration. Emergency departments using the Canadian Triage and Acuity Scale triage system exhibited the lowest rates of analgesic use and displayed longer median times to initial analgesic administration. CONCLUSIONS Although there were some differences between triage systems, all sites and systems demonstrated unacceptably long times to analgesic provision. Many patients with moderate to severe pain received no analgesic during their ED stay. Future studies should examine whether ED overcrowding impacts timeliness of analgesic administration and identify specific strategies to improve pain management practices in this challenging environment.

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.

Safety and Efficacy of Rapid Titration Using 1mg Doses of Intravenous Hydromorphone in Emergency Department Patients With Acute Severe Pain: The “1+1” Protocol

STUDY OBJECTIVE We evaluate the safety and efficacy of a pain protocol using 1 mg intravenous (IV) hydromorphone followed by an optional dose of 1 mg IV hydromorphone 15 minutes later. METHODS Prospective interventional study at an urban academic emergency department (ED). One milligram of IV hydromorphone was administered to adults 21 to 64 years of age who had acute severe pain. Fifteen minutes later, patients were asked whether they wanted more pain medication. If they answered yes, they received another 1 mg of IV hydromorphone and were again asked 15 minutes later whether they wanted more pain medication. The primary efficacy outcome was the proportion of patients who had adequate analgesia, defined as declining additional hydromorphone within 1 hour of entering the protocol. The primary safety outcome was incidence of oxygen desaturation less than 95%. Secondary outcomes included numeric rating scale pain scores and adverse events. RESULTS Of the 223 patients with complete data, 1 mg IV hydromorphone provided adequate analgesia for 77% (95% confidence interval 71% to 82%) within 15 minutes and 96% (95% confidence interval 92% to 98%) within 1 hour of entering the protocol. Eighty-six percent of patients reported pain scores that decreased by 2 or more numeric rating scale units. Five percent experienced transient oxygen desaturation below 95%, which was corrected promptly with oxygen. CONCLUSION A rapid titration protocol using IV hydromorphone (1 mg hydromorphone followed by an optional 1 mg 15 minutes later) is efficacious in nonelderly ED patients with acute severe pain. There were no serious adverse events.

Dosing and titration of intravenous opioid analgesics administered to ED patients in acute severe pain

OBJECTIVES The objectives were to describe the dose of opioids and incidence of titration for management of acute pain in emergency department patients and, secondarily, to assess the association between change in pain and dose. METHODS Data from control groups of 2 randomized clinical trials were analyzed. Patients 21 to 64 years with acute pain judged to warrant intravenous (i.v.) opioids were eligible. We calculated the mean weight-based dose of i.v. opioids, distribution of dose, proportion of patients receiving additional i.v. opioids, and 95% confidence intervals. We compared these statistics to 3 recommendations: 0.1 mg/kg morphine, 10 mg morphine, and titration to analgesic effect. We used multiple linear regression to assess the association between change in pain measured on a numerical rating scale and dose. RESULTS There were 281 patients with an initial median pain score of 10 (interquartile range: 8, 10). Mean weight-based dose of i.v. opioids was 0.08 mg/kg (0.07, 0.08 mg/kg). A total of 268 patients (95.4% [92.2%, 97.5%]) received less than 10 mg i.v. morphine equivalents; 7 patients (2.5% [1.0%, 5.0%]) received additional opioids. There was a weak association between change in pain in the 15, 30, and 60 minutes after the initial bolus and dose: b = 0.22 (0.07, 0.37), b = 0.17 (0.02, 0.32), and b = 0.12 (-0.03, 0.28), respectively, after adjustment for baseline pain. CONCLUSION Analgesic practice did not conform to recommended doses or regimens. There was only a weak association between change of pain and dose in the range of doses given. These findings suggest that oligoanalgesia continues to be a problem despite improvements over the past 20 years.

Nonconvulsive Status Epilepticus

Nonconvulsive status epilepticus (NCSE) refers to a prolonged seizure that manifests primarily as altered mental status as opposed to the dramatic convulsions seen in generalized tonic-clonic status epilepticus. There are 2 main types of NCSE, each of which has a different presentation, cause, and expected outcome. In the first type of NCSE, patients present with confusion or abnormal behavior, suggesting the diagnosis of absence status epilepticus (ASE) or complex partial status epilepticus (CPSE). The second type of NCSE (subtle status epilepticus [SSE]) must be considered in comatose patients who present after a prolonged generalized tonic-clonic seizure and who may have only subtle motor manifestations of a seizure, such as facial or hand twitchings. Whereas the morbidity and mortality in patients with prolonged ASE or CPSE is low, the mortality associated with SSE can exceed 30% if the seizure duration is greater than 60 minutes.

Effect of a Single Dose of Oral Opioid and Nonopioid Analgesics on Acute Extremity Pain in the Emergency Department: A Randomized Clinical Trial

Importance The choice of analgesic to treat acute pain in the emergency department (ED) lacks a clear evidence base. The combination of ibuprofen and acetaminophen (paracetamol) may represent a viable nonopioid alternative. Objectives To compare the efficacy of 4 oral analgesics. Design, Settings, and Participants Randomized clinical trial conducted at 2 urban EDs in the Bronx, New York, that included 416 patients aged 21 to 64 years with moderate to severe acute extremity pain enrolled from July 2015 to August 2016. Interventions Participants (104 per each combination analgesic group) received 400 mg of ibuprofen and 1000 mg of acetaminophen; 5 mg of oxycodone and 325 mg of acetaminophen; 5 mg of hydrocodone and 300 mg of acetaminophen; or 30 mg of codeine and 300 mg of acetaminophen. Main Outcomes and Measures The primary outcome was the between-group difference in decline in pain 2 hours after ingestion. Pain intensity was assessed using an 11-point numerical rating scale (NRS), in which 0 indicates no pain and 10 indicates the worst possible pain. The predefined minimum clinically important difference was 1.3 on the NRS. Analysis of variance was used to test the overall between-group difference at P = .05 and 99.2% CIs adjusted for multiple pairwise comparisons. Results Of 416 patients randomized, 411 were analyzed (mean [SD] age, 37 [12] years; 199 [48%] women; 247 [60%] Latino). The baseline mean NRS pain score was 8.7 (SD, 1.3). At 2 hours, the mean NRS pain score decreased by 4.3 (95% CI, 3.6 to 4.9) in the ibuprofen and acetaminophen group; by 4.4 (95% CI, 3.7 to 5.0) in the oxycodone and acetaminophen group; by 3.5 (95% CI, 2.9 to 4.2) in the hydrocodone and acetaminophen group; and by 3.9 (95% CI, 3.2 to 4.5) in the codeine and acetaminophen group (P = .053). The largest difference in decline in the NRS pain score from baseline to 2 hours was between the oxycodone and acetaminophen group and the hydrocodone and acetaminophen group (0.9; 99.2% CI, −0.1 to 1.8), which was less than the minimum clinically important difference in NRS pain score of 1.3. Adverse events were not assessed. Conclusions and Relevance For patients presenting to the ED with acute extremity pain, there were no statistically significant or clinically important differences in pain reduction at 2 hours among single-dose treatment with ibuprofen and acetaminophen or with 3 different opioid and acetaminophen combination analgesics. Further research to assess adverse events and other dosing may be warranted. Trial Registration clinicaltrials.gov Identifier: NCT02455518

Randomized Clinical Trial of Hydrocodone/Acetaminophen Versus Codeine/Acetaminophen in the Treatment of Acute Extremity Pain After Emergency Department Discharge

OBJECTIVES The objective was to test the hypothesis that hydrocodone/acetaminophen (Vicodin [5/500]) provides more efficacious analgesia than codeine/acetaminophen (Tylenol #3 [30/300]) in patients discharged from the emergency department (ED). Both are currently Drug Enforcement Administration (DEA) Schedule III narcotics. METHODS This was a prospective, randomized, double-blind, clinical trial of patients with acute extremity pain who were discharged home from the ED, comparing a 3-day supply of oral hydrocodone/acetaminophen (5 mg/500 mg) to oral codeine/acetaminophen (30 mg/300 mg). Pain was measured on a valid and reproducible verbal numeric rating scale (NRS) ranging from 0 to 10, and patients were contacted by telephone approximately 24 hours after being discharged. The primary outcome was the between-group difference in improvement in pain at 2 hours following the most recent ingestion of the study drug, relative to the time of phone contact after ED discharge. Secondary outcomes compared side-effect profiles and patient satisfaction. RESULTS The median time from ED discharge to follow-up was 26 hours (interquartile range [IQR] = 24 to 39 hours). The mean NRS pain score before the most recent dose of pain medication after ED discharge was 7.6 NRS units for both groups. The mean decrease in pain scores 2 hours after pain medications were taken were 3.9 NRS units in the hydrocodone/acetaminophen group versus 3.5 NRS units in the codeine/acetaminophen group, for a difference of 0.4 NRS units (95% confidence interval [CI] = -0.3 to 1.2 NRS units). No differences were found in side effects or patient satisfaction. CONCLUSIONS Both medications decreased NRS pain scores by approximately 50%. However, the oral hydrocodone/acetaminophen failed to provide clinically or statistically superior pain relief compared to oral codeine/acetaminophen when prescribed to patients discharged from the ED with acute extremity pain. Similarly, there were no clinically or statistically important differences in side-effect profiles or patient satisfaction. If the DEA reclassifies hydrocodone as a Schedule II narcotic, as recently recommended by its advisory board, our data suggest that the codeine/acetaminophen may be a clinically reasonable Schedule III substitute for hydrocodone/acetaminophen at ED discharge. These findings should be regarded as tentative and require independent validation in similar and other acute pain models.

Double-dose external cardioversion for refractory unstable atrial fibrillation in the ED

A 45-year-old man with dilated cardiomyopathy, atrial fibrillation, and hypertension presented to the emergency department with palpitations and shortness of breath for 2 days after running out of his medications. An electrocardiogram disclosed atrial fibrillation with rapid ventricular response. The patient was hemodynamically unstable and failed multiple cardioversion attempts up to 360 J. A second defibrillator was then attached and the patient successfully cardioverted once both defibrillators were set to their maximum levels, thus delivering a total of 720 J. Double-dose external cardioversion with 2 defibrillators is an important alternative method that the emergency physician should be aware of when treating refractory atrial fibrillation in the hemodynamically unstable patient.

Comparative Analgesic Efficacy of Oxycodone/Acetaminophen vs Codeine/Acetaminophen for Short-Term Pain Management Following ED Discharge

OBJECTIVE To test the hypothesis that oxycodone/acetaminophen provides analgesia superior to codeine/acetaminophen following emergency department (ED) discharge. DESIGN Prospective, randomized, double-blind, trial. SETTING Adult inner city ED. SUBJECTS ED patients with acute extremity pain who were discharged home. METHODS Patients randomized to oxycodone/acetaminophen (5 mg/325 mg) or codeine/acetaminophen (30 mg/300 mg). The primary outcome, obtained via telephone one day after ED discharge, was the between-group difference in improvement in numerical rating scale (NRS) pain scores over a 2-hour period following the most recent ingestion of study drug. Secondary outcomes included proportion of patients with >50% pain reduction, side-effect profile, and patient satisfaction. RESULTS Two hundred and forty patients were enrolled. Mean baseline NRS scores were 7.9 in both groups. Mean decrease over 2 hours was 4.5 NRS units in the oxycodone/acetaminophen group vs 4.2 NRS units in the codeine/acetaminophen group, for a clinically and statistically nonsignificant difference of 0.2 NRS units (95% CI -0.4-0.9 NRS units). Similarly, 66% vs 61% achieved >50% pain relief for a nonsignificant difference of 5% (95% CI -8% to 17%). Side-effect profile and patient satisfaction were similar. CONCLUSION Our hypothesis that oxycodone/acetaminophen provides analgesia superior to codeine/acetaminophen was rejected. Although pain within each group was reduced by more than half, the between-group difference was not significant. Pending independent validation, these unexpected findings suggest that codeine/acetaminophen, a Schedule III agent, may be a clinically reasonable outpatient opioid alternative to oxycodone/acetaminophen, a more tightly restricted Schedule II agent thought to be more prone to misuse.

Comparative Analgesic Efficacy of Oxycodone/Acetaminophen Versus Hydrocodone/Acetaminophen for Short‐term Pain Management in Adults Following ED Discharge

OBJECTIVES The objective was to test the hypothesis that oxycodone/acetaminophen provides superior analgesia to hydrocodone/acetaminophen for the treatment of acute extremity pain following emergency department (ED) discharge. METHODS This was a prospective, randomized, double-blind clinical trial of nonelderly adult ED patients with acute musculoskeletal extremity pain, randomly allocated at discharge to receive oxycodone/acetaminophen (5 mg/325 mg) or hydrocodone/acetaminophen (5 mg/325 mg). The primary outcome was the between-group difference in improvement in numerical rating scale (NRS) pain scores over a 2-hour period following the most recent ingestion of study drug, obtained during telephone contact 24 hours after ED discharge. Secondary outcomes included proportionate decrease in pain, comparative side-effect profiles, and patient satisfaction. RESULTS A total of 240 patients were enrolled. The final sample consisted of 220 patients, 107 randomly allocated to oxycodone/acetaminophen and 113 to hydrocodone/acetaminophen. At 24 hours after ED discharge, the mean NRS pain scores prior to the most recent dose of outpatient pain medication were 7.8 and 7.9 in the oxycodone/acetaminophen and hydrocodone/acetaminophen groups, respectively. The mean decreases in pain scores over 2 hours were 4.4 NRS units in the oxycodone/acetaminophen group versus 4.0 NRS units in the hydrocodone/acetaminophen group, for a difference of 0.4 NRS units (95% confidence interval = -0.2 to 1.1 NRS units). Satisfaction with the analgesics was similar. CONCLUSIONS This study design could not detect a clinically or statistically significant difference in analgesic efficacy between oxycodone/acetaminophen (5 mg/325 mg) and hydrocodone/acetaminophen (5 mg/325 mg) for treatment of acute musculoskeletal extremity pain in adults following ED discharge. Both opioids reduced pain scores by approximately 50%.