Barnet Eskin

Safety and efficacy of diclofenac ophthalmic solution in the treatment of corneal abrasions

STUDY OBJECTIVE To determine whether the use of diclofenac ophthalmic solution is a safe and effective analgesic in the treatment of traumatic corneal abrasions in the emergency department. METHODS We conducted a prospective, randomized, double-blinded, placebo-controlled clinical trial. Consenting consecutive patients with corneal abrasions who presented to a community-based ED from August through February 1998 were randomly assigned to receive either diclofenac or control vehicle drops. Pain relief was measured using a visual Numeric Pain Intensity Scale (NPIS) before and after treatment. Exclusion criteria were as follows: age younger than 18 years, pregnancy, history of glaucoma, ocular infection, recent eye surgery, other signs of ocular trauma, narcotics within 6 hours, minimal pain (NPIS score <3), and any allergy to diclofenac or nonsteroidal anti-inflammatory drugs. Patients were discharged with study drug or control vehicle solution, a topical antibiotic, oxycodone-acetaminophen as a rescue analgesic, and a pain diary. The outcome measurements were improvement in NPIS score 2 hours after treatment, use of oxycodone-acetaminophen, and occurrence of any adverse effects. RESULTS Forty-nine patients were enrolled in the study; 25 received diclofenac and 24 received control vehicle drops. Both groups were similar in gender, age, pretreatment pain duration, NPIS score, and analgesic use. There was significantly greater improvement in the 2-hour NPIS score in the diclofenac group (3.1; 95% confidence interval [CI] 2.3 to 4) compared with the control group (1.0; 95% CI 0.1 to 2.0). The difference between the 2 groups was 2.1+/-1.3 (95% CI 0.8 to 3.4). There was a trend toward fewer patients taking rescue oxycodone-acetaminophen in the diclofenac group (20%; 95% CI 4% to 36%) versus the control group (42%; 95% CI 22% to 62%). Other than transient mild stinging, there were no complications associated with diclofenac use. CONCLUSION Diclofenac ophthalmic solution appears to be a safe and effective analgesic in the treatment of traumatic corneal abrasions in the ED.

Steroids for Migraine Headaches: A Randomized Double-Blind, Two-Armed, Placebo-Controlled Trial

BACKGROUND Recurrence of migraine headache after treatment in the emergency department (ED) is common. Conflicting evidence exists regarding the utility of steroids in preventing migraine headache recurrence at 24-48 h. OBJECTIVE To determine if steroids decrease the headache recurrence in patients treated for migraine headaches in the ED. METHODS Double-blind placebo-controlled, two-tailed randomized trial. Patients aged >17 years with a moderately severe migraine headache diagnosed by treating Emergency Physician were approached for participation. Enrollees received either dexamethasone (10 mg i.v.) if intravenous access was utilized or prednisone (40 mg by mouth × 2 days) if no intravenous access was obtained. Each medication was matched with an identical-appearing placebo. Patients were contacted 24-72 h after the ED visit to assess headache recurrence. RESULTS A total of 181 patients were enrolled. Eight were lost to follow-up, 6 in the dexamethasone group and 2 in the prednisone arm. Participants had a mean age of 37 years (±10 years), with 86% female. Eighty-six percent met the International Headache Society Criteria for migraine headache. Of the 173 patients with completed follow-up, 20/91 (22%) (95% confidence interval [CI] 13.5-30.5) in the steroid arm and 26/82 (32%) (95% CI 21.9-42.1) in the placebo arm had recurrent headaches (p = 0.21). CONCLUSION We did not find a statistically significant decrease in headache recurrence in patients treated with steroids for migraine headaches.

Droperidol for acute migraine headache

The use of intramuscular droperidol to treat acute migraine headache has not been previously reported in the emergency medicine literature. It is a promising therapy for migraine. The authors performed a pilot review of all patients receiving droperidol for migraine in our emergency department (ED) to evaluate its efficacy. We used a retrospective case series, in a suburban ED with an annual patient census of 48,000. All patients with a discharge diagnosis of migraine headache who were treated with i.m. droperidol during a consecutive 5-month period in our ED were identified. All patients received droperidol 2.5 mg intramuscular. As per ED protocol, their clinical progress was closely followed and documented at 30 minutes after drug administration (t30). Demographic and clinical variables were recorded on a standardized, closed-question, data collection instrument. The primary outcome measurement was relief of symptoms at t30 to the point that the patient felt well enough to go home without further ED intervention (symptomatic relief). Thirty-seven patients were treated (84% female), with an ED diagnosis of acute migraine with droperidol during the study period. The mean age was 36 +/- 12 years. Analgesics had been used within 24 hours before ED presentation by 62% of patients. At t30, 30 (81%) patients had symptomatic relief, 2 (5%) felt partial relief but required rescue medication, and 5 (14%) had no relief of symptoms. Drowsiness (14%) and mild akathisia (8%) were the only adverse reactions observed following drug administration. Droperidol 2.5 mg intramuscular may be a safe and effective therapy for the ED management of acute migraine headache. Randomized, controlled trials are warranted to further validate the findings of this preliminary study.

Effectiveness of Corticosteroid Treatment in Acute Pharyngitis: A Systematic Review of the Literature

OBJECTIVES The objective was to examine the effectiveness of corticosteroid treatment for the relief of pain associated with acute pharyngitis potentially caused by group A beta-hemolytic Streptococcus (GABHS). METHODS This was a systematic review of the literature. Data sources used were electronic databases (Cochrane Library, MEDLINE, EMBASE, Biosis Previews, Scopus, and Web of Science), controlled trial registration websites, conference proceedings, study references, experts in the field, and correspondence with authors. Selection criteria consisted of randomized controlled trials (RCTs) in which corticosteroids, alone or in combination with antibiotics, were compared to placebo or any other standard therapy for treatment of acute pharyngitis in adult patients, pediatric patients, or both. Two reviewers independently assessed for relevance, inclusion, and study quality. Weighted mean differences (WMDs) were calculated and are reported with corresponding 95% confidence intervals (CIs). RESULTS From 272 potentially relevant citations, 10 studies met the inclusion criteria. When compared to placebo, corticosteroids reduced the time to clinically meaningful pain relief (WMD = -4.54 hours; 95% CI = -7.19 to -1.89); however, they provided only a small reduction in pain scores at 24 hours (WMD = -0.90 on a 0-10 visual analog scale; 95% CI = -1.5 to -0.3). Heterogeneity among pooled studies was identified for both outcomes (I(2) = 81 and 74%, respectively); however, the GABHS-positive subgroup receiving corticosteroid treatment did have a significant mean reduction in time to clinically meaningful pain relief of 5.22 hours (95% CI = -7.02 to -3.42; I(2) = 0%). Short-term side effect profiles between corticosteroids and placebo groups were similar. CONCLUSIONS Corticosteroid administration for acute pharyngitis was associated with a relatively small effect in time to clinically meaningful pain relief (4.5-hour reduction) and in pain relief at 24 hours (0.9-point reduction), with significant heterogeneity in the pooled results. Decision-making should be individualized to determine the risks and benefits; however, corticosteroids should not be used as routine treatment for acute pharyngitis.

Prednisone for Emergency Department Low Back Pain: A Randomized Controlled Trial

BACKGROUND Although oral corticosteroids are commonly given to emergency department (ED) patients with musculoskeletal low back pain (LBP), there is little evidence of benefit. OBJECTIVE To determine if a short course of oral corticosteroids benefits LBP ED patients. METHODS DESIGN Randomized, double-blind, placebo-controlled trial. SETTING Suburban New Jersey ED with 80,000 annual visits. PARTICIPANTS 18-55-year-olds with moderately severe musculoskeletal LBP from a bending or twisting injury ≤ 2 days prior to presentation. Exclusion criteria were suspected nonmusculoskeletal etiology, direct trauma, motor deficits, and local occupational medicine program visits. PROTOCOL At ED discharge, patients were randomized to either 50 mg prednisone daily for 5 days or identical-appearing placebo. Patients were contacted after 5 days to assess pain on a 0-3 scale (none, mild, moderate, severe) as well as functional status. RESULTS The prednisone and placebo groups had similar demographics and initial and discharge ED pain scales. Of the 79 patients enrolled, 12 (15%) were lost to follow-up, leaving 32 and 35 patients in the prednisone and placebo arms, respectively. At follow-up, the two arms had similar pain on the 0-3 scale (absolute difference 0.2, 95% confidence interval [CI] -0.2, 0.6) and no statistically significant differences in resuming normal activities, returning to work, or days lost from work. More patients in the prednisone than in the placebo group sought additional medical treatment (40% vs. 18%, respectively, difference 22%, 95% CI 0, 43%). CONCLUSION We detected no benefit from oral corticosteroids in our ED patients with musculoskeletal LBP.

Do workshops in evidence-based practice equip participants to identify and answer questions requiring consideration of clinical research? A diagnostic skill assessment.

Evidence-based practice (EBP) requires practitioners to identify and formulate questions in response to patient encounters, and to seek, select, and appraise applicable clinical research. A standardized workshop format serves as the model for training of medical educators in these skills. We developed an evaluation exercise to assess the ability to identify and solve a problem requiring the use of targeted skills and administered it to 47 North American junior faculty and residents in various specialties at the close of two short workshops in EBP. Prior to the workshop, subjects reported prior training in EBP and completed a previously validated knowledge test. Our post-workshop exercise differed from the baseline measures and required participants to spontaneously identify a suitable question in response to a simulated clinical encounter, followed by a description of a stepwise approach to answering it. They then responded to successively more explicitly prompted queries relevant to their question. We analyzed responses to identify areas of skill deficiency and potential reasons for these deficiencies. Twelve respondents (26%) initially failed to identify a suitable question in response to the clinical scenario. Ability to choose a suitable question correlated with the ability to connect an original question to an appropriate study design. Prior EBP training correlated with the pretest score but not with performance on our exercise. Overall performance correlated with ability to correctly classify their questions as pertaining to therapy, diagnosis, prognosis, or harm. We conclude that faculty and residents completing standard workshops in EBP may still lack the ability to initiate and investigate original clinical inquiries using EBP skills.

Do all patients with shoulder dislocations need prereduction x-rays?

OBJECTIVE Some would advocate against routine use of prereduction x-rays for shoulder dislocations. Our objective was to examine the percent of dislocations that also had fractures as a function of age to determine whether there are some decades of life with a sufficiently low risk of fracture to avoid routine prereduction x-rays. METHODS This was a retrospective cohort study in 19 New Jersey and New York emergency departments. We used The International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9) codes to identify patients with shoulder dislocations and, among these, those who also had fractures. A priori, we chose to group the patients by decade of life. For patients with dislocations in each age group, we calculated the percent that also had fractures. RESULTS Of the total 5,408,837 visits in the database, there were 7209 patients with dislocations, of which 465 (6.5%) had fractures. We found the lowest percent of fractures in the 2nd and 3rd decades of life (0.7% [95% confidence interval, 0.3%-1.2%] and 0.8% [0.4%-1.3%]). In the 4th and 5th decades of life, the percents were 2.6% (1.7%-3.5%) and 4.6% (3.2-6.0%), respectively, and they steadily increased to 19% or greater in the 8th to 10th decades of life. Omitting the prereduction x-rays for patients in the 2nd and 3rd decades of life would reduce the total number of prereduction x-rays by 40%. CONCLUSION In the second and third decades of life, less than 1% of patients with shoulder dislocations also had fractures. Because these patients have a sufficiently low risk of fracture, routine prereduction x-rays may not be necessary for them.

Diagnosis of Aortic Dissection in Emergency Department Patients is Rare

Introduction Aortic dissection is a rare event. While the most frequent symptom is chest pain, that is a common emergency department (ED) chief complaint and other diseases causing chest pain occur much more often. Furthermore, 20% of dissections are without chest pain and 6% are painless. For these reasons, diagnosing dissections may be challenging. Our goal was to determine the number of total ED and atraumatic chest pain patients for every aortic dissection diagnosed by emergency physicians. Methods Design: Retrospective cohort. Setting: 33 suburban and urban New York and New Jersey EDs with annual visits between 8,000 and 80,000. Participants: Consecutive patients seen by emergency physicians from 1-1-1996 through 12-31-2010. Observations: We identified aortic dissection and atraumatic chest pain patients using the International Classification of Diseases 9th Revision and Clinical Modification codes. We then calculated the number of total ED and atraumatic chest pain patients for every aortic dissection, along with 95% confidence intervals (CIs). Results From a database of 9.5 million ED visits, we identified 782 aortic dissections or one for every 12,200 (95% CI [11,400–13,100]) visits. The mean age of dissection patients was 66±16 years and 38% were female. There were 763,000 (8%) with atraumatic chest pain diagnoses. Thus, there is one dissection for every 980 (95% CI [910–1,050]) atraumatic chest pain patients. Conclusion The diagnosis of aortic dissections by emergency physicians is rare and challenging. An emergency physician seeing 3,000 to 4,000 patients a year would diagnose an aortic dissection approximately every three to four years.

Clinical Policy for Well-Appearing Infants and Children Younger Than 2 Years of Age Presenting to the Emergency Department With Fever.

This clinical policy from the American College of Emergency Physicians addresses key issues for wellappearing infants and children younger than 2 years presenting to the emergency department with fever. A writing subcommittee conducted a systematic review of the literature to derive evidence-based recommendations to answer the following clinical questions: (1) For wellappearing immunocompetent infants and children aged 2 months to 2 years presenting with fever ( 38.0 C [100.4 F]), are there clinical predictors that identify patients at risk for urinary tract infection? (2) For wellappearing febrile infants and children aged 2 months to 2 years undergoing urine testing, which laboratory testing method(s) should be used to diagnose a urinary tract infection? (3) For well-appearing immunocompetent infants and children aged 2 months to 2 years presenting with fever ( 38.0 C [100.4 F]), are there clinical predictors that identify patients at risk for pneumonia for whom a chest radiograph should be obtained? (4) For wellappearing immunocompetent full-term infants aged 1 month to 3 months (29 days to 90 days) presenting with fever ( 38.0 C [100.4 F]), are there predictors that identify patients at risk for meningitis from whom cerebrospinal fluid should be obtained? Evidence was graded and recommendations were made based on the strength of the available data. INTRODUCTION Fever is the most common chief complaint among infants and children presenting to an emergency department (ED), accounting for 15% of all ED visits in a given year for patients younger than 15 years. The majority of febrile children will have a benign, self-limited viral infection. However, a small number of pediatric patients, especially those younger than 3 months because of their relatively immature immune system, will have a serious infection. The management of the toxic or illappearing pediatric patient is straightforward; however, the dilemma for the health care provider is to differentiate the well-appearing febrile infant or child with a serious bacterial infection (SBI) from the febrile infant or child with a benign, usually viral infection. In a study of more than 3,000 febrile infants, only 58% of those with bacteremia or bacterial meningitis appeared clinically ill. There are multiple considerations in the initial assessment of the febrile pediatric patient younger than 2 years: infants and children may have a serious infection and 626 Annals of Emergency Medicine be hypothermic or have a normal temperature; antipyretic use in the previous 4 hours may result in a normal or lower temperature when the infant or child presents to the ED or other health care setting; there should be a determination of the accuracy or validity of the temperature obtained with a home measuring device; fever may be the result of a bacterial or nonbacterial infection (eg, viral infection) or have a noninfectious cause; some viral infections, such as herpes simplex virus, can have devastating consequences in this age group; and the presence of a viral infection does not preclude the coexistence of a bacterial infection. In terms of management, other complex issues to consider include immunization status (ie, fully, partially, or not immunized) and the capacity of the parent or caregiver to continuously monitor the infant or child if discharged home, or to return within 12 to 24 hours. Fever without a source, or fever without a focus, has the following criteria: acute onset, duration of less than 1 week, and absence of localizing signs. In the prepneumococcal vaccine era, even after a thorough history and physical examination, a source of infection was not identified in 27.1% of children. There are many difficulties inherent in developing an evidence-based clinical policy for the management of infants and children with fever. This includes the heterogeneity of definitions, age groups, clinical settings, patient populations, types of diagnostic studies, inclusion or exclusion criteria, thresholds for positive or negative test results, and endpoints or outcomes. Even the definition of fever varies between studies, although the generally used definition is a rectal temperature of greater than or equal to 38.0 C (100.4 F), documented in the clinical setting or at home within the past 24 hours. The definitions (and thus incidence, outcomes, etc) of SBI vary greatly. In some studies, SBI includes bacteremia, bacterial meningitis, urinary tract infection, pneumonia, septic arthritis, osteomyelitis, cellulitis, and enteritis, whereas others include only bacteremia, bacterial meningitis, and urinary tract infection. In the majority of studies, the reference standard for the diagnosis of SBI is a positive culture result from a sample of blood, urine, cerebrospinal fluid, or stool (typically performed only if diarrhea is present). In the prepneumococcal vaccine era, for febrile infants and children the risk of SBI by age has been reported as 13% in neonates (aged 3 to 28 days), 9% in infants aged 29 to 56 days, and 7% in infants aged 90 days or younger. Also, the risk of a positive blood culture result (ie, bacteremia) in an otherwise well-appearing febrile infant or child, aged 3 months to 36 months, was approximately 12% with a fever ( 40 C [104 F]) or with the combination of a fever ( 39.5 C [103 F]) and WBC Volume 67, no. 5 : May 2016

Rates of ED visits and of intubations for congestive heart failure declined from 1996 to 2008

OBJECTIVE Many advances have been made recently in the treatment of congestive heart failure (CHF). We hypothesize that this should have resulted in fewer CHF patients presenting to the emergency department (ED) and fewer being intubated. DESIGN Retrospective cohort. SETTING consecutive patients seen by ED physicians in 4 suburban hospitals in New Jersey and New York from 1996 to 2008. OBJECTIVE PROTOCOL We classified patients as having CHF based on International Classification of Diseases, Ninth Revision, codes. For each year of the study, we determined CHF visit rates (as a percentage of total ED visits) and calculated the percentage of CHF patients intubated. We used the Student t test, calculated 95% confidence intervals (CIs), and performed regression analyses. RESULTS Of the 2,374,428 ED visits, 32,036 (1.3%) were for CHF. The mean age of the CHF patients was 76 ± 14 years, and 57% were female. Congestive heart failure visits declined from 1.6% of all ED visits in 1996 to 1.2% in 2008, a 26% relative decrease (95% CI: 21%-30%, P < .001, correlation coefficient R(2) = 0.94, P < .001). Of the CHF patients, 778 (2.4%) were intubated. Intubation rates declined from 3.6% in 1996 to 1.7% in 2008, a 53% (95% CI: 31%-68%, P < .001, R(2) = 0.83, P < .001) relative decrease. CONCLUSION The rates of annual ED visits for CHF and intubation rates declined from 1996 to 2008. These decreases are most likely due to better CHF treatments.