Carl R. Chudnofsky

Does End Tidal CO2 Monitoring During Emergency Department Procedural Sedation and Analgesia With Propofol Decrease the Incidence of Hypoxic Events? A Randomized, Controlled Trial

STUDY OBJECTIVE We determine whether the use of capnography is associated with a decreased incidence of hypoxic events than standard monitoring alone during emergency department (ED) sedation with propofol. METHODS Adults underwent ED propofol sedation with standard monitoring (pulse oximetry, cardiac and blood pressure) and capnography and were randomized into a group in which treating physicians had access to the capnography and a blinded group in which they did not. All patients received supplemental oxygen (3 L/minute) and opioids greater than 30 minutes before. Propofol was dosed at 1.0 mg/kg, followed by 0.5 mg/kg as needed. Capnographic and SpO2 data were recorded electronically every 5 seconds. Hypoxia was defined as SpO2 less than 93%; respiratory depression, as end tidal CO2 (ETCO2) greater than 50 mm Hg, ETCO2 change from baseline of 10%, or loss of the waveform. RESULTS One hundred thirty-two subjects were evaluated and included in the final analysis. We observed hypoxia in 17 of 68 (25%) subjects with capnography and 27 of 64 (42%) with blinded capnography (P=.035; difference 17%; 95% confidence interval 1.3% to 33%). Capnography identified all cases of hypoxia before onset (sensitivity 100%; specificity 64%), with the median time from capnographic evidence of respiratory depression to hypoxia 60 seconds (range 5 to 240 seconds). CONCLUSION In adults receiving ED propofol sedation, the addition of capnography to standard monitoring reduced hypoxia and provided advance warning for all hypoxic events.

The safety of fentanyl use in the emergency department

Fentanyl citrate is a synthetic narcotic 1,000 times as potent as meperidine. It produces minimal hemodynamic effects and is characterized by a rapid onset of sedation and analgesia, a relatively short duration of action (approximately 30 to 40 minutes), and rapid reversal with opiate antagonists. These properties make fentanyl and ideal drug for emergency department use. The safety of fentanyl use in an adult ED population has not previously been studied. We retrospectively reviewed the charts of 841 patients who received fentanyl at the University of Cincinnati Center for Emergency Care between January 1985 and June 1988. The study population included 497 (59%) men and 344 (41%) women, with an average age of 33 years. The average dose of fentanyl was 180 μg (range, 25 to 1,400 μm). Six patients (1%) experienced mild side effects including nausea (one), emesis (two), urticaria (one), and pruritis (two). Nine patients (1%) developed more serious complications including six cases (0.7%) of respiratory depression and three cases (0.4%) of hypotension. Two of 183 patients (1%) who received midazolam and two of nine patients (22%) who received haloperidol developed respiratory depression and two of the three patients with hypotension were intoxicated. All of the complications were transient, and none resulted in hospitalization. We conclude the fentanyl is a safe drug for use in the ED. to maximize safety, we recommend careful dosing and titratin, close patient monitoring, and the availability of naloxone hydrochloride and resuscitation equioment. In addition, we suggestt cautious use in the intoxicated patient and in patients receiving other drugs with central nervous system or respiratory depresant activity.

Comparison of midazolam and diazepam for conscious sedation in the emergency department

STUDY OBJECTIVE To compare the efficacy of diazepam and midazolam when used for conscious sedation in emergency department patients. DESIGN Prospective, randomized, double-blind, multicenter trial. SETTING Three university EDs. TYPE OF PARTICIPANTS Patients requiring one of the following procedures: abscess drainage, joint reduction, extensive suturing, chest tube insertion, or lumbar puncture. INTERVENTIONS Diazepam (2.5 mg/mL) or midazolam (1 mg/mL) was administered until the desired level of sedation was achieved to a maximum of 5 mL. Fentanyl citrate was administered if needed for pain. MEASUREMENTS AND MAIN RESULTS Thirty-three patients received diazepam and 36 received midazolam. Patients receiving midazolam had a greater degree of early sedation (P < .05), a higher 90-minute alertness scale score (P < .05), more patients ready for discharge at 90 minutes (P = .05), significantly less recall for the procedure (P < .02), and less pain on injection (P < .01) than patients who were given diazepam. CONCLUSIONS Diazepam and midazolam are both effective for conscious sedation in ED patients. Midazolam causes less pain on injection, a significantly greater degree of early sedation, and a more rapid return to baseline function.

Midazolam use in the emergency department

Midazolam is the first water-soluble benzodiazepine. As with other benzodiazepines it has amnestic, sedative, hypnotic, anxiolytic, and anticonvulsant properties. Midazolam is about two to four times more potent than diazepam. Midazolam has been extensively used for a variety of outpatient procedures, but there has been no documentation of its safety in emergency department patients. The authors retrospectively reviewed all patients receiving midazolam during a 2-year period at the University of Cincinnati Center for Emergency Care. The study population consisted of 389 patients (men 56%; women 44%) with an average age of 33.3 years. Midazolam was used intravenously for sedation before a wide variety of painful procedures and for agitation control. The average dose was 3.86 mg, with a range of 0.5 mg to 20.0 mg. The majority of patients (79.2%) received narcotics or sedative/hypnotic agents in addition to midazolam. There was an overall complication rate of 1.0%. Two patients (0.5%) developed clinically significant respiratory depression after midazolam use. Both patients had also received fentanyl citrate and the respiratory depression was reversed with naloxone. Two patients (0.5%) receiving several other drugs developed short periods of hypotension. There were no apparent long term sequelae. The authors conclude that midazolam can be safely used in the emergency department setting. Careful dosing and titration to the desired clinical effects is mandatory. Patients should be closely monitored to maximize safety.

Double-Blind, Multicenter Trial to Compare the Efficacy of Intramuscular Dihydroergotamine Plus Hydroxyzine Versus Intramuscular Meperidine Plus Hydroxyzine for the Emergency Department Treatment of Acute Migraine Headache☆☆☆★★★

STUDY OBJECTIVE To evaluate intramuscular dihydroergotamine in direct comparison with opioid analgesia in the treatment of acute migraine headache. METHODS This was a prospective, multicenter, double-blind trial performed in the emergency departments of 11 general hospitals in the United States. One hundred seventy-one patients between the ages of 18 and 60 years who presented to the ED with acute migraine headache were enrolled. Patients were randomly assigned to receive either 1 mg dihydroergotamine (DHE) or 1.5 mg/kg meperidine (MEP) by intramuscular injection. The anti-nauseant hydroxyzine (H) was coadministered in both treatment groups. RESULTS One hundred fifty-six patients were evaluable. Treatment groups were comparable in sample size, demographics, and baseline measurements of headache pain. Reduction of headache pain as measured on a 100-mm visual analog scale was 41+/-33 mm (53.5% reduction) for the DHE group, and 45+/-30 mm (55.7% reduction) for the MEP group at 60 minutes after treatment (difference=2.2%; 95% confidence interval [CI] -10%, 14.5%; P=.81). Reduction in the severity of nausea and improvement in functional ability were similar between treatment groups. Central nervous system adverse events were less common in the DHE group (DHE 23.5% versus MEP 37.6%, difference-14.1%: 95% CI -28%, 0%). In particular, dizziness was reported less commonly with DHE than MEP (2% versus 15%, difference=-13%: 95% CI -21%, -5%). CONCLUSION In this prospective, double-blind trial of a convenience sample of ED patients randomly assigned to one of two treatment regimens, DHE and MEP were comparable therapies for acute migraine. The use of DHE avoids several problems associated with opioid analgesia, including dizziness.

The Utility of Supplemental Oxygen During Emergency Department Procedural Sedation With Propofol: A Randomized, Controlled Trial

STUDY OBJECTIVE We determine whether supplemental oxygen reduces the incidence of hypoxia by 20% compared with breathing room air in adult study patients receiving propofol for emergency department procedural sedation. METHODS Patients were randomized to receive either supplemental oxygen or compressed air by nasal cannula at 3 L per minute. Physicians were blinded to the gas used and end tidal CO(2) (etco(2)) data. Respiratory depression was defined a priori as oxygen saturation less than or equal to 93%, an etco(2) level of greater than or equal to 50 mm Hg, an absolute etco(2) change from baseline of greater than or equal to 10 mm Hg, or loss of the etco(2) waveform. RESULTS Of the 110 patients analyzed, 56 received supplemental oxygen and 54 received room air. Ten (18%) patients in the supplemental oxygen group and 15 (28%) patients in the compressed air group experienced hypoxia (P=.3, effect size=10%, 95% confidence interval -24% to 7%). Twenty-seven patients (20 supplemental oxygen; 7 room air) met etco(2) criteria for respiratory depression but did not become hypoxic. Physicians identified respiratory depression in 23 of 25 patients who developed hypoxia compared with only 1 of 27 patients who met etco(2) criteria for respiratory depression but who did not have hypoxia. One patient in the supplemental oxygen group experienced a transient arrhythmia and had a short apneic episode, both of which resolved spontaneously. The patient was admitted for observation. CONCLUSION Supplemental oxygen (3 L/minute) trended toward reducing hypoxia in adult study patients; however, the 10% difference observed was not statistically significant and was below our a priori 20% threshold. Blinded capnography frequently identified respiratory depression undetected by the treating physicians.

Early versus late fluid resuscitation: Lack of effect in porcine hemorrhagic shock

The benefit of IV fluid therapy in the prehospital management of hemorrhagic shock is unproven. We used a reproducible, lightly anesthetized model of porcine continuous hemorrhage to evaluate the usefulness of pre-hospital IV fluid therapy. Incorporated into the model were time delays associated with ambulance request and dispatch, patient evaluation and treatment, and transport to the hospital in the average urban prehospital care system. Treatment occurred concurrently with hemorrhage. Twenty-eight immature swine (15 to 20 kg) were bled at a rate of 1.25 mL/kg/min. Animals in the prehospital IV group (n = 14) received fluid resuscitation at 1 mL/kg/min beginning 20 minutes after initiation of hemorrhage; those in the in-hospital IV group (n = 14) received fluid at a rate of 3 mL/kg/min beginning 35 minutes after hemorrhage. Both groups received blood and saline at 3 mL/kg/min 45 minutes after hemorrhage began, and both groups had hemorrhage controlled 25 minutes after simulated hospital arrival. Survival was 57% in both groups, and there were no statistically significant differences seen in measured hemodynamic or biochemical parameters. We conclude that early administration of IV normal saline has no effect on hemodynamics or survival in this porcine hemorrhagic shock model simulating an urban prehospital care system.

Where health and welfare meet: social deprivation among patients in the emergency department.

ContextAs a safety net provider for many disadvantaged Americans, the emergency department (ED) may be an efficient site not only for providing acute medical care, but also for addressing serious social needs.ObjectiveTo characterize the social needs of ED patients, and to evaluate whether the most disadvantaged patients have connections with the health and welfare system outside the ED.DesignCross-sectional survey conducted over 24 hours in the fall of 1997.SettingThree EDs: an urban public teaching hospital, a suburban university hospital, and a semirural community hospital.ParticipantsConsecutive patients presenting for care, including those transported by ambulance. The survey response rate was 91% (N=300; urban=115, suburban=102, rural=83).Main Outcome MeasureIndex of socioeconomic deprivation described by the US Census Bureau (based on food, housing, and utilities).ResultsOf all ED patients, 31% reported one or more serious social deprivations. For example, 13% of urban patients reported not having enough food to eat, and 9% of rural patients reported disconnection of their gas or electricity (US population averages both less than 3%). While 40% of all patients had no consistent health care outside the ED (≤1 visit/year), those with higher levels of social deprivation had the least contact with the health care system outside the ED (P<.01). Although those with higher levels of deprivation were more likely to receive public assistance, still almost one-quarter of patients with high-level social deprivation were not receiving public aid.ConclusionMany ED patients suffer from fundamental social deprivations that threaten basic health. The most disadvantaged of these patients frequently lack contact with other medical care sites or public assistance networks. Community efforts to address serious social deprivation should include partnerships with the local ED.

The utility of high-flow oxygen during emergency department procedural sedation and analgesia with propofol: a randomized, controlled trial.

STUDY OBJECTIVE We determine whether high-flow oxygen reduces the incidence of hypoxia by 20% in adults receiving propofol for emergency department (ED) sedation compared with room air. METHODS We randomized adults to receive 100% oxygen or compressed air at 15 L/minute by nonrebreather mask for 5 minutes before and during propofol procedural sedation. We administered 1.0 mg/kg of propofol, followed by 0.5 mg/kg boluses until the patient was adequately sedated. Physicians and patients were blinded to the gas used. Hypoxia was defined a priori as an oxygen saturation less than 93%; respiratory depression was defined as an end tidal CO(2) greater than 50 mm Hg, a 10% absolute change from baseline, or loss of waveform. RESULTS We noted significantly less hypoxia in the 59 patients receiving high-flow oxygen compared with the 58 receiving compressed air (19% versus 41%; P=.007; difference 23%; 95% confidence interval 6% to 38%). Respiratory depression was similar between groups (51% versus 48%; difference 2%; 95% confidence interval -15% to 22%). We observed 2 adverse events in the high-flow group (1 hypotension, 1 bradycardia) and 2 in the compressed air group (1 assisted ventilation, 1 hypotension). CONCLUSION High-flow oxygen reduces the frequency of hypoxia during ED propofol sedation in adults.

Acute pulmonary toxicity to nitrofurantoin

Nitrofurantoin is a widely prescribed antibiotic used for the treatment of urinary tract infections. In some patients it can produce an acute pulmonary reaction ranging from mild dyspnea to noncardiogenic pulmonary edema. Symptoms include fever, dyspnea, chills, cough, and chest pain. Physical examination generally reveals an acutely ill, extremely apprehensive patient in varying degrees of respiratory distress. Fever is usually present and there is an increase in heart rate and respiratory rate. Cyanosis, rales, and a maculopapular rash are common findings. Laboratory studies typically demonstrate a leukocytosis with eosinophilia, varying degrees of hypoxia and hypocapnia, and a mild to moderate elevation of the erythrocyte sedimentation rate. The chest x-ray study may be normal but more often demonstrates bilateral lower lobe interstitial infiltrates frequently accompanied by pleural effusions. Treatment in the majority of cases requires only stopping the drug, but steroids, bronchodilators, or antihistamines may be used in selected cases. Once the diagnosis is made and the drug withdrawn, prognosis for full recovery is excellent.