Christian Fromm

Intravenous Subdissociative-Dose Ketamine Versus Morphine for Analgesia in the Emergency Department: A Randomized Controlled Trial.

STUDY OBJECTIVE We assess and compare the analgesic efficacy and safety of subdissociative intravenous-dose ketamine with morphine in emergency department (ED) patients. METHODS This was a prospective, randomized, double-blind trial evaluating ED patients aged 18 to 55 years and experiencing moderate to severe acute abdominal, flank, or musculoskeletal pain, defined as a numeric rating scale score greater than or equal to 5. Patients were randomized to receive ketamine at 0.3 mg/kg or morphine at 0.1 mg/kg by intravenous push during 3 to 5 minutes. Evaluations occurred at 15, 30, 60, 90, and 120 minutes. Primary outcome was reduction in pain at 30 minutes. Secondary outcome was the incidence of rescue analgesia at 30 and 60 minutes. RESULTS Forty-five patients per group were enrolled in the study. The primary change in mean pain scores was not significantly different in the ketamine and morphine groups: 8.6 versus 8.5 at baseline (mean difference 0.1; 95% confidence interval -0.46 to 0.77) and 4.1 versus 3.9 at 30 minutes (mean difference 0.2; 95% confidence interval -1.19 to 1.46; P=.97). There was no difference in the incidence of rescue fentanyl analgesia at 30 or 60 minutes. No statistically significant or clinically concerning changes in vital signs were observed. No serious adverse events occurred in either group. Patients in the ketamine group reported increased minor adverse effects at 15 minutes post-drug administration. CONCLUSION Subdissociative intravenous ketamine administered at 0.3 mg/kg provides analgesic effectiveness and apparent safety comparable to that of intravenous morphine for short-term treatment of acute pain in the ED.

Absolute and relative changes (delta) in troponin I for early diagnosis of myocardial infarction: Results of a prospective multicenter trial

OBJECTIVES We investigated absolute and relative cardiac troponin I (TnI) delta changes, optimal sampling protocols, and decision thresholds for early diagnosis of myocardial infarction (MI). Serial cardiac biomarker values demonstrating a rise and/or fall define MI diagnosis; however the magnitude of change, timing, and diagnostic accuracy of absolute versus relative (percentage) deltas remains unsettled. METHODS We prospectively measured TnI (AccuTnI+3™, Beckman Coulter) at serial time intervals in 1929 subjects with chest pain or equivalent symptoms of acute coronary syndrome at 14 medical centers. Diagnosis was adjudicated by an independent central committee. RESULTS Elevated TnI above a threshold of 0.03ng/mL demonstrated significant diagnostic efficacy (AUC 0.96). For patients with TnI<0.03ng/mL and symptom onset≥8h, 99.1% (NPV) were diagnosed with conditions other than MI. Absolute delta performed significantly better than relative delta at 1-3h (AUC 0.84 vs 0.69), 3-6h (0.85 vs 0.73), and 6-9h (0.91 vs 0.79). Current recommendations propose ≥20% delta within 3-6h; however, results were optimized using an absolute delta of 0.01 or 0.02ng/mL. Sensitivity results for absolute delta at 1-3h and 3-6h (75.8%, 78.3%) were superior to relative delta (48.0%, 61.3%). NPV (rule out) was 99.6% when baseline TnI<0.03ng/mL and absolute delta TnI<0.01ng/mL. CONCLUSIONS Absolute delta performed significantly better than relative delta at all time intervals. Baseline TnI and absolute delta may be used in conjunction to estimate probability of MI. Consensus recommendations are supported for sampling on admission and 3h later, repeated at 6h in patients when clinical suspicion remains high.

Diagnostic performance of cardiac Troponin I for early rule-in and rule-out of acute myocardial infarction: Results of a prospective multicenter trial☆

OBJECTIVES To compare emergency department TnI serial sampling intervals, determine optimal diagnostic thresholds, and report representative diagnostic performance characteristics for early rule-in and rule-out of MI. METHODS We prospectively measured TnI (AccuTnI+3™, Beckman Coulter) at serial time intervals in 1929 subjects with chest pain or equivalent ischemic symptoms suggestive of acute coronary syndromes at 14 medical centers. Diagnosis was adjudicated by an independent central committee. RESULTS TnI ≥0.03ng/mL provided 96.0% sensitivity and 89.4% specificity at 1-3h after admission, and 94.9% sensitivity and 86.7% specificity at 3-6h. NPV (rule-out, non-MI) was 99.5% at 1-3h, and 99.0% at 3-6h when TnI is <0.03ng/mL. NPV was 99.1% when TnI is <0.03ng/mL and time of symptom onset is ≥8h. Approximately 50-58% (PPV) of patients with TnI ≥0.03ng/mL were diagnosed with MI, depending upon time from onset or admission; PPVs emphasize the importance of serial samples and delta TnI (rising or falling pattern) when low cutoffs are used. Nevertheless, even a single elevated TnI value increased the risk of MI. As TnI values rose, the probability of MI increased. Values ≥0.20ng/mL were associated with nearly 90% probability of MI. CONCLUSIONS We report a large multicenter prospective adjudicated trial assessing troponin for early rule-in and rule-out using the Universal Definition of MI and conducted in primary care hospital-associated emergency departments. Our study demonstrates high diagnostic accuracy at early observation times, and reinforces consensus recommendations for sampling on admission and 3h later, repeated at 6h when clinical suspicion remains high.

A prospective randomized, double-dummy trial comparing intravenous push dose of low dose ketamine to short infusion of low dose ketamine for treatment of moderate to severe pain in the emergency department

Study objective Compare adverse effects and analgesic efficacy of low‐dose ketamine for acute pain in the ED administered either by single intravenous push (IVP) or short infusion (SI). Methods Patients 18–65, presenting to ED with acute abdominal, flank, or musculoskeletal pain with initial pain score ≥ 5, were randomized to ketamine 0.3 mg/kg by either IVP or SI with placebo double‐dummy. Adverse effects were evaluated by Side Effects Rating Scale for Dissociative Anesthetics (SERSDA) and Richmond Agitation‐Sedation Scale (RASS) at 5, 15, 30, 60, 90, and 120 min post‐administration; analgesic efficacy was evaluated by Numerical Rating Scale (NRS). Results 48 patients enrolled in the study. IVP group had higher overall rates of feeling of unreality on SERSDA scale: 92% versus 54% (difference 37.5%; p = 0.008; 95% CI 9.3–59.5%). At 5 min median severity of feeling of unreality was 3.0 for IVP versus 0.0 for SI (p = 0.001). IVP also showed greater rates of sedation on RASS scale at 5 min: median RASS − 2.0 versus 0.0 (p = 0.01). Decrease in mean pain scores from baseline to 15 min was similar across groups: 5.2 ± 3.53 (95% CI 3.7–6.7) for IVP; 5.75 ± 3.48 (95% CI 4.3–7.2) for SI. There were no statistically significant differences with respect to changes in vital signs and need for rescue medication. Conclusion Low‐dose ketamine given as a short infusion is associated with significantly lower rates of feeling of unreality and sedation with no difference in analgesic efficacy in comparison to intravenous push.

Comparison of Intravenous Ketorolac at Three Single-Dose Regimens for Treating Acute Pain in the Emergency Department: A Randomized Controlled Trial.

Study objective Nonsteroidal anti‐inflammatory drugs are used extensively for the management of acute and chronic pain, with ketorolac tromethamine being one of the most frequently used parenteral analgesics in the emergency department (ED). The drugs may commonly be used at doses above their analgesic ceiling, offering no incremental analgesic advantage while potentially adding risk of harm. We evaluate the analgesic efficacy of 3 doses of intravenous ketorolac in ED patients with acute pain. Methods We conducted a randomized, double‐blind trial to assess the analgesic efficacy of 3 doses of intravenous ketorolac (10, 15, and 30 mg) in patients aged 18 to 65 years and presenting to the ED with moderate to severe acute pain, defined by a numeric rating scale score greater than or equal to 5. We excluded patients with peptic ulcer disease, gastrointestinal hemorrhage, renal or hepatic insufficiency, allergies to nonsteroidal anti‐inflammatory drugs, pregnancy or breastfeeding, systolic blood pressure less than 90 or greater than 180 mm Hg, and pulse rate less than 50 or greater than 150 beats/min. Primary outcome was pain reduction at 30 minutes. We recorded pain scores at baseline and up to 120 minutes. Intravenous morphine 0.1 mg/kg was administered as a rescue analgesic if subjects still desired additional pain medication at 30 minutes after the study drug was administered. Data analyses included mixed‐model regression and ANOVA. Results We enrolled 240 subjects (80 in each dose group). At 30 minutes, substantial pain reduction was demonstrated without any differences between the groups (95% confidence intervals 4.5 to 5.7 for the 10‐mg group, 4.5 to 5.6 for the 15‐mg group, and 4.2 to 5.4 for the 30‐mg group). The mean numeric rating scale pain scores at baseline were 7.7, 7.5, and 7.8 and improved to 5.1, 5.0, and 4.8, respectively, at 30 minutes. Rates of rescue analgesia were similar, and there were no serious adverse events. Secondary outcomes showed similar rates of adverse effects per group, of which the most common were dizziness, nausea, and headache. Conclusion Ketorolac has similar analgesic efficacy at intravenous doses of 10, 15, and 30 mg, showing that intravenous ketorolac administered at the analgesic ceiling dose (10 mg) provided effective pain relief to ED patients with moderate to severe pain without increased adverse effects.

An ethical framework for the management of pain in the emergency department.

Pain is a ubiquitous problem, affecting more than 100 million individuals in the United States chronically and many more in the acute setting. Up to three-quarters of patients presenting to the emergency department (ED) report pain as a key component of their reasons for requiring acute care. While pain management is a fundamental component of emergency medicine (EM), there are numerous attitudinal and structural barriers that have been identified to effectively providing pain control in the ED. Coupled with public demands and administrative mandates, concerns surrounding ED pain management have reached a crisis level that should be considered an ethical issue in the profession of EM. In this article, the authors propose an ethical framework based on a combination of virtue, narrative, and relationship theories that can be used to address the clinical dilemmas that arise in managing pain in ED patients.

A prospective analysis of patients presenting for medical attention at a large electronic dance music festival

Mass-Gathering Medicine studies have identified variables that predict greater patient presentation rates (PPRs) and transport to hospital rates (TTHRs). This is a descriptive report of patients who presented for medical attention at an annual electronic dance music festival (EDMF). At this large, single EDMF in New York City (NYC; New York, USA), the frequency of patient presentation, the range of presentations, and interventions performed were identified. This descriptive report examined consecutive patients who presented to the medical tent of a summertime EDMF held at an outdoor venue with an active, mobile, bounded crowd. Alcohol was available for sale. Entry was restricted to persons 18 years and older. The festival occurred on three consecutive days with a total cumulative attendance of 58,000. Medical staffing included two Emergency Medicine physicians, four registered nurses, and 86 Emergency Medical Services (EMS) providers. Data collected included demographics, past medical history, vital signs, physical exam, drug and alcohol use, interventions performed, and transport decisions. Eighty-four patients were enrolled over 2.5 days. Six were transported and zero died. The ages of the subjects ranged from 17 to 61 years. Forty-three (51%) were male. Thirty-eight (45%) initially presented with abnormal vital signs; four (5%) were hyperthermic. Of these latter patients, 34 (90%) reported ingestions with 3,4-methylenedioxymethamphetamine (MDMA) or other drugs. Eleven (65%) patients were diaphoretic or mydriatic. The most common prehospital interventions were intravenous normal saline (8/84; 10%), ondansetron (6/84; 7%), and midazolam (3/84; 4%). Electronic dance music festivals are a growing trend and a new challenge for Mass-Gathering Medicine as new strategies must be employed to decrease TTHR and mortality. Addressing common and expected medical emergencies at mass-gathering events through awareness, preparation, and early, focused medical interventions may decrease PPR, TTHR, and overall mortality. Friedman MS , Plocki A , Likourezos A , Pushkar I , Bazos AN , Fromm C , Friedman BW . A prospective analysis of patients presenting for medical attention at a large electronic dance music festival. Prehosp Disaster Med. 2017; 32(1):78-82.

Self‐reported Financial Conflicts of Interest During Scientific Presentations in Emergency Medicine

OBJECTIVES This study was a review of the scientific abstracts presented at a national conference for the required conflict of interest (COI) disclosure both before the meeting and during presentation. METHODS All presenters were given specific instructions regarding COI reporting at the time of abstract acceptance. All poster presentations were required to have a COI statement. Three physicians using standardized data abstraction forms reviewed abstracts accepted for poster presentation at the 2010 annual meeting of the Society for Academic Emergency Medicine (SAEM). Posters were reviewed for the presence of a required COI disclosure statement, and these results were compared to the mandatory continuing medical education (CME) disclosure form that was sent by the presenters to the SAEM central office before the meeting. RESULTS There were 412 posters accepted for presentation at the 2010 SAEM annual meeting. The reviewers observed 382 (93%) of the total posters for the conference. Sixty-nine abstracts (18%) reported a COI. Only 26 (38%) of these were actually reported to the SAEM office on the CME disclosure form before the meeting; the remaining 62% were found on the poster alone. COI that were reported on the CME disclosure form were found on the poster 46% of the time. The remaining posters without a COI actually displayed the mandatory disclosure statement only 14% of the time. CONCLUSIONS This review of presentations at a national meeting found a lack of compliance with printed guidelines for COI disclosure during scientific presentation. Efforts to increase uniformity and clarity may result in increased compliance.

Intravenous subdissociative-dose ketamine versus morphine for acute geriatric pain in the Emergency Department: A randomized controlled trial

Study objective: We compare the analgesic efficacy and safety of subdissociative intravenous‐dose ketamine (SDK) versus morphine in geriatric Emergency Department (ED) patients. Methods: This was a prospective, randomized, double‐blind trial evaluating ED patients aged 65 and older experiencing moderate to severe acute abdominal, flank, musculoskeletal, or malignant pain. Patients were randomized to receive SDK at 0.3mg/kg or morphine at 0.1mg/kg by short intravenous infusion over 15min. Evaluations occurred at 15, 30, 60, 90, and 120min. Primary outcome was reduction in pain at 30min. Secondary outcomes included overall rates of adverse effects and incidence of rescue analgesia. Results: Thirty patients per group were enrolled in the study. The primary change in mean pain scores was not significantly different in the ketamine and morphine groups: 9.0 versus 8.4 at baseline (mean difference 0.6; 95% CI −0.30 to 1.43) and 4.2 versus 4.4 at 30min (mean difference −0.2; 95% CI −1.93 to1.46). Patients in the SDK group reported higher rates of psychoperceptual adverse effects at 15, 30, and 60min post drug administration. Two patients in the ketamine group and one in the morphine group experienced brief desaturation episodes. There were no statistically significant differences with respect to changes in vital signs and need for rescue medication. Conclusion: SDK administered at 0.3mg/kg over 15min provides analgesic efficacy comparable to morphine for short‐term treatment of acute pain in the geriatric ED patients but results in higher rates of psychoperceptual adverse effects. ClinicalTrials.gov Registration #: NCT02673372.

Management of Major Bleeding Events in Patients Treated With Dabigatran for Nonvalvular Atrial Fibrillation: A Retrospective, Multicenter Review

Study objective There are limited data on the clinical presentations and management of dabigatran‐associated major bleeding outside the clinical trial setting. The aim of this study is to describe clinical characteristics, interventions, and outcomes in patients with dabigatran‐associated major bleeding who present to the emergency department (ED). Methods We performed a retrospective observational chart review study of dabigatran‐treated patients with nonvalvular atrial fibrillation who presented with acute major bleeding to the ED. We searched electronic medical record databases cross‐referencing medication lists and hemorrhage International Classification of Diseases, Ninth Revision (ICD‐9) and ICD‐10 codes. We studied the resulting charts to yield confirmed nonvalvular atrial fibrillation in patients with an index event of major bleeding and at least 1 dose of dabigatran in the 5 preceding days. Results The electronic search yielded 284 cases, and we assessed 93 as ineligible, leaving 191 in the final cohort. Of these, 118 patients (62%) had gastrointestinal hemorrhage; 36 (19%) had intracranial hemorrhage, 8 (4%) of which were nontraumatic cases and 28 (15%) traumatic. Thirty‐six (19%) of the index events were in “other” locations and 1 (0.5%) “unknown.” There were 12 deaths (6%): 8 from patients presenting with gastrointestinal bleeding events, 2 from intracranial hemorrhage (both nontraumatic), and 2 from other. Although RBC and plasma transfusions were common, only 11 patients (6%) received purified coagulation factors. Conclusion Despite rare use of reversal strategies, mortality was low and outcomes were favorable, similar to reported outcomes from clinical trials, in this sample of patients with major bleeding while receiving dabigatran.