David E. Fosnocht

The use of etomidate for rapid-sequence intubation in the air medical setting.

Objective. To describe the use of etomidate for rapid-sequence intubation (RSI) in the air medical environment. Methods. This was a retrospective review of a consecutive series of patients receiving etomidate for RSI by a university hospital-based air medical program. Records of all patients more than 10 years of age requiring intubation during a 13-month period were reviewed. Data collected included demographics, site of intubation, person performing intubation, indication, diagnosis, medications administered, complications, and pre- and post-RSI vital signs. Results. Of 79 patients who underwent intubation, 53 (67%) received etomidate for RSI. Forty-two (79%) patients who received etomidate were also given succinylcholine. The overall intubation success rate was 96%. Two patients required a cricothyrotomy. Hemodynamic data were complete for 46 patients. The average systolic blood pressures (SBPs) were 139.11 ± 31.21 mm Hg prior to RSI and 137.85 ± 32.00 mm Hg after RSI. These were not significantly different (p = 0.82). The mean change in SBP was −1.26 ± 37.03 mm Hg (95% CI −6.61 to 4.09). The average heart rates (HRs) were 101.59 ± 23.95 beats/min prior to RSI and 97.76 ± 23.45 beats/min after RSI. These were also not significantly different (p = 0.15). The mean change in HR was −3.52 ± 15.67 beats/min (95% CI −5.79 to −1.26). Conclusion. This study supports the safety of etomidate for RSI in the air medical setting. The intubation success rate was comparable to those in other studies evaluating RSI. There was no significant change in average SBP or HR during RSI.

Effect of an airway education program on prehospital intubation

INTRODUCTION The purpose of this study was to determine the impact of an airway education program (AEP) on prehospital intubation. SETTING University-based air medical program METHODS Retrospective review of 372 consecutive intubations for 3 years before and 3 years after the institution of an AEP. Descriptive statistics were used and comparisons were made using chi-square analysis. RESULTS Intubation success rate was 170/180 (94%) for the preAEP group and 186/192 (97%) for the postAEP group (P > 0.05). Neuromuscular blockade (NMB) was used in 113/180 (63%) of preAEP intubations and 145/192 (76%) of postAEP intubations (P < 0.01). NMB without sedation decreased from 62/113 (55%) in the preAEP group to 12/145 (8%) in the postAEP group (P < 0.001). Cricothyrotomy rate decreased from 10/180 (6%) in the preAEP group to 3/192 (2%) in the postAEP group (P < 0.05). Failed intubation rate in nonarrested patients during the 6-year period was 10/154 (6%) in patients receiving no medications or partial rapid sequence intubation (RSI) compared with 3/184 (2%) in patients who had full RSI (P < 0.025). CONCLUSION Establishment of an AEP resulted in an increase in NMB for intubation, a dramatic decrease in the use of NMB without sedation, and a decrease in cricothyrotomy rate. The rate of intubation failure in nonarrested patients was higher in those who received no medications or partial RSI compared with full RSI.

Resolution of acute pain following discharge from the emergency department: the acute pain trajectory.

UNLABELLED We demonstrate and evaluate a method for modeling acute pain resolution in individual patients over 6 days following an emergency department visit for an acutely painful condition. Five hundred and thirteen patients presenting with acutely painful conditions provided 11-point numerical ratings of pain intensity at discharge from an emergency department and daily thereafter for a total of 6 days. Latent growth curve modeling with a linear fit yielded measures of initial pain intensity (intercept) and rate of pain resolution (slope) for each individual patient. The linear fits provided good approximations of individual pain trajectories. The average patient had intercept of 6.57 with a slope of -.61. On Day 4, 54.6% of patients reported a pain level equal to or greater than 4. Classification of individual patients by slope revealed that 79% of the sample had the expected negative slope for acute pain resolution while 21% had flat or positive slopes, indicating lack of pain resolution or worsening of pain over time following discharge. The standard errors of measurement for the acute pain trajectories were markedly smaller than those for conventional pain ratings, indicating that the trajectory approach to pain measurement improves measurement precision. PERSPECTIVE The acute pain trajectory provides more information than conventional pain measurement and increases measurement precision. It provides a means of determining the efficacy of acute pain management in the emergency department. The rate of pain resolution is a potentially valuable outcome measure for controlled clinical trials.

Geriatric Patients May Not Experience Increased Risk of Oligoanalgesia in the Emergency Department

STUDY OBJECTIVE The aim of this study is to compare the pain management practices in geriatric patients in the emergency department (ED) with that in other adult ED patients to determine whether these patients face increased risk of oligoanalgesia. METHODS This study was a prospective analysis of a convenience sample of patients presenting to an urban academic tertiary care hospital ED from 2000 through 2010. We compared patients aged 65 years and older (geriatric) with adults younger than 65 years and evaluated analgesic administration rates, opioid administration and dosing, and pain and satisfaction scores (0 to 10 scale). RESULTS A total of 15,387 patients presented to the ED during the 10-year study period and agreed to participate in the study; 1,169 patients were geriatric (7.6%). Geriatric patients had a mean age of 75.0 years (SD 7.2 years), whereas mean age of the 14,218 nongeriatric patients was 35.5 years (SD 12.2 years). Geriatric patients reported less pain at presentation (6.2 versus 6.9). After adjusting for presentation pain scores, geriatric patients were not less likely to receive an analgesic during the ED visit (odds ratio 0.90; 95% confidence interval 0.78 to 1.05) or less likely to receive an opioid (odds ratio 1.01; 95% confidence interval 0.87 to 1.18). Geriatric patients, on average, received lower doses of morphine (3.3 versus 4.2 mg) and had longer waiting times for their initial dose of an analgesic medication (65 versus 75 minutes). CONCLUSION Despite longer wait times for analgesia, geriatric and nongeriatric patients were similar in rates of analgesia and opioid administration for pain-related complaints. These findings contrast with previous studies reporting lower rates of analgesia administration among geriatric patients.

Anthrax threats: a report of two incidents from Salt Lake City.

The threat of anthrax as an agent of bioterrorism in the U.S. is very real, with 47 incidents of possible exposure involving 5664 persons documented by the Federal Bureau of Investigation over a 14-month period in 1998 and 1999. The highly visible and potentially devastating effects of these threats require a well-coordinated and well-organized Emergency Medical Services (EMS) and Emergency Department (ED) response to minimize panic and reduce the potential spread of an active and deadly biologic agent. This requires planning and education before the event. We describe the events of two anthrax threats in a major metropolitan area. The appropriate EMS and ED response to these threats is outlined.

Pain medication use before ED arrival

The objective of this study was to determine the frequency and types of pain medications taken before ED arrival based on pain intensity, duration of pain, chief complaint, gender, age, and race. A convenience sample of patients in pain was enrolled in this university hospital-based prospective, observational study. A total of 1233 patients were enrolled. Five hundred thirty-nine of 1233 (44%) patients took pain medication before arrival. Two hundred three (38%) took ibuprofen, 147 of 539 (27%) took oral opioids, and 135 of 539 (25%) took acetaminophen, which were the most frequently used medications. Severity of pain, age, duration of pain, and chief complaint were associated (chi-squared P <.05) with variations in prior medication use. Race and gender were not associated (chi-squared P >.05) with differences in medication use before arrival. Many patients (44%) take medication before arrival in the ED. Age, severity and duration of pain, as well as chief complaint are associated with differences in frequency of self-administered medication.

Prospective evaluation of the treatment of pain in the ED using computerized physician order entry

BACKGROUND Treatment of pain in the emergency department (ED) is a significant area of focus, as previous studies have noted generally inadequate treatment of pain in ED patients. Previous studies have not evaluated the impact of computerized physician order entry (CPOE) on the treatment of pain in the ED. We sought to evaluate treatment of pain before and after implementation of CPOE in an academic ED. METHODS We prospectively enrolled a convenience sample of patients presenting to the ED with a pain-related complaint in 4-month periods before and after CPOE implementation. We compared numbers who received pain medications, time from registration to administration of pain medication, and repeat dosing of pain medication. RESULTS Six hundred forty-six ED patients participated in the pre-CPOE period, whereas 592 patients participated post-CPOE. Similar numbers of patients received pain medications in the pre-CPOE and post-CPOE periods (55% vs 59%; P = .139), whereas those in the post-CPOE period were more likely to receive a repeat dose of pain medications (10.5% vs 17.6%; P < .001). CONCLUSION The use of CPOE in the ED may offer modest benefits in the treatment of patients with pain-related complaints.

Prospective, 10-year evaluation of the impact of Hispanic ethnicity on pain management practices in the ED☆☆☆★★★

INTRODUCTION Hispanic ethnicity has been reported as an independent risk factor for oligoanalgesia in the emergency department (ED). OBJECTIVES The objectives are to compare pain management practices in White and Hispanic patients in the ED to determine whether treatment differences exist. METHODS Prospective analysis of a convenience sample of patients presenting to an urban, academic, tertiary-care ED over the 10-year period from 2000 to 2010. We compared patients with pain-related complaints of any nature, who self-identified their race as White or Hispanic, and evaluated initial morphine administration/dosing, arrival/disposition pain scores, and overall ED satisfaction scores (0-10 scale). RESULTS Fifteen thousand sixty patients were enrolled. Eighty-one point 2 percent (n, 12 232) of the patients were White and 11.2% (n, 1680), Hispanic. White and Hispanic patients reported similar pain at presentation (6.7 vs 7.3, P < .001) and discharge/admission (4.6 vs 4.8, P = .14). Hispanic patients were not less likely to receive an analgesic during the ED visit (odds ratio, 1.06; confidence interval, 0.96-1.17; P = .62), nor less likely to receive an opioid analgesic (odds ratio, 0.97; confidence interval, 0.88-1.08; P = .70). Hispanic patients, on average, received similar initial doses of morphine (4.1 vs 4.3 mg, P = .29) and had similar wait times from arrival to initial dose of morphine (82 vs 86 minutes). Overall ED satisfaction scores were the same (8.7 vs 8.7, P = .65). CONCLUSION White and Hispanic patients were similar in rates of initial morphine administration for pain-related complaints. These findings contrast with previous studies reporting lower rates of initial analgesia administration among Hispanic patients in the ED.

Longitudinal Trends in the Treatment of Abdominal Pain in an Academic Emergency Department

BACKGROUND Abdominal pain is a top chief complaint of patients presenting to Emergency Departments (ED). Historically, uncertainty surrounded correct management. Evidence has shown adequate analgesia does not obscure the diagnosis, making it the standard of care. OBJECTIVE We sought to evaluate trends in treatment of abdominal pain in an academic ED during a 10-year period. METHODS We prospectively evaluated a convenience sample of patients in an urban academic tertiary care hospital ED from September 2000 through April 2010. Adult patients presenting with a chief complaint of abdominal pain were included in this study. Analgesic administration rates and times, pain scores, and patient satisfaction at discharge were analyzed to evaluate trends by year. RESULTS There were 2,646 patients presenting with abdominal pain who were enrolled during the study period. Rates of analgesic administration generally increased each year from 39.9% in 2000 to 65.5% in 2010 (p value for trend <0.001). Similarly, time to analgesic administration generally decreased by year, from 116 min in 2000 to 81 min in 2009 (p < 0.001). There was no improvement in mean pain scores at discharge by year (p = 0.27) and 48% of patients during the 10-year period still reported moderate to severe pain at discharge. Patient satisfaction with pain treatment increased from a score of 7.1 to 9.0 during the study period (p < 0.005), following the trend of increase in analgesic administration. CONCLUSIONS In patients presenting to the ED with abdominal pain, analgesia administration increased and time to medication decreased during the 10-year period. Despite overall improvements in satisfaction, significant numbers of patients presenting with abdominal pain still reported moderate to severe pain at discharge.

COMPARISON OFETOMIDATE ANDMIDAZOLAM FORPREHOSPITALRAPID-SEQUENCEINTUBATION

Objective. This study compares etomidate with midazolam for prehospital rapid-sequence intubation (RSI). Methods. The authors conducted a retrospective review of consecutive intubations at a university-based air medical program from January 1995 to December 2000. Exclusion criteria were patients not undergoing RSI, age <15 years, and incomplete chart data. Outcome measures included intubation success, incidence of hypotension, and percentage of change in heart rate (HR) and systolic blood pressure (SBP). Results. The intubation success rate was 110 out of 112 (98%) with etomidate, and 96 out of 97 (99%) with midazolam. Mean ages, patient gender distributions, and initial SBPs and HRs did not differ between the two groups. The mean dose of etomidate was 24 mg, the mean percentage of change in HR was −1% (95% confidence interval [CI], −6 to 4), and the mean percentage of change in SBP was 2% (95% CI, −3 to 7). The mean dose of midazolam was 3.5 mg, the mean percentage of change in HR was 1% (95% CI, −5 to 7), and the mean percentage change in SBP was 3% (95% CI, −3 to 9). The number of hypotensive episodes with etomidate (7 out of 74) compared with midazolam (3 out of 56) did not differ significantly (Fishers exact test, p = 0.51). Conclusion. Intubation success rate was very high with both etomidate (98%) and midazolam (99%). There was no statistically significant mean percentage of change in SBP or HR with either agent. The authors found a low incidence of hypotension with both agents, although the mean dose of midazolam used was considerably less than typically recommended for induction.