F. Fiesseler

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.

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.

Care plans reduce ED visits in those with drug-seeking behavior☆

UNLABELLED Patients with drug-seeking behavior can be both labor and resource intensive to the emergency department (ED). OBJECTIVE To determine the effectiveness of ED care plans for individuals at high risk for drug-seeking behavior on ED visits. METHODS A retrospective, cohort observational study. LOCATION A suburban teaching hospital with an annual census of 80,000 patients. The number of ED visits was determined 1 year before and 2 subsequent years following care plan initiation. EXCLUSION CRITERIA Unclaimed letter, incomplete data, and/or non-drug-seeking care plan. STATISTICS Two-tailed Wilcoxon signed-rank test with significance of P < .05. RESULTS Sixty patients were enrolled and 7 were excluded, leaving 53 patients for analysis. Mean annual visits before care plan initiation were 7.6 (95% confidence interval [CI], 6.3-9.1). One year following implementation, mean visits decreased to 2.3 (95% CI, 1.5-3.1) (P ≤ .0001). Two years following implementation, mean visits continued to decline to 1.5 (95% CI, 0.9-2.1) (P ≤ .0001). A significant reduction in visits occurred 1 and 2 years following care plan implementation. CONCLUSIONS Emergency department care plans are an effective method to reduce ED visits in those with drug-seeking behavior.

Carbon Monoxide Exposure Associated with High-risk Features and Intentional Exposure are Infrequently Treated with Hyperbaric Oxygen

Data is conflicting regarding the management of carbon monoxide (CO) poisoned patients. Objective: To determine the emergency department management (ED) of intentional CO poisoned patients regarding hyperbaric oxygen therapy (HBO2), compared to those who are unintentionally exposed. Methodology Design: A multi-center retrospective emergency department cohort study. Population: Consecutive patients presenting to 23 Northeastern United States hospital emergency departments, comprising academic, non-academic, urban, suburban, and rural hospitals with the International Classification of Disease primary diagnosis of “toxic effects CO”. Patients were “a priori” divided into intentional/unintentional and “high-risk” (syncope, serum carboxyhemoglobin level ≥ 20%, change in mental status, cardiac arrest, and/or seizures) or “low-risk” (without the above). Results: “Toxic effects of CO” was diagnosed in 1136 patients, 1026 charts were available for analysis and 52 (4.8%) met inclusion criteria as intentional.Mean age was 40 years (standard deviation (SD) ± 13), for intentional patients. Overall, high risk intoxication was reported in 12% (N = 124/1026) of patients, compared to 50% (N= 26/52) of the intentional patients (p ≤ 0.0001). Mean overall CO level was 7%, compared to an intentional rate of 17% (p ≤ 0.0001). Fifty percent of intentionally exposed high-risk patients received HBO2, while only 36% (N = 45/124) of high-risk patients overall did (p = 0.27). Conclusions: Carbon monoxide poisoned patients with intentional exposures and high-risk clinical features are not more likely to receive HBO2.