Michael A. Turturro

Intramuscular Ketorolac Versus Oral Ibuprofen in Acute Musculoskeletal Pain

STUDY OBJECTIVE To evaluate the efficacy of IM ketorolac versus that of oral ibuprofen in acute musculoskeletal pain. DESIGN Randomized, prospective, double-blind clinical trial. SETTING Urban teaching emergency department with an annual census of 43,000. PARTICIPANTS Convenience sample of 82 patients aged 18 to 70 years with acute musculoskeletal pain due to trauma. INTERVENTIONS Forty-two subjects each received 60 mg ketorolac by IM injection and ingested a placebo capsule. Forty subjects each ingested 800 mg ibuprofen and received a placebo (saline) IM injection. Pain was evaluated with a 100-mm visual analog scale at baseline and 15, 30, 45, 60, 75, 90, and 120 minutes after dosing. The prevalence of side effects was elicited in each patient. RESULTS Mean pain scores improved in each group during the course of the study but did not significantly differ between groups at baseline or at any subsequent interval. The numbers of dropouts due to inadequate analgesia and prevalence of side effects in the two groups did not differ significantly. CONCLUSION IM ketorolac and oral ibuprofen provide comparable analgesia in ED patients with acute musculoskeletal pain.

Tramadol Versus Hydrocodone-Acetaminophen in Acute Musculoskeletal Pain: A Randomized, Double-Blind Clinical Trial

STUDY OBJECTIVE To evaluate the efficacy of an oral tramadol preparation versus that of an oral hydrocodone-acetaminophen preparation in acute musculoskeletal pain. METHODS A randomized, prospective, double-blind clinical trial was conducted in an urban teaching emergency department with an annual census of 41,000. Participants comprised a convenience sample of 68 adult ED patients with acute musculoskeletal pain caused by minor trauma. Thirty-three patients received tramadol (100 mg), and 35 patients received hydrocodone-acetaminophen (5 mg hydrocodone with 500 mg acetaminophen). The drugs were prepared in identical-appearing capsules. Pain was evaluated by a 100-mm visual analog scale (VAS) at baseline and at 30, 60, 90, 120, and 180 minutes after dosing. VAS scores were analyzed by 2-way repeated-measures ANOVA, and nominal data were analyzed by Fishers exact test. RESULTS Mean pain scores did not differ at baseline (tramadol, 68.3+/-21.8; hydrocodone-acetaminophen, 69.1+/-17.8; P=NS) but were significantly lower in the hydrocodone-acetaminophen group beginning at 30 minutes through 180 minutes. There were 6 dropouts as a result of reported inadequate analgesia, 3 in each group (P=NS). The discharge diagnoses and prevalence of side effects did not differ significantly between groups. CONCLUSION Tramadol provides inferior analgesia to hydrocodone-acetaminophen in ED patients with acute musculoskeletal pain.

Hydrocodone versus codeine in acute musculoskeletal pain

STUDY OBJECTIVES To evaluate the efficacy and prevalence of side effects of hydrocodone versus codeine in acute pain syndromes. TYPE OF PARTICIPANTS/SETTING: Sixty-two consecutive adult emergency department patients 18 to 70 years old with acute musculoskeletal pain. Patients using other analgesics or having any contraindication to opioid therapy were excluded. In addition, 12 patients were excluded because of insufficient data or study dropout. DESIGN/INTERVENTIONS In a randomized, double-blind prospective manner, patients received either 5 mg hydrocodone with 500 mg acetaminophen or 30 mg codeine with 500 mg acetaminophen to take on discharge from the ED and every four hours thereafter as needed for pain. MEASUREMENTS Pain intensity was evaluated by a visual analog scale at zero, one, two, four, eight, 24, and 48 hours. Specific side effects were sought, along with the number of patients reporting inadequate analgesia. MAIN RESULTS Data were obtained on 50 subjects (25 per group). Mean and median pain scores did not differ significantly at time zero (x vs y, 6.03 vs 5.99 and 6.8 vs 6.1, respectively) or subsequent intervals. Side effects were noted in eight hydrocodone/acetaminophen and 18 codeine/acetaminophen patients (P = .005). No significant differences in gastrointestinal side effects were reported; however, less nausea or vomiting was reported in the hydrocodone group (P = .23). Central nervous system side effects (sedation or lightheadedness) were reported in six hydrocodone/acetaminophen patients compared with 16 codeine/acetaminophen patients (P less than .005). In addition, no hydrocodone/acetaminophen patients reported inadequate analgesia compared with six codeine/acetaminophen patients (P less than .05). CONCLUSION Although pain scores were not significantly different, hydrocodone may be a more effective analgesic than codeine in acute musculoskeletal pain, as demonstrated by significantly fewer treatment failures. Central nervous system side effects are less common with hydrocodone than with codeine.

Pain, priorities, and prehospital care.

reason for patients to seek emergency care, and annually accounts for approximately

Oral narcotic analgesics. Choosing the most appropriate agent for acute pain.

100 billion in direct medical costs and lost productivity in the United States. Given these staggering statistics, it should follow that emergency care providers are proficient in providing effective pain management. Unfortunately, this is not the case. Several emergency department (ED) studies have shown insufficient treatment of pain in ED patients, from lack of analgesic administration,1–3 excessive delays in administration,1,4 underestimation of pain,5,6 and inadequate dosing of analgesic agents.4,7 Patients most at risk for not receiving analgesics are children,2,8 the elderly,9 and African American and Hispanic patients.10,11 This phenomenon, termed “oligoanalgesia,” has been pervasive and has its roots in medical training of physicians, nurses, ancillary staff, and out-ofhospital providers. Why are we so stingy? The assessment and management of pain are often inadequate since many practitioners have had little to no formal training in pain management. Many have learned behaviors in managing pain from copying the habits of their predecessors, who may have likewise poorly understood the appropriate management of pain. Medical training emphasizes searching for a diagnosis and instituting diagnosis-specific treatment, not managing symptoms while the search for a diagnosis is made. Many fear that relieving pain while searching for a diagnosis will mask the ability to make the diagnosis, despite any evidence to support this phenomenon. Studies have demonstrated that physicians and nurses typically underestimate the amount of pain experienced by patients,5,6,12,13 and by the sheer nature of working with patients in pain become desensitized to the suffering that patients endure. Many have seen and treated those with abuse problems and consequently are irrationally concerned about abuse and addiction to opioid analgesics in all patients suffering from acute pain.14 Many fear government retaliation for the use of opioid analgesics for acute pain, despite that regulatory agencies do not discipline practitioners for appropriate use of opioid medications for pain. In this issue of Prehospital Emergency Care, McLean et al.15 estimate that a minimum of 4.9 million patients transported to hospitals via ambulance in 1999 were suffering from pain. They appropriately state that this is a conservative estimate since opioid analgesics were also administered to an additional 13% of 7.6 million patients in whom no pain was reported, accounting for nearly an additional 1 million patients. Additionally, since pain was not recorded until the time of ED arrival, emergency medical services (EMS) interventions to relieve pain could have resulted in underreporting. Since this estimate does not include patients in whom analgesic administration was withheld or refused, the number of patients transported suffering from acute pain is undoubtedly higher. What impact could we have made in the field on these 6 million patients who accounted for a considerable proportion of all ED visits in 1999? Since analgesics were given to only 21% of those in whom moderate to severe pain was recorded, this would indicate that oligoanalgesia is at least as prevalent in the out-ofhospital environment as well as within the hospital. While we may be very effective in treating chest pain due to coronary ischemia in the field, how effective are we in treating other types of pain? McEachin et al.16 reported that only a minority (18.3%) of adult patients transported by EMS to their hospital over a four-month period with lower-extremity or hip fractures received any prehospital analgesics, although most did receive analgesia in the ED. Considering that multiple trauma patients were excluded, it would appear that the majority of these patients could have benefited from prehospital analgesia. Their results also suggest that older patients PAIN, PRIORITIES, AND PREHOSPITAL CARE

Contact lens complications

Narcotic analgesics are the most effective oral agents available for treatment of acute pain. A familiarity with the salient characteristics of the various agents enables physicians to choose the most effective one for use in the outpatient setting.

Acute Coronary Syndrome Screening and Diagnostic Practice Variation

Contact lens wearers who develop complications related to their lens use are likely to present to emergency departments for care. The pathophysiology of contact lens complications is outlined, and clinical presentations of various conditions related to both soft and hard lens wear are summarized. Guidelines for emergency department management are suggested.

Cyclobenzaprine with ibuprofen versus ibuprofen alone in acute myofascial strain: A randomized, double-blind clinical trial

BACKGROUND In the absence of the existing acute coronary syndrome (ACS) guidelines directing the clinical practice implementation of emergency department (ED) screening and diagnosis, there is variable screening and diagnostic clinical practice across ED facilities. This practice diversity may be warranted. Understanding the variability may identify opportunities for more consistent practice. METHODS This is a cross-sectional clinical practice epidemiology study with the ED as the unit of analysis characterizing variability in the ACS evaluation across 62 diverse EDs. We explored three domains of screening and diagnostic practice: 1) variability in criteria used by EDs to identify patients for an early electrocardiogram (ECG) to diagnose ST-elevation myocardial infarction (STEMI), 2) nonuniform troponin biomarker and formalized pre-troponin risk stratification use for the diagnosis of non-ST-elevation myocardial infarction (NSTEMI), and 3) variation in the use of noninvasive testing (NIVT) to identify obstructive coronary artery disease or detect inducible ischemia. RESULTS We found that 85% of EDs utilize a formal triage protocol to screen patients for an early ECG to diagnose STEMI. Of these, 17% use chest pain as the sole criteria. For the diagnosis of NSTEMI, 58% use intervals ≥4 hours for a second troponin and 34% routinely risk stratify before troponin testing. For the diagnosis of noninfarction ischemia, the median percentage of patients who have NIVT performed during their ED visit is 5%. The median percentage of patients referred for NIVT in hospital (observation or admission) is 61%. Coronary CT angiography is used in 66% of EDs. Exercise treadmill testing is the most frequently reported first-line NIVT (42%). CONCLUSION Our results suggest highly variable ACS screening and clinical practice.