Paul Dominici

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 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.

Routine Packing of Simple Cutaneous Abscesses Is Painful and Probably Unnecessary

OBJECTIVES The objective was to determine whether the routine packing of simple cutaneous abscesses after incision and drainage (I&D) confers any benefit over I&D alone. METHODS In a prospective, randomized, single-blinded trial, subjects with simple cutaneous abscesses (less than 5 cm largest diameter) underwent incision, drainage, irrigation, and standard abscess preparation in the usual manner. Subjects were then randomized to either packing or no-packing. Visual analog scales (VAS; 100 mm) of pain were recorded in the emergency department (ED). All patients received trimethoprim-sulfamethoxazole (TMP-SMX), ibuprofen, and narcotic prescriptions, recorded twice daily VAS pain scores, and returned in 48 hours at which time dressings and packing, if present, were removed and a physician blinded to the randomization and not part of the initial visit repeated measurements and determined the need for further intervention. RESULTS Forty-eight subjects were included in the final analysis. There were no significant differences in age, sex, abscess location, or initial pain scores between the two groups. There was no significant difference in need for a second intervention at the 48-hour follow-up between the packed (4 of 23 subjects) and nonpacked (5 of 25 subjects) groups (p = 0.72; relative risk = 1.3, 95% confidence interval [CI] = 0.4 to 4.2). Patients in the group that received packing reported higher pain scores immediately postprocedure (mean difference = 23.8 mm; p = 0.014, 95% CI = 5 to 42 mm) and at 48 hours postprocedure (mean difference = 16.4 mm; p = 0.03, 95% CI = 1.6 to 31.2 mm), as well as greater use of ibuprofen (mean difference = 0.32; p = 0.12, 95% CI = -1.4 to 2.0) and oxycodone/acetaminophen (mean difference = 2.19; p = 0.03, 95% CI = 0.2 to 4.1). CONCLUSION In this pilot study, not packing simple cutaneous abscesses did not result in any increased morbidity, and patients reported less pain and used fewer pain medications than packed patients.

Two Days of Dexamethasone Versus 5 Days of Prednisone in the Treatment of Acute Asthma: A Randomized Controlled Trial

STUDY OBJECTIVE Dexamethasone has a longer half-life than prednisone and is well tolerated orally. We compare the time needed to return to normal activity and the frequency of relapse after acute exacerbation in adults receiving either 5 days of prednisone or 2 days of dexamethasone. METHODS We randomized adult emergency department patients (aged 18 to 45 years) with acute exacerbations of asthma (peak expiratory flow rate less than 80% of ideal) to receive either 50 mg of daily oral prednisone for 5 days or 16 mg of daily oral dexamethasone for 2 days. Outcomes were assessed by telephone follow-up. RESULTS Ninety-six prednisone and 104 dexamethasone subjects completed the study regimen and follow-up. More patients in the dexamethasone group reported a return to normal activities within 3 days compared with the prednisone group (90% versus 80%; difference 10%; 95% confidence interval 0% to 20%; P=.049). Relapse was similar between groups (13% versus 11%; difference 2%; 95% confidence interval -7% to 11%, P=.67). CONCLUSION In acute exacerbations of asthma in adults, 2 days of oral dexamethasone is at least as effective as 5 days of oral prednisone in returning patients to their normal level of activity and preventing relapse.

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.

Immunization histories given by adult caregivers accompanying children 3-36 months to the emergency department: Are their histories valid for the Haemophilus influenzae B and pneumococcal vaccines?

Objective: To obtain immunization histories from adult caregivers accompanying children to the emergency department (ED), to determine the accuracy of the caregivers report for the Haemophilus influenzae B (Hib)and 7-valent pneumococcal vaccine (PCV7). Methods: This was a prospective, observational study of children age 3 to 36 months presenting to the Albert Einstein Medical Center ED during the period of November 1, 2004, through January 31, 2005. Caregivers were asked to complete a questionnaire about their childs immunization status and if the childs vaccinations were up-to-date. Immunization records were obtained from the childs most recent primary care physician (PCP) to determine whether the caregivers report was correct for PCV7 and Hib. Children were considered delayed if they were more than 30 days past due date for one or both vaccines according to the PCP records. Results: Of 205 PCP offices contacted, we were able to obtain 173 immunization records for our analysis. Examination of vaccine records showed that 109 (63.0%) of the 173 children were up-to-date on both immunizations. When the childs caregiver was asked if shots were up-to-date, 159 (91.9%) of 173 said that all shots were given, and only 14 (8.1%) of 173 reported being behind schedule. Of the adults reporting the child up to date, 105 (66.0%) of the 159 children were confirmed to be up-to-date. Thus, 34.0% of caregivers were incorrect in stating that their childs immunization status was up-to-date for both these vaccines. Conclusions: Caregiver report was determined to be inaccurate for Hib and PCV7. Despite 91.5% of caregivers stating that shots were up-to-date, only 66.0% were correct that their child was up-to-date with these 2 vaccines. The ED physician should use caution in making clinical decisions based on the history given by a caregiver regarding their childs immunization status.

Double-blind, Randomized, Placebo-controlled Study Evaluating the Use of Platelet-rich Plasma Therapy (PRP) for Acute Ankle Sprains in the Emergency Department.

BACKGROUND Over 23,000 people per day require treatment for ankle sprains. Platelet-rich plasma (PRP) is an autologous concentration of platelets that is thought to improve healing by promoting inflammation through growth factor and cytokine release. Studies to date have shown mixed results, with few randomized trials. OBJECTIVES To determine patient function among patients randomized to receive standard therapy plus PRP, compared to patients who receive standard therapy plus sham injection (placebo). METHODS Prospective, randomized, double-blinded, placebo-controlled trial. Patients with severe ankle sprains were randomized. Severity was graded on degree of swelling, ecchymosis, and ability to bear weight. PRP with lidocaine and bupivacaine was injected at the point of maximum tenderness by a blinded physician under ultrasound guidance. The control group was injected in a similar fashion with sterile 0.9% saline. Both groups had visual analog scale (VAS) pain scores and Lower Extremity Functional Scale (LEFS) on days 0, 3, and 8. LEFS and a numeric pain score were obtained via phone call on day 30. All participants were splinted, given crutches, and instructed to not bear weight for 3 days; at this time patients were reevaluated. RESULTS There were 1156 patients screened and 37 were enrolled. Four withdrew before PRP injection was complete; 18 were randomized to PRP and 15 to placebo. There was no statistically significant difference in VAS and LEFS scores between groups. CONCLUSION In this small study, PRP did not provide benefit in either pain control or function over placebo.

Case Series of Overdosed Patients Managed in an Observation Unit

Background: Observation units (OU) are an increasing aspect of hospitals in the United States. OU provide more efficient use of resources in an increasingly taxed healthcare system. The majority of poisoned patients’ medical issues resolve within 24 hours, making them ideal candidates for an OU. The purpose of this study was to examine the types and safety of overdoses placed in our OU at Einstein Medical Center Philadelphia, an urban, level one trauma center with 100,000 emergency department (ED) visits annually in Philadelphia, Pennsylvania. We hypothesized that the majority of patients admitted to the OU do not require further medical intervention or upgrading to a higher level of care. Methods: The study is a retrospective chart review of patients with ICD-9 codes associated with overdose or poisoning admitted to our OU between 7/1/10 and 12/31/12. A total of 137 patients were identified, 112 were included. Exclusions were: admission to the hospital prior to transfer to OU (17); transfer to psychiatry (4); miscoded (2); and seen at another site (2). Research associates, reviewed medical charts using a structured data collection form to record disposition, age, gender, etnicity, ingested substances, mental status, medical interventions and any upgrades in disposition. Results: Between 7/1/10 and 12/31/12 there were 112 patients admitted to the OU. Patient’s age ranged from 17 to 76 years old (mean 38), with 46 males (41%) and 66 females (59%). Ethnicity was mostly African American 73 (65%). A total of 230 different substances were recorded with 61 (26.5%) patients taking more than one intoxicant. The most common overdoses were sedative- hypnotics 66 (28.7%) and antipsychotics 22 (9.6%). Initial OU mental status recorded was: alert and oriented to person, place and time 60 (54%); 46 (41%) sedated, and 6 (5%) confused. The most common medical interventions in the ED were sedatives 18 (16%) and naloxone 12 (10.7%). The most common medical interventions in the OU were: sedatives 24 (21.4%); oxygen 10 (8.9%); and naloxone 5 (4.5%). No intubations or cardiac arrests occurred in the ED or OU. No patients were upgraded to a higher level of care. Seven patients were transferred to psychiatry. Conclusions: The disposition of stable patients to an OU who present to the ED after overdoses appears to be safe. Understanding the types of overdoses that are safe to be managed in an OU can assist in disposition, patient flow, use of resources, and provide appropriate level of care.

Eye Irrigation is More Comfortable With a Lidocaine: Containing Irrigation Solution Compared With Normal Saline

BACKGROUND Is eye irrigation with a Morgan lens more comfortable with a lidocaine-containing solution compared with standard saline? METHODS Prospective randomized double-blind volunteer placebo controlled study. Subjects received two drops of 2% tetracaine in each eye. Morgan lenses were applied to each eye and connected to separate 1-L bags of room temperature 0.9% saline. Subjects were randomized to continuous irrigation with 0.01% lidocaine solution (10 mL of 1% lidocaine [100 mg] in 1 L saline) in either the right or left eye with the opposite eye serving as control. pH was measured and fluid flow rate set at 35 mL/min. Blinded interviewers asked the subjects at 5 minutes intervals to rate their discomfort on a five-point Likert scale. Differences in mean Likert scores and standard deviation at 5, 10, 15, 20, and 25 minutes in each eye were calculated. Data were analyzed using one-way analysis of variance and the Bonferroni (BON) multiple comparison test (paired sample t test). RESULTS One-way analysis of variance p value for the combined time sets was very significant (<0.0001). The difference in mean Likert scores for 5 minutes was not statistically significant; approached statistical significance at 10 minutes and were very significant at 15 minutes {1.22 [95% confidence interval (CI) 0.16-2.28]; BON 3.02}, 20 minutes [1.44 (95% CI 0.38-2.5); BON 3.57], and 25 minutes [1.55 (95% CI 0.62-2.88); BON 4.09]. There were no reported long-term adverse effects. CONCLUSIONS Continuous irrigation of the eye with a lidocaine-saline solution and a Morgan lens causes less discomfort than saline alone in healthy volunteers.

A modified goldfrank sniffing bar improves accuracy in identifying simulated toxins in a case-based teaching model

ObjectiveTo determine if olfactory analysis of toxin proxies aid in the identification of poisons when compared to case histories alone. Methods: A convenience sample of 42 emergency medicine residents participated in a prospective single-blind observational study using a sniffing bar designed with the technique described by Goldfrank et.al. Each subject received 12 written cases describing a patient with a chemical exposure. Ten chemicals with odors corresponding to a specific case history and 2 chemical case controls with no odor comprised the sniffing bar. Each subject was asked to identify the toxin first by reading the case history alone, then again after smelling the corresponding odor. All subjects were asked to record their level of confidence for each case before and after the addition of the sniffing bar using a 5-point Likert scale. Percentages correct before and after the sniffing bar intervention were calculated and two-tailed p-values and 95% confidence intervals were measured. Continuous comparative variables such as the means of the Likert scale confidence measurements were analyzed with the two-tailedt-test. Results: Median percentage of toxins correctly identified was 64.3% (range 9.5–97.6) when based on case description alone and 86.9% (range 9.5–95.2) with addition of the sniffing bar. The percentage of initially incorrect identification reversed after additional data provided by the sniffing bar was 11.5% (range 0–14). Of the 10 actual toxins, correct identification of 6 achieved statistical significance after introduction of the sniffing bar (p = 0.0017; 95% CI 4.6–11.4). There was no association between level of training and improved accuracy with use of the sniffing bar, and overall confidence did not improve significantly after addition of the sniffing bar. Conclusion: Diagnostic accuracy of poisons in case-based scenarios is improved with the use of a sniffing bar. The sniffing bar is a useful adjunct to a traditional case-based emergency medicine toxicology teaching curriculum.