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Articles of interest in Annals of Emergency Medicine - May 2019

Sam Shahid, MBBS, MPH
Practice Management Manager, ACEP

ACEP would like to provide you with very brief synopses of the latest articles and articles coming soon to Annals of Emergency Medicine. Some of these have not appeared in print. These synopses are not meant to be thorough analyses of the articles, simply brief introductions. Before incorporating into your practice, you should read the entire articles and interpret them for your specific patient population.

Andolfatto G, Innes K, Dick W, Jenneson S, Willman E, Stenstrom R, Zed PJ4, Benoit G. Prehospital Analgesia With Intranasal Ketamine (PAIN-K): A Randomized Double-Blind Trial in Adults.

This randomized double-blind study compared use of intranasal ketamine with intranasal placebo in providing pain reduction at 30 minutes when added to usual paramedic care with nitrous oxide, for out-of-hospital patients with acute pain who reported a verbal numeric rating scale (VNRS) pain score greater than or equal to 5. The primary outcome was the proportion of patients with VNRS score reduction greater than or equal to 2 at 30 minutes. One hundred twenty subjects were enrolled and seventy-six percent of intranasal ketamine patients versus 41% of placebo patients reported a greater than or equal to 2-point VNRS reduction at 30 minutes (difference 35%; 95% confidence interval 17% to 51%). Median VNRS reduction at 15 minutes was 2.0 and 1.0 and at 30 minutes was 3.0 and 1.0 for ketamine and placebo, respectively. The study concluded that added to nitrous oxide, intranasal ketamine provides clinically significant pain reduction and improved comfort compared with intranasal placebo, with more minor adverse events. Full text available here

Sampson FC, Goodacre SW, O'Cathain A. The Reality of Pain Scoring in the Emergency Department: Findings From a Multiple Case Study Design.

In this study, the authors utilized naturalistic, qualitative methods to understand how pain scores are used in practice and the mechanisms by which pain scoring may influence pain management. They undertook a multiple case study design, using qualitative research in 3 EDs in England (the cases) and incorporated 143 hours of nonparticipant observation, documentary analysis, and semi structured interviews with 36 staff and 19 patients. The analysis identified that ED staff used the pain score for 2 conflicting purposes: as an auditable tool for guiding patient management and as a tool for monitoring patient experience. This led to ED staff's facing conflict between reporting their own judgment of what the pain score ought to be and what the patient said it was. The authors found that in practice, pain scoring may not accurately reflect patient experience and that using pain scoring to determine the appropriateness of triage and treatment decisions reduces its validity as a measure of patient experience. They concluded that pain scoring should not be central to audit and systems of accountability for pain management. Full text available here

Probst MA, Su E, Weiss RE, Yagapen AN, Malveau SE, Adler DH, Bastani A, Christopher W. Baugh CW, Caterino JM, Clark CL, Diercks DB, Hollander JE, Bret A. Nicks BA, Nishijima DK, MD, Shah MN, Stiffler KA, Storrow AB, Wilber ST, Sun BC. Clinical Benefit of Hospitalization for Older Adults with Unexplained Syncope: A Propensity-Matched Analysis.

In order to determine whether hospitalization versus outpatient management for older adults with unexplained syncope was associated with a reduction in post-disposition serious adverse events at 30 days, the authors performed a propensity score analysis using data from a prospective, observational study of older adults with unexplained syncope/near-syncope who presented to 11 emergency departments (ED). The study enrolled 2,492 adults (≥60 years) who presented with syncope/near-syncope and no serious ED diagnosis from April, 2013 to September, 2016. Mean age was 73 years and 51% were female. The incidence of serious adverse events within 30 days after the index visit was 7.4% for hospitalized patients and 3.19% for discharged patients. After propensity score matching on risk of hospitalization, there was no statistically significant difference in serious adverse events at 30 days between the hospitalized group and the discharged group and the authors concluded that hospitalization was not associated with improvement in 30-day serious adverse event rates.

Berg LM, Ehrenberg A, Florin J, Östergren J, Discacciati A, Göransson KE. Associations between crowding and 10-day mortality among patients allocated lower triage acuity levels without need of acute hospital care upon departure from the emergency department.

In order to describe the association between emergency department (ED) crowding and 10-day mortality for patients triaged to lower triage acuity levels at ED arrival and without need of acute hospital care upon ED departure, the authors conducted a registry study based on ED visits with all patients ≥18 years with triage acuity levels 3–5 and without need of acute hospital care upon ED departure during 2009–2016 (n=705,699). The sample was divided into patients surviving (n=705,076) or dying (n=623) within 10 days. The results of the study showed that the 10-day mortality rate was 0.09 % (n=623). The event group had larger proportions of patients ≥80 years (51.4% vs. 7.7%), triaged with acuity level 3 (63.3% vs. 35.6%), and greater co-morbidity (ACCI median IQR 6 vs. 0). They also observed an increased 10-day mortality for patients with a mean ED LOS ≥8 vs. <2 hours. The authors concluded that patients triaged to lower triage acuity levels when arriving to the ED and without need of acute hospital care upon departure from the ED had higher 10-day mortality when the mean ED LOS exceeded 8 hours and when ED occupancy ratio increased.

Weiner SG, Olesya B, Bernson D, Schuur JD. One Year Mortality of Patients after Emergency Department Treatment for Nonfatal Opioid Overdose

In order to determine the one-year mortality of patients who were treated for a non-fatal opioid overdose in Massachusetts emergency departments the authors of this study conducted a retrospective observational study of patients from three linked statewide Massachusetts datasets: a master demographics list, an acute care hospital case mix database, and death records. Patients discharged from the emergency department (ED) with a final diagnosis of opioid overdose were included and the primary outcome measure was death from any cause within one year of overdose treatment. During the study period, 17,241 patients treated for opioid overdose. Of the 11,557 who met study criteria, 635 (5.5%) died within one year, 130 (1.1%) died within one month and 29 (0.25%) died within 2 days. The authors concluded that the short-term and one-year mortality of patients treated in the ED for non-fatal opioid overdose is high, with the first month, and particularly the first two days after overdose, being the highest risk period. They added that patients who survive opioid overdose should be considered high risk and receive interventions such as offering buprenorphine, counseling and referral to treatment prior to ED discharge.

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