Emergency medicine updates: Droperidol.

INTRODUCTION: Droperidol is a butyrophenone that has recently been reintroduced after a United States Food and Drug Administration (US FDA) black box warning in 2001. Evidence demonstrates utility in a variety of clinical conditions. OBJECTIVE: This paper provides evidence-based updates concerning the use of droperidol for the emergency clinician. DISCUSSION: Droperidol received a black box warning by the US FDA in 2001 due to concerns for QT prolongation and torsades de pointes; however, reevaluation of the available data suggests droperidol is a safe and efficacious medication. It can be used in the emergency department (ED) setting for many conditions, including acute agitation, headaches, vertigo, nausea, and vomiting. Extensive literature supports that the QT-prolonging effects are transient and that the risk of torsades de pointes is rare with doses utilized in the ED. An electrocardiogram does not need to be routinely obtained before droperidol use but should be considered in patients at high risk for QT prolongation. CONCLUSIONS: Current evidence suggests that droperidol is a safe and effective medication for treating nausea and vomiting, headache, vertigo, and agitation in the ED setting.

Essential pharmacologic options for acute pain management in the emergency setting.

Pain is the root cause for the overwhelming majority of emergency department (ED) visits worldwide. However, pain is often undertreated due to inappropriate analgesic dosing and ineffective utilization of available analgesics. It is essential for emergency providers to understand the analgesic armamentarium at their disposal and how it can be used safely and effectively to treat pain of every proportion within the emergency setting. A 'balanced analgesia' regimen may be used to treat pain while reducing the overall pharmacologic side effect profile of the combined analgesics. Channels-Enzymes-Receptors Targeted Analgesia (CERTA) is a multimodal analgesic strategy incorporating balanced analgesia by shifting from a system-based to a mechanistic-based approach to pain management that targets the physiologic pathways involved in pain signaling transmission. Targeting individual pain pathways allows for a variety of reduced-dose pharmacologic options - both opioid and non-opioid - to be used in a stepwise progression of analgesic strength as pain advances up the severity scale. By developing a familiarity with the various analgesic options at their disposal, emergency providers may formulate safe, effective, balanced analgesic combinations unique to each emergency pain presentation.

'SCALD-ED' Block: Superficial Cutaneous Anesthesia in a Lateral Leg Distribution within the Emergency Department - A Case Series.

BACKGROUND: In the midst of a nationwide opioid epidemic, focus has been placed on identifying and utilizing safe, effective opioid-free analgesic alternatives. Lower-extremity peripheral nerve blockades are common and often involve both motor and sensory anesthesia, resulting in leg weakness and ambulatory difficulty. The aim of this case report is to describe an ultrasound-guided peripheral nerve block technique (superficial cutaneous anesthesia in a lateral (leg) distribution within the emergency department ['SCALD-ED' block]) that provides motor-sparing, purely sensory anesthesia after a superficial injury to the lateral leg in patients presenting to the emergency department. DISCUSSION: Two separate patients presenting with lateral leg pain after superficial injury (burn, cellulitis) reported continued breakthrough pain despite a standard analgesic modality of combination acetaminophen and ibuprofen. With the patient placed in prone position for ultrasound-guided access to lower-extremity nerve branches, the lateral sural cutaneous nerve (LSCN) was identified by tracing its pathway from the proximal sciatic nerve to the common peroneal (fibular) nerve to the superficial peroneal (fibular) nerve. Five mL of lidocaine (1%, with epinephrine) was injected along the superficial LSCN route for anesthetic blockade. Temporal assessments of anesthetic effect and pain improvement, and monitoring of motor or ambulatory impairment were conducted at regular intervals to assess the efficacy and feasibility of the blockade. Regional anesthesia along the LSCN sensory distribution was experienced at 7-9 min post blockade. Peak analgesic effect was experienced at 25-29 min. The duration of anesthesia was 120-150 min. A negligible amount of delayed sensory anesthesia was noted along the distal sural nerve distribution. No motor deficit, ambulatory difficulty, or adverse effects were experienced in either patient post blockade. CONCLUSION: The LSCN is an identifiable target under ultrasound guidance, susceptible to localized, purely sensory blockade of pain from superficial cutaneous lateral leg injuries.

Utilization of Ocular Ultrasound in the Evaluation of Posterior Reversible Encephalopathy Syndrome: A Case Report.

Posterior reversible encephalopathy syndrome (PRES) is an infrequently encountered cause of altered mental status and seizure activity in the emergency setting. Diagnosis is often delayed by extensive testing and failure to consider PRES in the differential. Though MRI remains the gold standard for diagnosis, ultrasound-guided measurement of intra-ocular pressure is a safe, effective alternative that can expedite the diagnosis. The treatment of PRES involves the rapid reversal of offending agents and aggressive blood pressure management. The prognosis of PRES is favorable and neurologic sequelae are uncommon. This clinical case highlights the importance of the emergency physicians' consideration of this pathology and the utilization of ultrasound as a non-invasive means of assessing intra-ocular pressure.

Approach to buprenorphine use for opioid withdrawal treatment in the emergency setting.

INTRODUCTION: Opioid use disorder (OUD) is increasing in prevalence throughout the world, with approximately three million individuals in the United States affected. Buprenorphine is a medication designed, researched, and effectively used to assist in OUD recovery. OBJECTIVE: This narrative review discusses an approach to initiating buprenorphine in the emergency department (ED) for opioid-abuse recovery. DISCUSSION: Buprenorphine is a partial mu-opioid receptor agonist with high affinity and low intrinsic activity. Buprenorphine's long half-life, high potency, and 'ceiling effect' for both euphoric sensation and adverse effects make it an optimal treatment alternative for patients presenting to the ED with opioid withdrawal. While most commonly provided as a sublingual film or tablet, buprenorphine can also be delivered via transbuccal, transdermal, subdermal (implant), subcutaneous, and parenteral routes. Prior to ED administration, caution is recommended to avoid precipitation of buprenorphine-induced opioid withdrawal. Following the evaluation of common opioid withdrawal symptoms, a step-by-step approach to buprenorphine can by utilized to reach a sustained withdrawal relief. A multimodal medication-assisted treatment (MAT) plan involving pharmacologic treatment, as well as counseling and behavioral therapy, is essential to maintaining opioid remission. Patients may be safely discharged with safe-use counseling, close outpatient follow-up, and return precautions for continued management of their OUD. Establishing a buprenorphine program in the ED involves a multifactorial approach to establish a pro-buprenorphine culture. CONCLUSIONS: Buprenorphine is an evidence-based, safe, effective treatment option for OUD in an ED-setting. Though successfully utilized by many ED-based treatment programs, the stigma of 'replacing one opioid with another' remains a barrier. Evidence-based discussions on the safety and benefits of buprenorphine are essential to promoting a culture of acceptance and optimizing ED OUD treatment.

A Randomized, Double-Blind, Placebo-Controlled Trial of Naproxen With or Without Orphenadrine or Methocarbamol for Acute Low Back Pain.

STUDY OBJECTIVE: In US emergency departments (EDs), patients with low back pain are often treated with nonsteroidal anti-inflammatory drugs and muscle relaxants. We compare functional outcomes among patients randomized to a 1-week course of naproxen+placebo versus naproxen+orphenadrine or naproxen+methocarbamol. METHODS: This was a randomized, double-blind, comparative effectiveness trial conducted in 2 urban EDs. Patients presenting with acute, nontraumatic, nonradicular low back pain were enrolled. The primary outcome was improvement on the Roland-Morris Disability Questionnaire (RMDQ) between ED discharge and 1 week later. All patients were given 14 tablets of naproxen 500 mg, to be used twice a day, as needed for low back pain. Additionally, patients were randomized to receive a 1-week supply of orphenadrine 100 mg, to be used twice a day as needed, methocarbamol 750 mg, to be used as 1 or 2 tablets 3 times per day as needed, or placebo. All patients received a standardized 10-minute low back pain educational session before discharge. RESULTS: Two hundred forty patients were randomized. Baseline demographic characteristics were comparable. The mean RMDQ score of patients randomized to naproxen+placebo improved by 10.9 points (95% confidence interval [CI] 8.9 to 12.9). The mean RMDQ score of patients randomized to naproxen+orphenadrine improved by 9.4 points (95% CI 7.4 to 11.5). The mean RMDQ score of patients randomized to naproxen+methocarbamol improved by 8.1 points (95% CI 6.1 to 10.1). None of the between-group differences surpassed our threshold for clinical significance. Adverse events were reported by 17% (95% CI 10% to 28%) of placebo patients, 9% (95% CI 4% to 19%) of orphenadrine patients, and 19% (95% CI 11% to 29%) of methocarbamol patients. CONCLUSION: Among ED patients with acute, nontraumatic, nonradicular low back pain, combining naproxen with either orphenadrine or methocarbamol did not improve functional outcomes compared with naproxen+placebo.

Age But Not Sex Is Associated With Efficacy and Adverse Events Following Administration of Intravenous Migraine Medication: An Analysis of a Clinical Trial Database.

BACKGROUND: Migraine prevalence is associated with both sex and age. Differences in efficacy of parenteral migraine medication administration based on the sex and age of the patient have not been explored in the published literature. OBJECTIVE: The objective was to determine whether sex and age are associated with short-term headache relief, sustained headache freedom, or adverse medication effects in data collected during 3 emergency department (ED)-based acute migraine comparative efficacy trials. METHODS: Data were combined from 3 studies in which patients who presented to an ED with acute migraine were randomized to one of the following intravenous medication regimens: (1) metoclopramide combined with diphenhydramine; (2) metoclopramide combined with diphenhydramine and dexamethasone; (3) metoclopramide alone; (4) ketorolac; or (5) valproate. In each of these studies, (1) short-term efficacy (patient description of the headache as "mild" or "none" 1 hour after medication administration); (2) sustained efficacy (patient description of the headache as "none" within 2 hours of medication administration and no headache recurrence for 24 hours post ED discharge); and (3) the frequency of any adverse medication effects within 24 hours of medication administration was determined. For each of the medication regimens studied, efficacy and adverse event rates were compared between men vs women and the older vs the younger half of patients. Multivariate logistic regression models were constructed in which sex and age were maintained in the model as well as variables representing each of the medication regimens patients received. RESULTS: A total of 884 patients were included in this analysis (140 men and 744 women). The median age was 35 years. After controlling for age and medication received, female sex was not associated with short-term efficacy (OR 0.98 [95% confidence interval (CI): 0.66, 1.46]), sustained efficacy (OR 0.72 [95%CI: 0.45, 1.15]), or adverse events (OR 1.14 [95%CI: 0.77, 1.71]). Age >36 years, however, was associated with short-term efficacy (OR 0.66 [95%CI: 0.49, 0.88]), sustained efficacy (OR 0.50 [95%CI: 0.34, 0.73]), and adverse events (OR 1.36 [95%CI: 1.02, 1.82]). CONCLUSION: Sex was not associated with response to parenteral acute migraine medication. Age was associated with both efficacy and adverse events.