Emergency physicians' attitudes toward a clinical prediction rule for the identification and early discharge of low risk patients with chest discomfort.

OBJECTIVES: To determine Canadian emergency physicians' estimates regarding the safety and efficiency of chest discomfort management in their emergency department (ED), and their attitudes toward and perception of the need for a chest discomfort clinical prediction rule that identifies very low risk patients who are safe to discharge after a brief ED assessment. METHODS: 300 members of the Canadian Association of Emergency Physicians (CAEP) were randomly selected to receive a confidential mail survey, which invited them to provide information on current disposition of patients with chest discomfort and their opinions regarding the value of a clinical prediction rule to identify patients with chest discomfort who are safe to discharge after a brief (approximately 2 hour) assessment. RESULTS: Of the 300 physicians selected, 288 were eligible for the survey and 235 (82%) responded. Only 5% follow discharged patients to measure safe practice. Overall, 165 (70%) felt the proposed prediction rule would be very useful and 43 (18%) felt it would be useful. Almost all (94%) believed a prediction rule would be useful if it identified patients safe for discharge without increasing the current rate of missed acute myocardial infarction (estimated at 2%). Most respondents (59%) believed that a clinical prediction rule should suggest a course of action, while 30% felt it should convey a probability of disease. CONCLUSIONS: Canadian emergency physicians support the concept of a clinical prediction rule for the early discharge of patients with chest discomfort. Most believe that such a rule would be useful if it identified patients who are safe for discharge after a brief assessment, while maintaining current levels of safety. Future research should be aimed at deriving a clinical prediction rule to identify low risk patients who can be safely discharged after a limited emergency department evaluation.

The NARC (nonsteroidal anti-inflammatory in renal colic) trial. Single-dose intravenous ketorolac versus titrated intravenous meperidine in acute renal colic: a randomized clinical trial.

OBJECTIVES: Intravenous (IV) opioid titration is an accepted method of relieving acute renal colic. Studies have shown that nonsteroidal anti-inflammatory drugs (NSAIDs) are also effective in this setting. Our objective was to compare single-dose ketorolac and titrated meperidine, both administered intravenously, with respect to speed and degree of analgesia, adverse effects and functional status. Our primary hypothesis was that these agents provide equivalent analgesia within 60 minutes. Our secondary hypotheses were that ketorolac-treated patients would experience fewer adverse effects and would be better able to resume usual activity. METHODS: This was a multicentre, double-blind randomized equivalence trial in a convenience sample of patients age 18-65 with moderate or severe renal colic, documented by intravenous pyelogram, ultrasound or stone passage. Meperidine-treated patients received 50 mg IV meperidine at 0 minutes, then 25-50 mg every 15 minutes as needed for ongoing pain. Ketorolac-treated patients received 30 mg IV ketorolac at 0 minutes and placebo injections every 15 minutes as needed. Pain levels and adverse effects were assessed every 15 minutes, and functional status was evaluated at 60 minutes. Our primary outcome was the proportion of patients with mild or no pain at 60 minutes. RESULTS: Overall, 49 of 77 meperidine-treated patients (64%; 95% confidence interval [CI], 53%-75%) and 47 of 65 ketorolac-treated patients (72%; 95% CI, 61%-83%) achieved successful pain relief at 60 minutes (p value for equivalence = 0.002). Ten percent of meperidine-treated patients and 44% of ketorolac-treated patients were able to resume usual activity at 60 minutes (p = 0.001). CONCLUSIONS: In the doses studied, single-dose IV ketorolac is as effective as titrated IV meperidine for the relief of acute renal colic and causes less functional impairment.

Dexamethasone prevents relapse after emergency department treatment of acute migraine: a randomized clinical trial.

OBJECTIVE: To determine whether the addition of intravenous dexamethasone to standard emergency department (ED) migraine therapy would decrease the incidence of severe recurrent headache 24 to 48 hours after initial treatment. METHODS: Patients aged 19 to 65 years whose headache was severe enough to require parenteral therapy and who met International Headache Society migraine criteria were eligible for this randomized, double-blind trial. The study was conducted in the ED of 2 community hospitals, 1 of which was a tertiary referral centre. Exclusion criteria included pregnancy, focal findings, fever, meningismus, allergy to the study drug, active peptic ulcer disease and diabetes mellitus. Demographic and clinical data, including headache severity, were recorded. After abortive therapy (antiemetics, intravenous nonsteroidal agents, dihydroergotamine or opioids), blinded nurses administered dexamethasone (24 mg intravenously) or placebo. Patients recorded headache severity on a Visual Analogue Scale (VAS) at time T = 0, T = 30 minutes and T = 60 minutes and at discharge. They were contacted 48 to 72 hours later and asked whether they had suffered a recurrence of their headache, categorized as class A (severe, provoking another physician visit), class B (severe, interfering with daily activity but not provoking a physician visit), class C (mild, requiring self-medication but not limiting activity) or class D (mild, requiring no treatment). RESULTS: Two of 100 patients were lost to follow-up, leaving 98 in the study sample. Placebo recipients were more likely to be female; other baseline characteristics were similar between groups. Median VAS pain score was 83 mm on ED arrival, 35 mm after initial treatment and 12 mm on discharge. At follow-up, 65 of 98 patients had suffered headache recurrence. In the placebo versus dexamethasone groups, respectively, the results were 11 versus 0 in class A, 11 versus 9 in class B, 7 versus 11 in class C and 4 versus 12 in class D. Regarding the primary outcome, 9 of 49 dexamethasone patients (18%) and 22 of 49 placebo patients (45%) had severe (classes A and B) recurrent headache (odds ratio 0.28; 95% CI, 0.11 to 0.69; p = 0 .005). CONCLUSIONS: Migraine recurrence is common after "successful" ED treatment. Inflammation may be a critical factor in migraine genesis. Intravenous dexamethasone decreases the incidence of severe recurrent headache after ED treatment and should be offered to patients thought to be at risk of recurrent headache.

Ketorolac versus acetaminophen-codeine in the emergency department treatment of acute low back pain.

Acute low back pain is a common problem in the emergency department (ED). Effective management of acute pain enhances early rehabilitation and recovery. Given the importance of inflammatory mediators in pain generation and the adverse effects associated with opioids, it is logical to expect that a non-opioid agent with antiinflammatory and analgesic properties would provide excellent analgesia with fewer adverse effects. This double-blind, randomized, multicenter clinical trial, performed in six university and community hospital EDs, compares the analgesic efficacy and adverse effects of ketorolac to those of acetaminophen-codeine in ED patients with acute musculoskeletal low back pain. Our hypothesis was that ketorolac would provide superior analgesia with fewer adverse effects. One hundred twenty-three patients with acute low back pain were randomized to receive ketorolac (KET, N = 63) or acetaminophen-codeine (ACOD, N = 60). Most (79%) were males, and the mean age was 34.5 years. After baseline clinical assessment, patients were treated with ketorolac (10 mg every 4 to 6 h as needed, up to four daily doses) or acetaminophen-codeine (600 mg-60 mg, respectively, every 4 to 6 h as needed, up to six daily doses) and followed for one week. Pain intensity was assessed on visual analogue and categorical scales. Functional capacity, overall pain relief, and overall medication rating were assessed on categorical scales. Adverse events were documented. Primary outcomes included: 1) Pain intensity differences, based on visual analogue scores, for the 0 to 6 h treatment phase. 2) Incidence of adverse events. Secondary outcomes included analgesic efficacy, functional capacity, and overall subjective drug evaluation at one week. Both drugs provided substantial pain relief, with maximal effect 2.2 h after oral dosing. There were no significant differences in analgesic efficacy, functional capacity, or overall pain relief between the two groups. Sixteen patients (10 KET vs. 6 ACOD, NS) withdrew prematurely because of drug inefficacy. Patients in the ACOD group reported significantly more adverse drug events and serious adverse drug events. Seven patients--all in the ACOD group--withdrew from the study because of adverse drug events. Based on comparable efficacy and a superior adverse event profile, ketorolac was preferable to acetaminophen with codeine for the treatment of acute low back pain in the ED.

Low-molecular-weight heparin in the emergency department treatment of venous thromboembolism.

Accepted initial therapy for deep vein thrombosis (DVT) is intravenous heparin infusion, which requires hospitalization, inhibits patient ambulation, consumes nursing time, and generates laboratory cost. The effects of heparin are unpredictable, and maintaining optimal anti-coagulation requires careful laboratory monitoring. Many patients are underdosed and 5-20% of heparin-treated patients suffer hemorrhagic complications. Low-molecular-weight (LMW) heparins have a predictable anticoagulant response, require no laboratory monitoring, and can be administered once or twice daily by subcutaneous injection, thus facilitating outpatient treatment. LMW heparins are at least as safe and effective as standard intravenous heparin for the treatment of uncomplicated DVT. LMW heparin use is associated with decreased admission rates, shorter lengths of stay, decreased nursing time, better patient quality of life, and lower laboratory costs. In our emergency department, we have adopted a LMW heparin protocol for the outpatient treatment of suspected or proven DVT.

Effectiveness of verapamil-quinidine versus digoxin-quinidine in the emergency department treatment of paroxysmal atrial fibrillation.

STUDY OBJECTIVE: To determine the relative effectiveness of a verapamil-quinidine sequential combination versus digoxin-quinidine in the emergency department treatment of paroxysmal atrial fibrillation (PAF). METHOD: This prospective, double-blind, randomized, controlled trial involved patients, aged 18 to 75 years, with new-onset (< 48 hours) atrial fibrillation who presented to a community-based urban hospital with an annual ED census of 65,000. Exclusion criteria included ventricular response rate lower than 100 or higher than 200 beats/minute, allergy to study drugs, hypotension with evidence of end-organ hypoperfusion, and conduction abnormalities. Consenting patients were randomly assigned to receive rapid digitalization (1.0 mg over 2 hours) or i.v. verapamil (sequential 5-mg boluses up to 20 mg). After ventricular rate was controlled (< 100 beats/minute), oral quinidine (200 mg) was initiated and repeated every 2 hours until conversion to normal sinus rhythm (NSR) occurred, until 1 g of quinidine was administered, or until adverse effects supervened. Heart rate, blood pressure, cardiac rhythm, time to conversion, and adverse effects were documented. RESULTS: Forty-four patients received the study drugs. Three were withdrawn, leaving 19 in the verapamil-quinidine (VER-Q) group and 22 in the digoxin-quinidine (DIG-Q) group. Sixteen patients (84%) in the VER-Q group and 10 (45%) in the DIG-Q group converted to NSR within 6 hours (P < .02). Mean time to conversion (+/-SD) was 185 +/- 146 minutes for VER-Q and 368 +/- 386 minutes for DIG-Q patients (P = NS). Twelve VER-Q patients (63%) and 6 DIG-Q patients (27%) were discharged from the ED (P < .05). Minor adverse effects were more common in the VER-Q group. No mortality or significant morbidity occurred. CONCLUSION: The sequential combination of verapamil and quinidine, in the doses studied, is an effective treatment for PAF and is superior to digoxin-quinidine. Digoxin should no longer be considered the treatment of choice for uncomplicated PAF.