ABSTRACT
BACKGROUND: Biomechanical reduction techniques for shoulder dislocations have demonstrated high reduction success rates with a limited pain experience for the patient. We postulated that the combination of biomechanical reduction techniques with the shortest length of stay would also have the lowest pain experience and the highest first reduction success rate. METHODS: A randomized multicenter clinical trial was performed to compare different biomechanical reduction techniques in treating anterior shoulder dislocations without the use of invasive pain relief. Patients who were able to perform adduction of the arm were randomly assigned to Cunningham, the modified Milch, and the scapular manipulation technique. Those who were not able to do so were randomly assigned to modified Milch and the scapular manipulation technique. Primary outcomes were emergency department length of stay and pain experienced during the reduction process, measured by the numeric pain rating scale. Secondary outcomes were reduction time, reduction success, use of analgesics or sedatives, and complications. RESULTS: Three hundred eight patients were included, of whom 134 were in the adduction group. In both groups, no differences in emergency department length of stay and experienced pain were observed between the treatment arms. In the adduction group, the modified Milch technique had the highest first reduction success rates 52% (p = 0.016), within protocol 61% (p = 0.94), and with sedation in the ED 100% ( -). In the no-adduction group, the modified Milch was also the most successful primary reduction technique with 51% success (p = 0.040), within protocol 66% (p = 0.90), and with sedation in the ED 98% (p = 0.93). No complications were recorded in any of the techniques. CONCLUSION: A combination of biomechanical techniques resulted in a similar length of stay in the emergency department and showed similar pain scores with an overall high success rate of reduction. In both groups, the modified Milch had the highest first-reduction success rate. TRIAL REGISTRATION: Netherlands Trial Register NTR5839-1 April 2016. Ethical committee Noord-Holland with the CCMO-number NL54173.094.15.
ABSTRACT
BACKGROUND: Nasal inhalation of isopropyl alcohol (IPA) seems an effective anti-emetic for the symptomatic treatment of nausea in the emergency department (ED) compared to conventional anti-emetics (Ondansetron and Metoclopramide). However, it is not yet known what the practical consequences are related to the use of IPA in the ED. OBJECTIVES: The purpose of this study was to assess the practical implications for patient care associated with IPA use and to evaluate the viability of permanent implementation of IPA inhalation as a first-line therapy for nausea in the ED. METHODS: We conducted a prospective, single-center implementation study comparing ED-based care for nauseated patients before (n=106) and after (n=104) the introduction of IPA. We evaluated the treatment process and cost and assessed implementation using a survey based on recommended implementation outcome measures. RESULTS: Comparing baseline phase to implementation phase, we found a significant increase in the percentage of patients receiving nausea treatment (66.0% versus 97.1%; p<0.001) and a reduction in time to treatment initiation (7 versus 1 min, p<0.001). Additionally, IPA introduction was associated with a decrease in the administration of conventional anti-emetics (0.52 versus 0.23 administrations per patient, p<0.001) and a notable drop in treatment cost (1.33 versus 0.67 per patient). Nurses were content with IPA implementation and regarded definitive implementation as feasible and sustainable. CONCLUSION: Implementation of IPA as the first-line nausea treatment in the ED can increase the quality of care and improve care efficiency. Definitive implementation of IPA as a first-line treatment in the ED is both viable and practically feasible. TRIAL REGISTRATION: NTR, NL7717 , Registered on March 23, 2018 - Retrospectively registered.
ABSTRACT
In the Emergency Department (ED) actual body weight (ABW) is essential for accurate drug dosing. Frequently, the ABW is unknown and direct measurement troublesome. A method using the mid-arm circumference (MAC) to estimate ABW has been developed and validated in the United States of America (USA). This study aimed to validate the MAC-formula for estimating ABW in the Dutch population and compare its performance within the American population.Data were obtained from the Dutch National Institute for Public Health and the Environment (RIVM) and extracted from the American National Health and Nutrition Examination Survey (NHANES) datasets. We included all subjects' ≥70 years whose MAC and weight were recorded and obtained additional anthropometric data. We used the equation: kgâ=â4â×âMAC-50 to estimate the ABW of all subjects and compared results.We retrieved 723 and 972 subjects from the Dutch and American dataset, respectively. The MAC is better correlated with ABW in the American dataset when compared with the Dutch dataset (Pearson râ=â0.84 and 0.68, respectively). Bland-Altman bias was -7.49âkg (Limits-of-Agreement [LOA] -27.5 to 12.27âkg) and -0.50âkg (LOA -20.99 to 19.99âkg) in the Dutch and American datasets, respectively.The MAC based formula to estimate ABW is a promising tool for the elderly American population. However it is not accurate within the Dutch elderly ED population. Consequently, it is not applicable to Dutch EDs. This study highlights that the results of anthropometric studies performed within the USA are not per se generalizable to the European population.
