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The purpose of this study is to investigate if an orally administered combination of aspirin and ketamine will provide better analgesia than a ketamine alone in adult patients presenting to the Emergency Department (ED) with acute musculoskeletal pain.We conducted a prospective, randomized, open-label trial of ED patients aged 18 and older presenting with moderate to severe acute musculoskeletal pain as defined by an 11-point numeric rating scale (NRS) with an initial score of ≥5. Patients were randomized to receive either 324 mg of VTS-Aspirin™ and 0.5 mg/kg of oral ketamine (AOK) that is directly swallowed or 0.5 mg/kg of oral ketamine (OK) alone that is swished first and then swallowed. Patients were assessed at baseline, 30, 60, 90, and 120 min. The primary outcome was a difference in pain scores between the two groups at 60 min post-administration. Secondary outcomes included adverse events and the need for rescue analgesia.We enrolled 60 patients in the study (30 per group). The difference in mean pain scores at 60 min between the AOK and OK groups was 2.6 [95% CI: 1.38-3.77] showing a lower mean pain score in the OK group. At 60 min, the AOK group had a change in mean pain score from 8.4 to 6.3 (difference 2.1; 95% CI: 1.35-3.00). The OK group had a change in mean pain score from 7.8 to 3.7 (difference 4.1, 95% CI: 3.25-4.90). No clinically concerning changes in vital signs were observed. No serious adverse events occurred in either group. The most commonly reported adverse effects were dizziness and fatigue. None of the participants required rescue analgesia at 60 min post-medications administration.The administration of an oral combination of VTS-Aspirin ™ and ketamine resulted in less analgesia compared to oral ketamine alone, for the short-term treatment of moderate to severe acute musculoskeletal pain in the ED.govRegistration: NCT04860804.

Emergency department (ED) visits are known to be anxiety-ridden and stress-provoking experiences especially in the pediatric population. Distraction techniques have been used as a means to reduce anxiety and stress thereby facilitating care in the ED and making the visit less unpleasant. Our study aimed to evaluate the effectiveness of an active and immersive distraction technique, using a mindfulness-based virtual reality (VR) program (Take-Pause), to alleviate anxiety in pediatric ED patients.A prospective, randomized, single-blinded study, evaluating ED patients aged 13-17 years with a chief complaint of acute pain was conducted. Patients were randomized either to the active distraction intervention (VR group), utilizing the VR headset for 5 min, or to the passive distraction intervention (iPad group), playing on an iPad for 5 min. The primary outcome was a difference in the change in anxiety scores on the Spielberger State-Trait Anxiety Inventory between the two groups. Secondary outcomes included a difference in pain scores, respiratory rate, and heart rate between the groups.A total of 110 subjects were enrolled. At 15 min, the mean anxiety score for the VR group improved by 10 points versus 6 points in the iPad group (p 0.001; 95% confidence interval = 0.44 to 7.6). There was no statistical significance in the reduction of pain scores (p = 0.953) and respiratory rates (p = 0.776) between the groups. Patients enrolled in both groups did not experience any adverse effects.Take-Pause, offering an active and immersive distraction technique, is more effective than a passive distraction approach to lower anxiety levels in adolescent ED patients.

Study objective We aimed to assess and compare the analgesic efficacies and adverse effects of ketamine administered through a breath-actuated nebulizer at 3 different dosing regimens for emergency department patients presenting with acute and chronic painful conditions. Methods This was a prospective, randomized, double-blinded trial comparing 3 doses of nebulized ketamine (0.75 mg/kg, 1 mg/kg, and 1.5 mg/kg) administered through breath-actuated nebulizer in adult emergency department patients aged 18 years and older with moderate to severe acute and chronic pain. The primary outcome included the difference in pain scores on an 11-point numeric rating scale between all 3 groups at 30 minutes. Secondary outcomes included the need for rescue analgesia (additional doses of nebulized ketamine or intravenous morphine) and adverse events in each group at 30 and 60 minutes. Results We enrolled 120 subjects (40 per group). The difference in mean pain scores at 30 minutes between the 0.75 mg/kg and 1 mg/kg groups was 0.25 (95% confidence interval [CI] 1.28 to 1.78); between the 1 mg/kg and 1.5 mg/kg groups was −0.225 (95% CI −1.76 to 1.31); and between the 0.75 mg/kg and 1.5 mg/kg groups was 0.025 (95% CI −1.51 to 1.56). No clinically concerning changes in vital signs occurred. No serious adverse events occurred in any of the groups. Conclusion We found no difference between all 3 doses of ketamine administered through breath-actuated nebulizer for short-term treatment of moderate to severe pain in the emergency department.

Introduction Vasopressor administration is a critical medical intervention for patients with hypotension in undifferentiated shock states. Over the years, prehospital care has advanced with protocols and training that allow paramedics in the field to administer a variety of vasopressors. The primary objective of this investigation was to evaluate vasopressor experience among paramedics with regard to preference as well as the barriers to its preparation and administration. Methods A cross-sectional survey of vasopressor use by nationally certified paramedics (NRPs) was performed. A 20-item questionnaire was constructed to capture the prehospital perceptions and barriers of dopamine infusion, norepinephrine infusion, and IV bolus "push-dose" epinephrine (PD-E). Data collection was carried out from June to September 2021. Results A total of 44 responses were obtained (response rate = 44%). All participants had experience using vasopressors and understood their medical indications. Overall, PD-E was the most common vasopressor used in the prehospital setting, and participants felt equally confident in "using" and "preparing" it. Participants felt less confident with "using" and "preparing" vasopressors that required channel setup and maintaining a flow rate. Younger paramedics with less than five years of experience were more eager to use norepinephrine if trucks were stocked with pre-mixed norepinephrine rather than the current formulation that required compounding. Conclusion This study provided preliminary data that evaluated perceptions of vasopressor use in the prehospital setting among paramedics in a large urban environment. Preference and barriers to its preparation and administration were surveyed. Further research is needed to identify the interventions to reduce barriers and allow paramedics to be less limited by logistical considerations when choosing vasopressors in the prehospital setting.

OBJECTIVE: We investigated the educational value of implementing a web‐based e‐learning program into a medical student emergency medicine rotation. We created “UltrasoundBox,” a browser‐based application where students interpret ultrasound (US) images. Our goal was to assess how this form of e‐learning performs when compared to more passive, lecture‐based online US education. We also assessed the how the students interpreted the addition this learning modality to the rotation. METHODS: This is a randomized, controlled study to assess the educational outcomes of implementing UltrasoundBox compared to lecture‐based US education. Fourth‐year medical students on their emergency medicine rotation were enrolled in the study. Students randomized to the control arm were instructed to watch widely available educational lecture videos. Students randomized to the intervention arm received access to UltrasoundBox and were instructed to complete the clinical modules. Both groups completed the same standardized US examination before and after the trial. All the trial participants were given a survey to complete after the trial. RESULTS: We enrolled 42 students, with 23 in the control group and 19 in the intervention group. On the post‐intervention examination, the control and intervention groups were found to have mean examination scores of 61.6% and 73.6% respectively, with a statistically significant difference of 12% (95% confidence interval 1.611 to 5.56; p

Background Intussusception (INT) is a common cause of bowel obstruction in young children. Delay in diagnosis can lead to significant morbidity and mortality. There have been several studies evaluating early point-of-care ultrasound (POCUS) in the diagnosis of INT by nonradiologists. Objective Our objective was to determine the diagnostic accuracy of POCUS by novice sonographer pediatric emergency medicine physicians (PEM-Ps) who received focused US training for diagnosing INT. Methods We performed a prospective observational study including 17 PEM-Ps (14 attendings, 3 fellows) trained to perform abdominal US for INT. Children suspected of having INT received POCUS performed and interpreted by a PEM-P, followed by a US study performed by a certified ultrasonographer and interpreted by an attending pediatric radiologist. Diagnostic concordance between PEM-P–and radiology-performed US (RPUS) results was assessed. Results One hundred patients were enrolled; median patient age was 24 months. There was excellent diagnostic agreement for presence or absence of INT between PEM-Ps and RPUS (97% of cases; κ = 0.826). POCUS-diagnosed INT was present in 8 of 9 patients with RPUS-diagnosed INT (sensitivity 89%; 95% confidence interval [CI] 51–99%; specificity 98%; 95% CI 92–100%; positive predictive value 80%; 95% CI 44–96%; negative predictive value 99%; 95% CI 93–100%). Likelihood ratio for INT with a positive POCUS was 40.44 (95% CI 10.07–162.36) and with a negative POCUS was 0.11 (95% CI 0.02–0.72). Conclusions POCUS performed by novice sonographers to diagnose INT has high diagnostic concordance with RPUS. Emergency department–performed POCUS is a rapid and accurate method for diagnosing INT.

Emergency clinicians often treat severe agitation resulting from intoxicants, psychiatric illness, and other CNS or systemic diseases. Recreational drugs-especially stimulants-are frequently used by attendees of electronic dance music festivals (EDMFs), and festivalgoers may become dangerously agitated and pose an immediate threat to themselves and others. Although benzodiazepines and antipsychotics are classically used to treat severe agitation, these medications are burdened by safety concerns including respiratory depression and cardiac arrhythmias. The effects of ketamine when used to treat severe agitation in an exclusive cohort of patients with psychostimulant drug-induced toxicity (PDIT) has not previously been reported, and existing literature describes a widely variant safety profile when ketamine is used for sedation of the agitated patient.To describe ketamine's adverse event profile when used to treat patients with severe agitation resulting from PDIT.This is a retrospective, observational study enrolling consecutive patients who presented for medical attention at a large outdoor EDMF over a period of eight days on two consecutive weekends in the summer of 2017. The EDMF had an estimated attendance of 40,000 per weekend. A medical tent was set up on-site; patients were managed by a team of EMS providers, nurses and emergency physicians. Medications used, adverse events and the need for repeat dosing were abstracted from prehospital care reports.Over the course of eight days, 1081 of 1186 patients who were evaluated in the medical tent had a recorded chief complaint. 274 of these patients (25.3%) had a chief complaint of altered mental status. In patients presenting with AMS, 68 patients (24.8%) had severe agitation that was treated with dissociative-dose (≥4 mg/kg) intramuscular ketamine. The mean initial dose of ketamine was 308 mg. There were four serious adverse events (5.9%): Two patients (2.9%) had copious hypersalivation treated with atropine, one patient (1.5%) had transient apnea requiring assisted ventilation, and one patient (1.5%) was intubated and transported to the hospital. 42 patients (61.8%) required redosing of calming medications. All patients who received ketamine except the single patient who was intubated and transported were observed in the medical tent until resolution of symptoms and discharged back to the festival.In this cohort of festival attendees who developed stimulant-induced severe agitation and were treated with dissociative-dose ketamine, serious adverse events occurred in 5.9% of patients including one patient who was intubated.

Background Ibuprofen (Motrin; Johnson & Johnson) and acetaminophen (APAP, paracetamol) are the most commonly used analgesics in the pediatric emergency department (ED) for managing a variety of acute traumatic and nontraumatic painful conditions. The multimodal pain management of using a combination of ibuprofen plus acetaminophen has the potential to result in greater analgesia. Objective We compared the analgesic efficacy of a combination of oral ibuprofen plus acetaminophen with either analgesic alone for pediatric ED patients with acute pain. Methods We performed a randomized, double-blind superiority trial assessing and comparing the analgesic efficacy of a combination of oral ibuprofen (10 mg/kg dose) plus acetaminophen (15 mg/kg per dose) to either analgesic alone for the treatment of acute traumatic and nontraumatic pain in the pediatric ED. Primary outcomes included a difference in pain scores among the three groups at 60 min. Results We enrolled 90 patients (30 per group). The difference in mean pain scores at 60 min between acetaminophen and combination groups was 0.30 (95% confidence interval [CI] −0.84 to 1.83); between ibuprofen and combination groups was −0.33 (95% CI −1.47 to 0.80); and between acetaminophen and ibuprofen groups was 0.63 (95% CI −0.54 to 1.81). Reductions in pain scores from baseline to 60 min were similar for all patients in each of the three groups. No adverse events occurred in any group. Conclusions We found similar analgesic efficacy of oral ibuprofen and acetaminophen in comparison with each analgesic alone for short-term treatment of acute pain in the pediatric ED, but the trial was underpowered to demonstrate the analgesic superiority of the combination of oral ibuprofen plus acetaminophen in comparison with each analgesic alone.

Ketamine administration in sub-dissociative doses in the emergency department (ED) results in effective pain relief in patients with acute traumatic and non-traumatic pain, chronic pain, and opioid-tolerant pain. This case series describes five adult ED patients who received nebulized ketamine for predominantly acute traumatic pain. Three patients received nebulized ketamine at 1.5 milligrams per kilogram (mg /kg) dose, one patient at 0.75 mg/kg, and one patient at 1 mg/kg. All five patients experienced a decrease in pain from the baseline up to 120 minutes. The inhalation route of ketamine delivery via breath-actuated nebulizer may have utility for managing pain in the ED.

Musculoskeletal pain (MSK) affects one out of three adults and is the most common source of significant long-term pain, physical disability, and under-treatment in the emergency department (ED).We aimed to assess the analgesic efficacy of a combination of oral VTS-Aspirin® (Vitalis Analgesics, New York, NY) and ketamine in managing acute MSK pain in adult ED patients.This was a prospective, proof-of-concept, single-arm, pilot study evaluating the analgesic efficacy of a single dose of oral combination of VTS-Aspirin and ketamine in adult ED patients with acute moderate-to-severe MSK pain. The primary outcome included the difference in pain scores on an 11-point numeric pain rating scale at 60 min. Secondary outcomes included the need for rescue analgesia, the occurrence of adverse events at 60 min, and a change in pain scores at 120 min.We enrolled 25 subjects in the study. The mean baseline pain score was 8.6 and the mean pain score at 60 min decreased to 4.8. The oral ketamine dose ranged from 24 mg to 50 mg, with a mean dose of 37.8 mg. No clinically concerning changes in vital signs were noted. No serious adverse events occurred in any of the subjects. Majority of adverse effects were transient and weak in intensity.We demonstrated that administration of an oral combination of VTS-Aspirin and ketamine to adult ED patients with acute MSK pain resulted in clinically significant pain relief in 80% of enrolled subjects.

Study objective Nonsteroidal anti-inflammatory drugs (NSAIDs) are used extensively for the management of acute pain, with ibuprofen being one of the most frequently used oral analgesics in the emergency department (ED). We compare the analgesic efficacy of oral ibuprofen at 3 different doses for adult ED patients with acute pain. Methods This was a randomized, double-blind trial comparing analgesic efficacy of 3 doses of oral ibuprofen (400, 600, and 800 mg) in adult ED patients with acute painful conditions. Primary outcome included difference in pain scores between the 3 groups at 60 minutes. Results We enrolled 225 subjects (75 per group). The difference in mean pain scores at 60 minutes between the 400- and 600-mg groups was –0.14 (95% confidence interval [CI] –0.67 to 0.39); between the 400- and 800-mg groups, 0.14 (95% CI –0.65 to 0.37); and between the 600- and 800-mg groups, 0.00 (95% CI –0.47 to 0.47). Reductions in pain scores from baseline to 60 minutes were similar for all subjects in each of the 3 groups. No adverse events occurred in any group. Conclusion Oral ibuprofen administered at doses of 400, 600, and 800 mg has similar analgesic efficacy for short-term pain relief in adult patients presenting to the ED with acute pain.

Study objective We compare the analgesic efficacy and safety of subdissociative intravenous-dose ketamine (SDK) versus morphine in geriatric Emergency Department (ED) patients. Methods This was a prospective, randomized, double-blind trial evaluating ED patients aged 65 and older experiencing moderate to severe acute abdominal, flank, musculoskeletal, or malignant pain. Patients were randomized to receive SDK at 0.3 mg/kg or morphine at 0.1 mg/kg by short intravenous infusion over 15 min. Evaluations occurred at 15, 30, 60, 90, and 120 min. Primary outcome was reduction in pain at 30 min. Secondary outcomes included overall rates of adverse effects and incidence of rescue analgesia. Results Thirty patients per group were enrolled in the study. The primary change in mean pain scores was not significantly different in the ketamine and morphine groups: 9.0 versus 8.4 at baseline (mean difference 0.6; 95% CI −0.30 to 1.43) and 4.2 versus 4.4 at 30 min (mean difference −0.2; 95% CI −1.93 to1.46). Patients in the SDK group reported higher rates of psychoperceptual adverse effects at 15, 30, and 60 min post drug administration. Two patients in the ketamine group and one in the morphine group experienced brief desaturation episodes. There were no statistically significant differences with respect to changes in vital signs and need for rescue medication. Conclusion SDK administered at 0.3 mg/kg over 15 min provides analgesic efficacy comparable to morphine for short-term treatment of acute pain in the geriatric ED patients but results in higher rates of psychoperceptual adverse effects. ClinicalTrials.gov Registration #: NCT02673372 .

Previous research demonstrated that administration of Morphine Sulfate Immediate Release (MSIR) results in similar analgesic efficacy to Oxycodone but with significantly lesser degrees of euphoria and reward. The purpose of this study sit to investigate if MSIR combined with Acetaminophen can serve as an opioid analgesic alternative to Oxycodone combined with acetaminophen (Percocet) for acute pain in the Emergency Department (ED).A prospective, randomized, double-blind trial of ED patients aged 18 to 64 years presenting with moderate to severe acute pain as defined by an 11-point numeric rating scale (NRS) with an initial score of ≥5 (0 = no pain and 10 = very severe pain). Patients were randomized to receive either 15 mg MSIR combined with 650 mg of Acetaminophen or 10 mg Oxycodone combined with 650 mg Acetaminophen. Patients were assessed at baseline, 30, 45 and 60 min. The primary outcome was reduction in pain at 60 min. Secondary outcomes include drug likeability and adverse events.80 patients were enrolled in the study (40 per group). Demographic characteristics were similar between the groups (P 0.05). Mean NRS pain scores at baseline were 8.44 for the MSIR group and 8.53 for the Percocet group (P = 0.788). Mean pain scores decreased over time but remained similar between the groups: 30 min (6.03 vs. 6.43; P = 0.453), 45 min (5.31 vs. 5.48; P = 0.779), and 60 min (4.22 vs. 4.87; P = 0.346). Reduction in mean NRS pain scores were statistically significant from baseline to 30, 45 and 60 min within each group (P 0.0001 at each time point for both groups). The largest NRS mean difference was from baseline to 60 min: 4.2 (95% CI: 3.43 to 5.01) for MSIR group and 3.61 (95% CI: 2.79 to 4.43) for Percocet group. No clinically significant changes or any serious adverse events were observed in either group.MSIR provides similar analgesic efficacy as Percocet for short-term pain relief in the ED, similar rates of nausea/vomiting, and lower rates of likeability of the drug.

Introduction: Family presence during emergency resuscitations is increasingly common, but the question remains whether the practice results in psychological harm to the witness. We examine whether family members who witness resuscitations have increased post-traumatic stress disorder (PTSD) symptoms at one month following the event. Methods: We identified family members of critically ill patients via our emergency department (ED) electronic health record. Patients were selected based on their geographic triage to an ED critical care room. Family members were called a median of one month post-event and administered the Impact of Event Scale-Revised (IES-R), a 22-item validated scale that measures post-traumatic distress symptoms and correlates closely with Diagnostic and Statistical Manual of Mental Disorders-IV criteria for post-traumatic stress disorder (PTSD). Family members were placed into two groups based on whether they stated they had witnessed the resuscitation (FWR group) or not witnessed the resuscitation (FNWR group). Data analyses included chi-square test, independent sample t-test, and linear regression controlling for gender and age. Results: A convenience sample of 423 family members responded to the phone interview: 250 FWR and 173 FNWR. The FWR group had significantly higher mean total IES-R scores: 30.4 vs 25.6 (95% confidence interval [CI], −8.73 to −0.75; P

Summary Background Benzodiazepine-refractory, or established, status epilepticus is thought to be of similar pathophysiology in children and adults, but differences in underlying aetiology and pharmacodynamics might differentially affect response to therapy. In the Established Status Epilepticus Treatment Trial (ESETT) we compared the efficacy and safety of levetiracetam, fosphenytoin, and valproate in established status epilepticus, and here we describe our results after extending enrolment in children to compare outcomes in three age groups. Methods In this multicentre, double-blind, response-adaptive, randomised controlled trial, we recruited patients from 58 hospital emergency departments across the USA. Patients were eligible for inclusion if they were aged 2 years or older, had been treated for a generalised convulsive seizure of longer than 5 min duration with adequate doses of benzodiazepines, and continued to have persistent or recurrent convulsions in the emergency department for at least 5 min and no more than 30 min after the last dose of benzodiazepine. Patients were randomly assigned in a response-adaptive manner, using Bayesian methods and stratified by age group ( 65 years), to levetiracetam, fosphenytoin, or valproate. All patients, investigators, study staff, and pharmacists were masked to treatment allocation. The primary outcome was absence of clinically apparent seizures with improved consciousness and without additional antiseizure medication at 1 h from start of drug infusion. The primary safety outcome was life-threatening hypotension or cardiac arrhythmia. The efficacy and safety outcomes were analysed by intention to treat. This study is registered in ClinicalTrials.gov , NCT01960075 . Findings Between Nov 3, 2015, and Dec 29, 2018, we enrolled 478 patients and 462 unique patients were included: 225 children (aged 65 years). 175 (38%) patients were randomly assigned to levetiracetam, 142 (31%) to fosphenyltoin, and 145 (31%) were to valproate. Baseline characteristics were balanced across treatments within age groups. The primary efficacy outcome was met in those treated with levetiracetam for 52% (95% credible interval 41–62) of children, 44% (33–55) of adults, and 37% (19–59) of older adults; with fosphenytoin in 49% (38–61) of children, 46% (34–59) of adults, and 35% (17–59) of older adults; and with valproate in 52% (41–63) of children, 46% (34–58) of adults, and 47% (25–70) of older adults. No differences were detected in efficacy or primary safety outcome by drug within each age group. With the exception of endotracheal intubation in children, secondary safety outcomes did not significantly differ by drug within each age group. Interpretation Children, adults, and older adults with established status epilepticus respond similarly to levetiracetam, fosphenytoin, and valproate, with treatment success in approximately half of patients. Any of the three drugs can be considered as a potential first-choice, second-line drug for benzodiazepine-refractory status epilepticus. Funding National Institute of Neurological Disorders and Stroke, National Institutes of Health.

Study objective Nonsteroidal anti-inflammatory drugs are used extensively for the management of acute and chronic pain, with ketorolac tromethamine being one of the most frequently used parenteral analgesics in the emergency department (ED). The drugs may commonly be used at doses above their analgesic ceiling, offering no incremental analgesic advantage while potentially adding risk of harm. We evaluate the analgesic efficacy of 3 doses of intravenous ketorolac in ED patients with acute pain. Methods We conducted a randomized, double-blind trial to assess the analgesic efficacy of 3 doses of intravenous ketorolac (10, 15, and 30 mg) in patients aged 18 to 65 years and presenting to the ED with moderate to severe acute pain, defined by a numeric rating scale score greater than or equal to 5. We excluded patients with peptic ulcer disease, gastrointestinal hemorrhage, renal or hepatic insufficiency, allergies to nonsteroidal anti-inflammatory drugs, pregnancy or breastfeeding, systolic blood pressure less than 90 or greater than 180 mm Hg, and pulse rate less than 50 or greater than 150 beats/min. Primary outcome was pain reduction at 30 minutes. We recorded pain scores at baseline and up to 120 minutes. Intravenous morphine 0.1 mg/kg was administered as a rescue analgesic if subjects still desired additional pain medication at 30 minutes after the study drug was administered. Data analyses included mixed-model regression and ANOVA. Results We enrolled 240 subjects (80 in each dose group). At 30 minutes, substantial pain reduction was demonstrated without any differences between the groups (95% confidence intervals 4.5 to 5.7 for the 10-mg group, 4.5 to 5.6 for the 15-mg group, and 4.2 to 5.4 for the 30-mg group). The mean numeric rating scale pain scores at baseline were 7.7, 7.5, and 7.8 and improved to 5.1, 5.0, and 4.8, respectively, at 30 minutes. Rates of rescue analgesia were similar, and there were no serious adverse events. Secondary outcomes showed similar rates of adverse effects per group, of which the most common were dizziness, nausea, and headache. Conclusion Ketorolac has similar analgesic efficacy at intravenous doses of 10, 15, and 30 mg, showing that intravenous ketorolac administered at the analgesic ceiling dose (10 mg) provided effective pain relief to ED patients with moderate to severe pain without increased adverse effects.

Objective Emergency Department patients with abdominal pain may require both an ultrasound (US) and computed tomography (CT) for an accurate diagnosis. Patients are often asked to drink oral radiocontrast while awaiting ultrasound, in order to better expedite a CT in the case of a non-diagnostic US. The impact of oral radiocontrast on US image quality has not been studied. We compared the quality of US images obtained before and after the ingestion of oral radiocontrast in healthy adult volunteers. Methods This was a prospective study in which adult volunteer subjects underwent sonographic studies of the aorta, the right upper quadrant, the right lower quadrant, and the Focused Assessment with Sonography in Trauma (FAST) examination. Initial studies were performed prior to ingestion of oral radiocontrast, with subsequent imaging occurring at 1 and 2 hour post-ingestion. All of the images from the sonographic exams were randomized and subsequently scored for quality by two emergency ultrasound fellowship trained emergency physicians with extensive experience in performing and interpreting US. Results 638 images from 240 exams were obtained from 20 subjects at three time points. Six exams were not scored due to inadequate images. There were no significant differences in image quality for any of the US exam types after the ingestion of oral radiocontrast at 1 and 2 h. Conclusion Ingestion of oral radiocontrast did not affect image quality of four common abdominal ultrasound examinations.

Objectives To determine the association of focused transthoracic echocardiography (ECHO) related interruption during cardiopulmonary resuscitation (CPR) with patient outcomes in the Emergency Department (ED). Methods This was a retrospective, single center, cohort study, conducted in an urban community teaching ED. Eligible study subjects were adult patients in the ED with sustained cardiac arrest. Exclusion criteria include traumatic cardiac arrest and age less than 18. All resuscitations were video recorded and were subsequently reviewed by 2 study investigators. The no-flow time from chest compression interruption was analyzed using video review and separated into ECHO-related and non-ECHO related. Our primary outcome was patient survival to hospital discharge and the secondary outcome was the rate of return of spontaneous circulation (ROSC). Multivariate logistic regression analyses were performed to examine the associations between independent variables and outcomes. Results From January 2016 to May 2017, a total of 210 patients were included for final analysis. The median total no-flow time observed on video was 99.5 s (IQR: 54.0–160.0 s). Among these, a median of 26.5 s (IQR: 0.0–59.0 s) was ECHO-related and a median of 60.5 s (IQR: 34.0–101.9) was non-ECHO-related. The ECHO-related no-flow time between 77 and 122 s (OR: 7.31, 95 % confidence interval [CI]: 1.59–33.59; p-value = 0.01) and ECHO-related interruption ≦ 2 times (OR: 8.22, 95% CI: 1.51–44.64; p-value = 0.01) were positively associated with survival to hospital discharge. ECHO-related interruption ≦ 2 times (OR: 5.55, 95% CI: 2.44–12.61; p-value Conclusion Short ECHO-related interruption during CPR was positively associated with ROSC and survival to hospital discharge. While ECHO can be a valuable diagnostic tool during CPR, the no-flow time associated with ECHO should be minimized.

Introduction Leaders in medical education have developed milestones and core competencies in an attempt to ensure that relational skills, such as communication and professionalism, are emphasized in addition to the usual skills of medical knowledge, data gathering, and emergency stabilization during students' emergency medicine (EM) medical education. Providers facile in each of these areas have better patient outcomes, patient experiences, and decreased incidence of malpractice cases. The authors attempted to demonstrate that by deliberate teaching of these skills during an EM medical student clerkship, students could significantly improve their clinical performance. Methods This prospective, randomized, single-blinded cohort study was performed at an academic, tertiary, urban ED to investigate the effects of a one-on-one preceptor shift on the clinical performance of fourth-year medical students. Students were randomized into two groups and assessed by pre- and post-intervention objective structured clinical encounters (OSCEs) with standardized patients (SPs) at weeks one and three. A crossover design was employed so that students in the control group participated in a preceptor shift after their second OSCE. Measurements were based on a five-point Likert scale assessment linked to early EM milestones as defined by the Accreditation Council on Graduate Medical Education (ACGME). Results: The mean improvement in total overall score was significantly greater in the intervention group: 4.31 versus 2.57 (Cohen's d = 0.57, p = 0.029). When each milestone was assessed individually, students in the intervention group improved significantly in data gathering (Cohen's d = 0.47, p = 0.048) and professionalism (Cohen's d = 0.66, p = 0.011). There was a nonstatistically significant improvement for the intervention compared to control group in emergency management and communication skills. There was no improvement for either group in medical knowledge. Conclusion A one-on-one preceptor shift can result in a statistically significant improvement in data gathering and professionalism skills as measured by OSCEs.

Background The interscalene brachial plexus nerve block (ISNB) is a potentially useful method of regional analgesia for humerus fracture and shoulder dislocation reduction in the Emergency Department (ED). We examined the effectiveness of an ISNB workshop given to emergency medicine (EM) residents. We also explored complication rates and effectiveness of ISNBs performed in the ED. Methods One-hour evidence-based ISNB workshops were conducted with EM residents. Participants were given pre-, post-, and 3-month post-workshop knowledge and technical assessments. Results were analyzed using descriptive statistics. A pre- and post-workshop chart review examined ISNB utilization, complications, post-ISNB opiate administration, and post-ISNB procedural sedation. Results 41 residents enrolled in the workshop. Pre-workshop pass rate: knowledge assessment 22%. Immediate post-workshop pass rates: knowledge assessment 100%, image acquisition 93%, needle placement 100%. Three months post-workshop pass rates: knowledge assessment 73%, image acquisition 76%, needle placement 100%. Areas of poorest knowledge retention were anatomical landmarks, block distribution, and early signs of LAST. In the chart review, 2 ISNBs were performed in the pre-workshop period, and 12 in the post-workshop period. No serious complications were recorded. 78.5% of attempted ISNBs were successful, without need for procedural sedation. Of the 11 successfully performed ISNBs, 91% received no opiates after the procedure. Conclusions Our study suggests that EM residents can learn the ISNB, perform it safely in the emergency department, and that the ISNB may be an alternative to procedural sedation and opiate use for shoulder dislocation. Residents are adept at ISNB technical skills but demonstrate some deficits in knowledge retention.

Study objective To compare analgesic efficacy and safety of intravenous lidocaine and ketorolac combination to each analgesic alone for ED patients with suspected renal colic. Methods We conducted a randomized, double-blind trial comparing analgesic efficacy of a combination of intravenous lidocaine (1.5 mg/kg) and ketorolac (30 mg), to ketorolac (30 mg), and to lidocaine (1.5 mg/kg) in patients aged 18–64 presenting to the ED with suspected renal colic. Primary outcome included difference in pain scores between the groups at 30 min. Secondary outcomes included a comparative reduction in pain scores in each group from baseline to 30 and 60 min as well as rates of adverse events and need for rescue analgesia at 30 and 60 min. Results We enrolled 150 subjects (50 per group). The difference in mean pain scores at 30 min between Lidocaine and Lidocaine/Ketorolac groups was −2.89 (95% CI: −4.39 to −1.39); between Ketorolac and Lidocaine/Ketorolac group was −0.92 (95% CI: −2.44 to 0.61); and between Ketorolac and Lidocaine was −1.98 (95% CI: −3.69 to −0.27). A comparative percentage of subjects in each group required rescue analgesia at 30 and 60 min. No clinically concerning changes in vital signs were observed. No serious adverse events occurred in either group. Commonly reported adverse effects were dizziness, nausea, and headache. Conclusion The administration of intravenous lidocaine/ketorolac combination to ED patients with suspected renal colic results in better analgesia in comparison to lidocaine alone but provides no analgesic advantages over ketorolac alone. Clinicaltrials.gov Registration: NCT02902770 .

OBJECTIVE Our aim was to compare the outcomes of tuberculous aortic aneurysms treated with endovascular aortic repair (TEVAR) or open surgery. METHODS An electronic search of the National Library of Medicine PubMed database for tuberculous aortic aneurysm was performed between January 1998 through December 2017. Cases were screened for completeness of information and outcomes were recorded and analyzed. RESULTS A total of 56 studies were reviewed, with 61 (20 TEVAR, 41 open surgical repair) having adequate case details and follow-up. The in-hospital/30-day mortality was 0% (0 out of 20) in the TEVAR group and 7% (three out of 41) in the open surgery group (P = .54). Overall mortality was 5% (1/20) in the TEVAR group and 10% (4/41) in the open surgery group (P = .53). Two-year survival and freedom from aneurysm recurrence were comparable in the two groups, P = .45 and P = .94, respectively. One patient in the TEVAR group and one patient in the open surgery group died due to a rupture of a recurrent aortic aneurysm 16 and 28 months after surgery, respectively. CONCLUSIONS TEVAR and anti-tuberculosis (TB) medications are reasonable initial treatment options for tuberculous aortic aneurysm especially in high-risk patients; however, careful follow-up is necessary.

To compare pain relief between patients with intracapsular and extracapsular hip fractures who received an ultrasound-guided femoral nerve block (USFNB).A multicenter, prospective, randomized, clinical trial.The study was conducted in the emergency departments of 3 academic hospitals located in New York City.Patients aged ≥60 years presenting to the emergency department with hip fracture.A subgroup analysis from a larger data set was conducted of patients with intracapsular and extracapsular hip fractures who received an USFNB. We compared pain scores at baseline and then at 2 and 3 hours after the nerve block was performed, and also assessed pain relief at 2 and 3 hours.Seventy-seven patients were randomized to receive USFNB, of which 68 had follow-up data at 2 and 3 hours and were included in the data analysis. Thirty-one were diagnosed with intracapsular and 37 with extracapsular hip fractures. In both groups, reductions in pain scores were clinically and statistically significant. In the intracapsular group, mean pain scores decreased from 6.23 to 3.81 (P.0001) at 2 hours and from 6.23 to 3.87 (P.0001) at 3 hours. In the extracapsular group, mean pain scores decreased from 6.62 to 3.89 (P.0001) at 2 hours and from 6.62 to 3.46 (P.0001) at 3 hours. These differences were similar between the extracapsular and intracapsular groups at 2 hours (P = .92) and at 3 hours (P = .58), thus demonstrating similar reductions in pain in the 2 groups. The differences in pain relief between the intracapsular and extracapsular groups were also similar: 1.61 (confidence interval [CI], 1.14-2.08) vs 1.35 (CI, 0.96-1.75) at 2 hours (P = .39) and 1.68 (CI, 1.21-2.15) vs 1.38 (CI, 0.89-1.87) at 3 hours (P = .38).Ultrasound-guided femoral nerve block was equally effective in reducing pain for patients with both intracapsular and extracapsular hip fractures.

Objective Most soft tissue neck masses represent benign inflammatory or infectious processes; however, in some cases the diagnosis is not clear and a broader differential must be considered. The aim of this study was to compare point-of-care ultrasound (POCUS) to radiology department imaging (RDI) in the diagnosis of soft tissue neck masses. Methods This prospective pilot study involved a convenience sample of patients ranging in age from 1 month to 18 years of age presenting to the Pediatric Emergency Department (PED) with a soft tissue neck mass. All children who presented to the PED with soft tissue neck mass at times when an investigator was in the department, and who were candidates for enrollment, underwent a POCUS. The managing pediatric emergency medicine (PEM) provider determined whether RDI was indicated. The results of the POCUS sonologist and radiologist were compared. The kappa statistic was used to analyze agreement with p Results Twenty-seven patients were enrolled into the study. Twenty-two received radiology ultrasound (RUS), 3 patients received CT, and 2 patients received both RUS and CT. There was agreement between POCUS and RDI diagnoses in 21/27 cases (78%). Accordingly, overall concordance between POCUS and RDI diagnoses was good: the kappa statistic comparing diagnoses obtained by POCUS versus RDI was 0.69 (p Conclusion This prospective pilot study describes the reliability of POCUS as an imaging modality in the management of patients with undifferentiated soft tissue neck masses. POCUS demonstrated good agreement with RDI as a bedside imaging tool in the evaluation of pediatric soft tissue neck masses.

Objective To describe our experience with intravenous lidocaine (IVL) to manage pain of renal colic origin in the emergency department (ED). Methods A retrospective analysis of all patients presenting with pain of renal colic origin from the periods of 2014 to 2017 by using the ED electronic medical record database (Allscripts™). Results Forty-four patients received IVL for renal colic over a three-year period. The average dose of IVL as a primary analgesic was 117.2 mg, and as a rescue was 108 mg. Administration of IVL resulted in a decrease in overall pain score by 6.3 points (numerical rating scale), by 7.4 points when IVL was used as a primary analgesic, and by 5.2 points when IVL was given as a rescue. There were no documented adverse effects. Conclusion Intravenous lidocaine has a potential of being used for patients presenting to the ED with a pain of renal colic origin as a primary analgesic or as a rescue. Although promising, this therapy will need to be studied in prospective randomized fashion and larger patients' population with underlying cardiac disease before it can be recommended for broad use in the ED.

Author(s): Motov, Sergey; Drapkin, Jefferson; Butt, Mahlaqa; Thorson, Andrew; Likourezos, Antonios; Flom, Peter; Marshall, John | Abstract: Introduction: We aimed to evaluate the patterns of analgesic prescribing for emergency department (ED) patients suffering from pain of renal colic before, during, and after implementation of an opioid reduction initiative. We hypothesized that this initiative based on the concept of channels/enzymes/receptors-targeted analgesia would result in overall decrease in opioid utilization in the ED and at discharge. Methods: We performed a retrospective analysis of ED electronic medical record of patients presenting with renal colic who received analgesics in the ED and at discharge over a five-year period. Patients were divided into three groups based on the following periods: 2012-2014 (pre-implementation phase); 2014-2015 (implementation phase); and 2015-2017 (post-implementation).Results: A total of 4,490 patients presented to the ED with renal colic over a five-year study period. Analgesics were administered to 3,793 ED patients of whom 1,704 received opioids and 2,675 received non-opioid analgesics. A total of 3,533 ED patients received a prescription for analgesic(s) upon discharge from the ED: 2,692 patients received opioids, and 2,228 received non-opioids. We observed a 12.7% overall decrease from the pre-implementation to post-implementation time period in opioid prescribing in the ED and a 25.5% decrease in opioid prescribing at discharge, which translated into 432 and 768 fewer patients receiving opioids, respectively. Conclusion: Implementation of an opioid-reduction initiative based on patient-specific, pain syndrome-targeted opioid alternative protocols resulted in a reduction in opioid administration in the ED by 12.7% and at prescriptions at discharge by 25.5%. Adoption of similar ED initiatives nationwide has the potential to foster effective non-opioid analgesic practices for ED patients presenting with renal colic and to reduce physicians’ reliance on administering and prescribing opioids.

The Publisher regrets that this article is an accidental duplication of an article that has already been published, http://dx.doi.org/10.1016/j.ajem.2018.03.017. The duplicate article has therefore been withdrawn. The full Elsevier Policy on Article Withdrawal can be found at https://www.elsevier.com/about/our-business/policies/article-withdrawal.

Introduction: Despite high rates of burnout in senior medical students, many schools provide the majority of their wellness training during the first and second preclinical years. Students planning a career in emergency medicine (EM) may be at particularly high risk of burnout, given that EM has one of the highest burnout rates of all the specialties in the U.S. We developed an innovative, mindfulness-based curriculum designed to be integrated into a standard EM clerkship for senior medical students to help students manage stress and reduce their risk of burnout. Methods: The curriculum included these components: (1) four, once-weekly, 60-minute classroom sessions; (2) prerequisite reading assignments; (3) individual daily meditation practice and journaling; and (4) the development of a personalized wellness plan with the help of a mentor. The design was based on self-directed learning theory and focused on building relatedness, competence, and autonomy to help cultivate mindfulness. Results: Thirty students participated in the curriculum; 20 were included in the final analysis. Each student completed surveys prior to, immediately after, and six months after participation in the curriculum. We found significant changes in the self-reported behaviors and attitudes of the students immediately following participation in the curriculum, which were sustained up to six months later. Conclusion: Although this was a pilot study, our pilot curriculum had a significantly sustained self-reported behavioral impact on our students. In the future, this intervention could easily be adapted for any four-week rotation during medical school to reduce burnout and increase physician wellness.

IMPORTANCE Emergency Physicians often rely on Lactic Acid (LA) values to make important clinical decisions. Accuracy of LA values improve when blood gas analysis is performed in the emergency department (ED) as opposed to a satellite laboratory (SL). OBJECTIVE To investigate an association between blood gas laboratory location and accuracy of ED lactic acid samples. METHODS The study team evaluated lactic acid values from venous and arterial blood gas samples drawn between June 1, 2015 and September 30, 2016. The study was exempt from institutional review board approval. Samples were separated into two groups: those which were drawn prior to and after relocation of the blood gas laboratory to the ED. The data, including patient demographic characteristics, acute illness severity indices, and blood gas results were compared within and between each group using t-test for continuous variables and chi-square test for categorical variables. The primary outcome was the mean lactate value measured in the SL group in 2015 compared to the ED group in 2016. Potassium and creatinine values were measured between the two groups as secondary outcomes. RESULTS Of the 21,595 consecutive samples drawn, 10,363 samples were from the SL group and 11,232 from the ED group. The SL group included 5458 (52.7%) women; mean (SD) age was 61.8 (21.0). The ED group contained 5860 (52.2%) women; mean (SD) age was 61.7 (20.5). Mean Emergency Severity Index (ESI) were the same in each group at 2.31 and rates of Systemic Inflammatory Response Syndrome (SIRS) were also equivalent in each group at 22.2%. Significant differences were found between LA values in the SL group (mean 2.21mmol/L) and in the ED group (mean 1.99mmol/L) with a p value of

PurposeTo identify the subjective and objective characteristics that pharmacy residency programs use to define a successful resident and to determine what percentage of their 2009-2010 residency class they felt were successful.MethodsAn electronic survey was sent via e-mail to all residency program directors (RPDs) of postgraduate year 1 (PGY1) and postgraduate year 2 (PGY2) pharmacy residency programs in the United States. A 3-part survey instrument was developed following validation of questions for clarity and reliability using a pilot survey. Respondents were asked to rank the importance of 20 subjective characteristics for a resident to possess in order to be considered successful and the importance of different objective measurements of accomplishment in the definition of a “successful” resident using a Likert scale where 1 = not at all important, 2 = some importance, 3 = very important, and 4 = critical.ResultsOf the 1,081 surveys sent to RPDs, 473 respondents answered at least one question, yielding a response rate of 43.8%. The most critically important subjective characteristics in defining a successful resident as ranked among PGY1 residency programs are dependability, professionalism, self-motivation/initiative, and work ethic. PGY2 programs ranked clinical knowledge and skills, critical thinking, and dependability as the most important. The most critically important objective characteristic in defining a successful resident as ranked among both PGY1 and PGY2 programs is obtaining a clinical position. The majority of PGY1 and PGY2 respondents felt that 76% to 100% of their 2009-2010 residency class was successful based on the characteristics they rated most important.ConclusionIdentification of the characteristics that pharmacy residency programs use to define success will allow them to identify predictors of success and optimal methods of selecting residents who possess these characteristics.

This is a case of a 19-year-old male who presented to the medical tent at an outdoor electronic dance music festival (EDMF) due to an altered mental state in the setting of acute 3,4-methylenedioxymethamphetamine (MDMA) intoxication. He was noted to be in severe respiratory distress, required endotracheal intubation in the field and subsequently developed Acute Respiratory Distress Syndrome (ARDS) without other acute organ dysfunction. He was hospitalized for 5days requiring endotracheal intubation and mechanical ventilation. By presenting this case, we will explore and discuss the cardiopulmonary effects of MDMA intoxication that can lead to a rare, deleterious complication of MDMA intoxication other than previously reported adverse outcomes.

Study objective Compare adverse effects and analgesic efficacy of low-dose ketamine for acute pain in the ED administered either by single intravenous push (IVP) or short infusion (SI). Methods Patients 18–65, presenting to ED with acute abdominal, flank, or musculoskeletal pain with initial pain score≥5, were randomized to ketamine 0.3mg/kg by either IVP or SI with placebo double-dummy. Adverse effects were evaluated by Side Effects Rating Scale for Dissociative Anesthetics (SERSDA) and Richmond Agitation-Sedation Scale (RASS) at 5, 15, 30, 60, 90, and 120min post-administration; analgesic efficacy was evaluated by Numerical Rating Scale (NRS). Results 48 patients enrolled in the study. IVP group had higher overall rates of feeling of unreality on SERSDA scale: 92% versus 54% (difference 37.5%; p =0.008; 95% CI 9.3–59.5%). At 5min median severity of feeling of unreality was 3.0 for IVP versus 0.0 for SI ( p =0.001). IVP also showed greater rates of sedation on RASS scale at 5min: median RASS −2.0 versus 0.0 ( p =0.01). Decrease in mean pain scores from baseline to 15min was similar across groups: 5.2±3.53 (95% CI 3.7–6.7) for IVP; 5.75±3.48 (95% CI 4.3–7.2) for SI. There were no statistically significant differences with respect to changes in vital signs and need for rescue medication. Conclusion Low-dose ketamine given as a short infusion is associated with significantly lower rates of feeling of unreality and sedation with no difference in analgesic efficacy in comparison to intravenous push.