Academic Emergency Medicine最新文献

Background: Ultrasound-guided nerve blocks (UGNBs) are a core component of multimodal analgesia for acute pain management in emergency departments (EDs). In addition to using standard local anesthetics, adjuncts have been demonstrated to extend the duration of UGNBs. We evaluated the efficacy and safety of dexamethasone and epinephrine as anesthetic adjuncts in UGNBs in the ED.

Methods: Data were analyzed from the National Ultrasound-guided neRVE (NURVE) Block Registry, a retrospective, multicenter, observational registry evaluating UGNBs performed in 11 EDs from January 1, 2022, to December 31, 2023. A generalized linear mixed effects model (GLMER) with a binomial family examined factors associated with pain reduction when comparing adjunct vs. non-adjunct UGNBs. The dependent variable and primary outcome were pain reduction. Secondary outcomes included safety, dosing of adjuncts, and complications.

Results: A total of 29.6% (812/2742) of UGNBs received adjuncts, most commonly dexamethasone (72.5%, 589/812) and epinephrine (23.5%, 191/812). Dexamethasone had a 1.99 odds ratio of > 50% pain reduction versus isolated local anesthetic blocks, while epinephrine had an odds ratio of 0.99 for > 50% pain reduction. There was no association between adjunct use and complications.

Conclusion: Compared to isolated local anesthetic nerve blocks, dexamethasone had an association with improved pain control within 60 min; without additional safety concerns in a large retrospective dataset. Prospective studies are needed to further investigate these findings in the ED setting.

Objectives: Identifying predictors of increased healthcare utilization for hyperglycemia may have important implications for designing interventions to improve patient outcomes and reduce costs. Studies examining predictors of 30-day recurrent ED hyperglycemia visits have been limited due to their retrospective nature. This study's objective was to prospectively identify predictors of 30-day recurrent ED visits for hyperglycemia in patients with diabetes.

Methods: We conducted a multicentre, prospective cohort study of adults ≥ 18 years at one of four Canadian tertiary care, academic EDs with a diagnosis of hyperglycemia, diabetic ketoacidosis, or hyperosmolar hyperglycemic state. Multivariable logistic regression analysis was used to identify variables independently associated with recurrent 30-day ED visits for hyperglycemia.

Results: We enrolled 594 patients; 80 (13.5%) had a recurrent ED visit for hyperglycemia within 30 days. Independently associated predictors of 30-day recurrent visits on complete case analysis include substance abuse history (odds ratio [OR] 2.32, 95% confidence interval [CI]: 1.23-4.38) and initial laboratory blood glucose (OR 1.04, 95% CI: 1.01-1.07), while a new diabetes diagnosis was negatively associated (OR 0.29, 95% CI: 0.09-0.94). Sensitivity analysis using multiple imputation for missing data found the following independently associated variables: substance abuse history (OR 2.55, 95% CI: 1.34-4.85), previous ED visit within the past 14 days (OR 2.14, 95% CI: 1.02-4.48), and initial laboratory blood glucose (OR 1.04, 95% CI: 1.01-1.07). Two variables were negatively associated: recent hospitalization within the past 30 days (OR 0.40, 95% CI: 0.19-0.98) and new diabetes diagnosis (OR 0.37, 95% CI: 0.14-0.97).

Conclusions: This multicentre prospective study reports predictors independently associated with 30-day recurrent ED visits for hyperglycemia. These predictors should be considered by ED clinicians when making disposition and follow-up plans for this important patient population, and future interventions should explore the interaction between hyperglycemia and substance use to prevent recurrent ED visits and reduce healthcare system costs and utilization.

Background: Managing pain associated with pediatric femur fractures is challenging. The ultrasound-guided fascia iliaca compartment nerve block (FICNB) provides regional analgesia for femur fractures in adults, but data on its effectiveness when provided by pediatric emergency medicine (PEM) physicians for children in the emergency department (ED) is limited.

Methods: This multi-center, prospective, observational study enrolled children aged 4-17 years who presented to the ED with an isolated, acute femur fracture. Participants received either a FICNB performed by a PEM physician or systemic analgesia alone, determined by each site's routine practice. Participants self-reported pain intensity using the Faces Pain Scale-Revised (0-10 continuous) at baseline, 60 min, and 240 min post-enrollment. The primary outcome was the mean difference in pain score reduction at 60 min compared to baseline between the two groups. Secondary outcomes included the mean difference in pain score at 240 min, opioid use, and adverse events.

Results: Across 12 sites 114 participants were enrolled, and 54 received the FICNB. The groups had similar baseline characteristics. The FICNB group had a larger reduction in pain score compared to the No-FICNB group at 60 min (mean 3.8 vs. 0.8, difference between groups 3.0 [95% CI, 1.7 to 4.3]) and 240 min (mean 3.6 vs. 1.7, difference between groups 1.9 [95% CI, 0.5 to 3.2]). The FICNB group used 73% fewer oral morphine equivalents per hour (0.3 vs. 1.1, difference between groups 0.8 [95% CI, 0.4 to 1.1]). There were no significant adverse events in either group.

Conclusions: Children who received a FICNB appeared to have a greater reduction in pain intensity and required less opioid medication than those who did not. This is the largest prospective study evaluating the ultrasound-guided FICNB performed on children in the ED, and its findings support the procedure's use for pediatric femur fracture pain management.

Trial registration: Clinicaltrials.gov (NCT05947292, https://clinicaltrials.gov/study/NCT05947292).

Background: Programs redirecting patients with non-urgent presentations from Emergency Departments (EDs) to the community (ED2C), by providing them a booked community appointment in lieu of waiting for ED care, may reduce ED crowding. We sought to evaluate the department- and patient-level impact of an ED2C program in an urban tertiary pediatric ED.

Methods: We conducted a matched cross-sectional study to describe patients redirected by a pediatric ED2C program and determine if the program changed ED operations. Days with the program were matched on day type (weekday vs. weekend) and department volume (±10%) to days when ED patients were not being redirected. Measures of ED flow and utilization on days with and without the program were compared using t-tests and linear regression models.

Results: Of the 6164 patients eligible for the ED2C program for 53 days that redirection was offered, 900 were redirected (14.6%). On average, 17.7 (SD 8.5) patients were redirected and 92.4 (SD 23.7) eligible patients were not redirected each day the ED2C was in operation. Patients who were redirected had a significantly shorter length of stay (LOS) than those who were eligible but not redirected (2.9 ± 2.0 h vs. 8.5 ± 4.3 h, p-value < 0.0001). Three patients who were redirected (0.3%) and 11 eligible but not redirected (0.2%) returned to the ED and were hospitalized. Average median departmental LOS, time to physician assessment, daily proportion hospitalized patients, proportion of patients left without being seen, and ED return visits did not differ on days with and without the program.

Conclusions: A small proportion of eligible patients were redirected. These patients experienced a lower LOS, without increasing the proportion of return visits. ED operations were unchanged. Refining eligibility criteria for pediatric redirection with an emphasis on patient safety is necessary.