Anirudh Ramachandran, Michelle Montenegro, Maninder Singh, Trevor Dixon, Waqas Kayani, Timothy Liang, Nick Yu, Srinivas Reddy, Anna Liveris, Mallika Manyapu, Alyssia A. McEwan, Vincent T. Nguyen, Nechama V. Sonenthal, Jill Corbo, Benjamin W. Friedman, Jeremy Sperling, Michael P. Jones, Michael Halperin
Clin Exp Emerg Med 2022;9(3):198-206. Published online September 20, 2022
Objective Hip fractures are associated with significant morbidity and mortality. Ultrasound-guided peripheral nerve blocks are a safe method to manage pain and decrease opioid usage. The pericapsular nerve group (PENG) block is a novel, potentially superior block because of its motor-sparing effects. Through training, simulation, and supervision, we aim to determine whether it is feasible to perform the PENG block in the emergency department.
Methods Phase 1 consisted of emergency physicians attending a workshop to demonstrate ultrasound proficiency, anatomical understanding, and procedural competency using a low-fidelity model. Phase 2 consisted of a prospective, observational, feasibility study of 10 patients with hip fractures. Pain scores, side effects, and opioid usage data were collected.
Results The median pain score at time 0 (time of block) was 9 (interquartile range [IQR], 6.5–9). The median pain score at 30 minutes was 4 (IQR, 2.0–6.8) and 3.5 (IQR, 1.0–4.8) at 4 hours. All 10 patients required narcotics prior to the initiation of the PENG block with a median dosage of 6.25 morphine milligram equivalents (MME; IQR, 4.25–7.38 MME). After the PENG block, only 30% of the patients required further narcotics with a median dosage of 0 MME (IQR, 0–0.6 MME) until operative fixation.
Conclusion In this feasibility study, PENG blocks were safely administered by trained emergency physicians under supervision. We demonstrated data suggesting a trend of pain relief and decreased opiate requirements, and further investigation is necessary to measure efficacy.
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Objective Alcohol use is associated with high levels of morbidity and mortality. Alcohol problems are common in emergency departments (EDs). This study investigated the effect of screening and a new brief intervention (BI) protocol on alcohol consumption of ED patients.
Methods The participants of this study were those aged 18 years or older who visited the ED due to injury over 12 weeks. BI was offered to patients with a score of 8 or higher on alcohol use disorders identification test (AUDIT) screening. Follow-up telephone assessments were conducted at one week, one month, and three months.
Results The risk drinker (RD) group (AUDIT 8–15) comprised 101 patients, and the alcohol use disorder (AUD) group (AUDIT >16) comprised 41 patients. Before the BI, the weekly mean alcohol intake amount for the RD group was 180.90±98.34 g and for the AUD group was 358.00± 110.62 g. Alcohol consumption was reduced to 132.39±75.87 g in the RD group and 181.86± 78.11 g in the AUD group in the 3-month follow-up assessment. Alcohol consumption in the AUD group reduced significantly compared to the RD group (P<0.001).
Conclusion Alcohol screening and BI contributed to alcohol intake reduction in ED patients. Specifically, the BI effect was greater in the AUD group than the RD group. The ED can be an effective place to begin implementing screening and intervention for alcohol use patients at risk.
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Objective Prompt reperfusion is important for patients with ST elevation myocardial infarction (STEMI). However, patients often require interhospital transfer for percutaneous coronary intervention (PCI) because not all hospitals can provide. The purpose of this study is to reduce the PCI delay using a regionalization protocol in patients with STEMI following transfer from another hospital lacking PCI facility.
Methods We established a revascularization protocol designated as Preparing Revascularization Effort before Patients’ Arrival via Regionalization Engagement (PREPARE) for the STEMI patients transferred from an outside regional hospital. The protocol included immediate referral acceptance by an emergency physician, real-time electrocardiogram sharing via mobile phone and early activation of the PCI team. We analyzed the differences between the PREPARE and the non-PREPARE groups.
Results In the PREPARE group, the median time from the first hospital visit to the ballooning procedure via PCI at the receiving facility (D1-to-B time) was 111.0 (interquartile range 97.0– 130.0) minutes, which was significantly shorter than in the non-PREPARE group 134.0 (interquartile range 115.0–182.0) minutes. The proportion of D1-to-B time within 120 minutes was 30.4% in the group and 60.0% in the PREPARE group, which represents a significant difference (P=0.004). Multivariate logistic regression analysis revealed that patient transfer via PREPARE protocol (odds ratio, 3.399; 95% confidence interval, 1.150–10.050, P=0.027) was related to adequate D1-to-B time. No statistically significant differences were found in the hospital length of stay or major adverse cardiac events within 4 weeks.
Conclusion The PREPARE protocol is an effective strategy to reduce the time to revascularization of the transferred STEMI patients.
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Objective We aimed to evaluate the factors influencing treatment option selection among urologists for patients with ureteral stones, according to the stone diameter and location.
Methods We retrospectively reviewed the records of 360 consecutive patients who, between January 2009 and June 2014, presented to the emergency department with renal colic and were eventually diagnosed with urinary stones via computed tomography. The maximal horizontal and longitudinal diameter and location of the stones were investigated. We compared parameters between patients who received urological intervention (group 1) and those who received medical treatment (group 2).
Results Among the 360 patients, 179 (49.7%) had stones in the upper ureter and 181 (50.3%) had stones in the lower ureter. Urologic intervention was frequently performed in cases of upper ureteral stones (P<0.001). In groups 1 and 2, the stone horizontal diameters were 5.5 mm (4.8 to 6.8 mm) and 4.0 mm (3.0 to 4.6 mm), stone longitudinal diameters were 7.5 mm (6.0 to 9.5 mm) and 4.4 mm (3.0 to 5.5 mm), and ureter diameters were 6.4 mm (5.0 to 8.0 mm) and 4.7 mm (4.0 to 5.3 mm), respectively (P<0.001). The cut-off values for the horizontal and longitudinal stone diameters in the upper ureter were 4.45 and 6.25 mm, respectively (sensitivity 81.3%, specificity 91.4%); those of the lower ureter were 4.75 and 5.25 mm, respectively (sensitivity 79.4%, specificity 79.4%).
Conclusion The probability of a urologic intervention was higher for patients with upper ureteral stones and those with stone diameters exceeding 5 mm horizontally and 6 mm longitudinally.
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