Background
Heart rate variability (HRV) analysis powered by artificial intelligence (AI) offers a rapid, non-invasive, and objective approach for acute coronary syndrome (ACS) risk stratification in the emergency department (ED). The objective of this study was to evaluate the feasibility and impact of aiTriage™, an AI HRV-guided tool for chest pain triage, compared with standard care.
Methods
In this single-blinded randomized controlled trial, 560 ED patients with suspected ACS underwent 5- minute ECG monitoring for HRV analysis, which generated a 0–100 risk score and triage recommendations (high, medium, or low risk). Patients were randomized to standard care (control) or an HRV-guided protocol (intervention). Physicians in the control group were blinded to HRV results.
Results
Of 426 analysed patients (mean age 54 ± 13 years, 35% female, 16.2% prior MI), the HRV-guided protocol reduced hospital admissions (50.2% vs 61.1%; risk difference -10.9 percentage points, 95% CI: -20.1 to -1.8) and serial cardiac enzyme testing (32.1% vs 41.7%; risk difference -9.6 percentage points, 95% CI: -18.4 to -0.9) compared with standard care. Among discharged patients, the median ED length of stay was 20 minutes shorter in the intervention group (95% CI: -45 minutes to 3 minutes). The overall 30-day MACE rate was 9.5%, with no events among discharged patients.
Conclusion
A rapid AI HRV-guided risk stratification tool was feasible to deploy, and has potential to reduce serial cardiac enzyme testing, ED LOS and hospital admissions. An adequately powered RCT is needed to confirm these findings and assess clinical safety. This trial is registered at ClinicalTrials.gov (NCT07074808).
Objective Abdominal pain is the most common emergency department (ED) chief complaint, with many patients experiencing recurrent episodes due to non–life-threatening etiologies such as disorders of gut-brain interaction. This pilot study aimed to characterize patients with recurrent low-risk abdominal pain, focusing on pain severity, management, biopsychosocial factors, opioid use, and 30-day return visits. Methods This prospective, observational pilot study enrolled adult ED patients with recurrent abdominal pain at a single academic center between July 2022 and June 2023. Inclusion required at least one similar episode in the prior year with symptom resolution between episodes. Exclusions included unstable clinical status or high-risk conditions. Patient-reported outcomes, social determinants of health, and clinical data were collected. Primary outcomes included pain severity, opioid use, and 30-day return visit rates. Results A total of 101 participants were enrolled (mean age, 43.7 years; 65.3% female; 69.3% Black). Pain severity was high (triage pain score, 7.1±2.6). Frequent prior computed tomography imaging was noted in 56.4% of participants. Opioids were administered in 50 participants (49.5%), while Patient-Reported Outcomes Measurement Information System (PROMIS)-29 scores highlighted risks of anxiety (T-score, 56.0±11.1) and pain interference (T-score, 60.8±8.2). Return visits occurred in 11 participants (10.9%) within 30 days. Conclusion In this pilot study, patients with recurrent low-risk abdominal pain showed high symptom burden and healthcare utilization. Targeted interventions addressing biopsychosocial factors and improving pain management are needed to reduce ED revisits and improve outcomes.
Objective Abdominal pain is one of the most common emergency department (ED) complaints, with many patients experiencing recurrent episodes due to cannabinoid hyperemesis syndrome (CHS), a syndrome characterized by pain and vomiting in the setting of chronic cannabis use. This pilot study aimed to demonstrate the ability to enroll patients with CHS, characterize patient-reported outcomes (PROs), and estimate 30-day revisit rates. Methods This prospective observational study enrolled adult ED patients with CHS at an academic center and community affiliate. The inclusion required a prior diagnosis of CHS and ED clinician judgment that symptoms at time of enrollment were likely due to CHS. Exclusions included unstable clinical status or other high-risk conditions. Primary outcomes included characterization of symptoms, assessment of multiple domains of PROs, measurement of the use of both computed tomography (CT) scans and opioid analgesia, and frequency of 30-day ED return visits. Results A total of 18 participants were enrolled (mean age, 34 years; 10 female patients, 55.6%). Automated chart reviews were completed for each outcome of interest at 30 days and at 12 months. Pain severity was high (mean triage pain score, 6.2±4.3) and prior CT imaging was noted in 13 patients (72.2%) in the past 5 years. Opioids were administered in four patients (22.2%), while the 29-Item Patient-Reported Outcome Measurement Information System (PROMIS-29) scores highlighted high risk of anxiety (mean T-score, 56.11±11.45) and how pain interfered with normal activities of living (mean T-score, 62.24±11.11). Return visits occurred in three patients (16.7%) within 30 days. Conclusion ED patients with CHS show a significant burden on PROs and high 30-day revisit rates. Future studies should consider interventions that address PROs and reduce ED revisits.
Objective Acute painful conditions are a common reason for emergency department (ED) referral, and a broad variety of analgesic drugs can be used. Among them, ketorolac is a nonsteroidal anti-inflammatory drug (NSAID) that has been increasingly used in the past two decades. To clarify the evidence for using ketorolac in EDs, a systematic review and meta-analysis was performed. Methods A search was performed in PubMed for English-language articles published on or before February 2023. Only randomized controlled trials in adult patients with acute painful conditions treated in an ED were selected. A meta-analysis was performed to evaluate the effectiveness of ketorolac in different pain conditions. Results Forty randomized controlled trials were selected, including studies focused on acute renal colic, headache, traumatic and nontraumatic musculoskeletal pain, and biliary colic. In these studies, ketorolac was mainly compared to opioids and showed a similar analgesic efficacy. On the other hand, ketorolac does not seem to have a stronger analgesic effect than other NSAIDs. Conclusion This systematic review indicates that ketorolac may be a valuable alternative to opioids for inducing analgesia in adult ED patients. This meta-analysis showed no significant difference in efficacy between ketorolac and other drugs. Nevertheless, the evidence comparing its efficacy with other common NSAIDs is sparse and should be further explored in future studies.
Objective Ketamine is a promising drug for analgesia in emergency medicine, but the high rate of side effects is a barrier to widespread usage. We hypothesized that ketamine bolus followed by ketamine infusion would provide a more even and longer duration of analgesia and lower rates of side effects in comparison to bolus-only administration.
Methods This was a double-blinded clinical trial. Eligible trauma patients were randomly allocated with the numeric rating scale ≥6 in two study groups. The first group received a dose of 0.3 mg/kg of ketamine over 1 minute, followed by an infusion of saline 0.9% over the next 30 minutes (bolus-only group). The second group was given 0.15 mg/kg of ketamine over 1 minute, followed by an infusion of 0.15 mg/kg over the next 30 minutes (bolus-and-infusion group). The primary outcome was to measure the average reduction in pain scores.
Results In total, 80 patients were recruited. Of these, 77 patients were analyzed. Both groups achieved a statistically significant decrease in pain scores (all P<0.001). After 30 minutes, patients in the bolus-and-infusion group reported lower pain scores in all intervals with lower rates of need for rescue analgesia, but this difference was not statistically significant. Vital signs remained stable during the study in both groups. No statistically significant difference was observed between study groups for any side effect (P<0.05).
Conclusion Both administration protocols resulted in significant pain control. No statistically significant difference was observed between study groups in terms of analgesic efficacy and side effects.
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Abdominal pain is one of the most common presenting chief complaints in the emergency department. Erector spinae plane block (ESPB) is an ultrasound-guided nerve block with proven effectiveness in treating visceral and somatic abdominal pain. Despite the increasing popularity of ESPB, its role in the management of nonsurgical abdominal pain has not yet been characterized. Our scoping review aims to synthesize current knowledge on the safety and efficacy of ESPB in the management of patients experiencing intractable, nonsurgical abdominal pain. We searched PubMed and Scopus to evaluate the existing literature on ESPB for nonsurgical abdominal pain. A total of 14 journal articles were included: 12 case-based studies, one systematic review, and one narrative review. All cases described the successful use of ESPB in treating abdominal pain refractory to oral or intravenous analgesic medications, and no complications were reported in any cases. This scoping review provides support for the use of ESPB to manage intractable, nonsurgical abdominal pain. ESPB has demonstrated efficacy in alleviating various conditions such as functional abdominal pain, renal colic, pancreatitis, herpetic pain, and cancer-related pain. Theoretical risks such as pneumothorax, bleeding, and infection are possible, although the studies reviewed did not report such complications.
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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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10.1016/s1959-5182(23)46578-6
CrossRef Listing of Deleted DOIs.2000;[Epub] CrossRef
Objective This study aimed to clarify the relative prognostic value of each History, Electrocardiography, Age, Risk Factors, and Troponin (HEART) score component for major adverse cardiac events (MACE) within 3 months and validate the modified HEART (mHEART) score.
Methods This study evaluated the HEART score components for patients with chest symptoms visiting the emergency department from November 19, 2018 to November 19, 2019. All components were evaluated using logistic regression analysis and the scores for HEART, mHEART, and Thrombolysis in Myocardial Infarction (TIMI) were determined using the receiver operating characteristics curve.
Results The patients were divided into a derivation (809 patients) and a validation group (298 patients). In multivariate analysis, age did not show statistical significance in the detection of MACE within 3 months and the mHEART score was calculated after omitting the age component. The areas under the receiver operating characteristics curves for HEART, mHEART and TIMI scores in the prediction of MACE within 3 months were 0.88, 0.91, and 0.83, respectively, in the derivation group; and 0.88, 0.91, and 0.81, respectively, in the validation group. When the cutoff value for each scoring system was determined for the maintenance of a negative predictive value for a MACE rate >99%, the mHEART score showed the highest sensitivity, specificity, positive predictive value, and negative predictive value (97.4%, 54.2%, 23.7%, and 99.3%, respectively).
Conclusion Our study showed that the mHEART score better detects short-term MACE in high-risk patients and ensures the safe disposition of low-risk patients than the HEART and TIMI scores.
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Objective The history, electrocardiogram, age, risk factors, troponin (HEART), the thrombolysis in myocardial infarction (TIMI), and Global Registry of Acute Coronary Events (GRACE) scores are useful risk stratification tools in the emergency department (ED). However, the accuracy of these scores in the cancer population is not well known. This study aimed to compare the performance of cardiac risk stratification scores in cancer patients with suspected acute coronary syndrome (ACS) in the ED.
Methods This prospective cohort study recruited patients with cancer who visited the ED because of suspected ACS. The development of any major adverse cardiac events (MACE) within 6 weeks was recorded, with the study outcome being a MACE within 6 weeks of ED admission.
Results A total of 178 patients participated in this study, of whom 5.6% developed a MACE. Statistically significant differences were found between the mean HEART and TIMI scores in predicting MACE. The HEART score had the highest area under the curve (0.64; 95% confidence interval, 0.48–0.81), highest sensitivity (80%), and highest negative predictive value (97.5) in patients with cancer.
Conclusion We found a similar rate of MACE in cancer patients with low-risk chest pain compared to that in the general population. However, the HEART, TIMI, and GRACE scores had a lower performance in cancer patients with MACE compared to that in the general population.
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Objective Rapid determination of acute coronary syndrome (ACS) in the emergency department (ED) is very important for patients presenting with ischemic symptoms. The aim of this study was to determine the predictive value of HEART score for ACS and significant coronary artery stenosis (SCS).
Methods We retrospectively analyzed data of patients who visited the ED with chest discomfort and were admitted to the cardiology department. Enrolled patients were classified into ACS and non-ACS groups according to their discharge diagnosis. Patients who underwent imaging were further divided into SCS and non-SCS groups according to study results. We compared age, sex, vital signs, risk factors, electrocardiogram, troponin, and HEART score for each group. For ACS and SCS predictive performance, the test characteristics of HEART score was calculated using sensitivity, specificity, predictive value, likelihood ratio, and receiver operating characteristic (ROC) curve analysis.
Results Of 207 patients, 112 had ACS. Among enrolled patients, 155 underwent imaging workup, of whom 67 had SCS. HEART score ≤3 had 93% sensitivity for ACS and 97% for SCS. HEART score ≥7 had 82% specificity for ACS and 83% for SCS. HEART score area under ROC curve for ACS was 0.706 (95% confidence interval, 0.627–0.776) and 0.737 (95% confidence interval, 0.660–0.804) for SCS.
Conclusion HEART score was a fair predictor of ACS and SCS in ED patients who presented with chest symptoms and were admitted to the cardiology department. The predictive power of HEART score was better for SCS than for ACS.
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Nicola Parenti, Giuseppe Lippi, Maria Letizia Bacchi Reggiani, Antonio Luciani, Mario Cavazza, Antonello Pietrangelo, Alberto Vegetti, Lucio Brugioni, Laura Bonfanti, Gianfranco Cervellin
Clin Exp Emerg Med 2019;6(3):212-217. Published online September 30, 2019
Objective To rapidly and safely identify the risk of developing acute coronary syndrome in patients with chest pain who present to the emergency department, the clinical use of the History, Electrocardiogram, Age, Risk Factors, and Troponin (HEART) scoring has recently been proposed. This study aimed to assess the inter-rater reliability of the HEART score calculated by a large number of Italian emergency physicians.
Methods The study was conducted in three academic emergency departments using clinical scenarios obtained from medical records of patients with chest pain. Twenty physicians, who took the HEART score course, independently assigned a score to different clinical scenarios, which were randomly administered to the participants, and data were collected and recorded in a spreadsheet by an independent investigator who was blinded to the study’s aim.
Results After applying the exclusion criteria, 53 scenarios were finally included in the analysis. The general inter-rater reliability was good (kappa statistics [κ], 0.63; 95% confidence interval, 0.57 to 0.70), and a good inter-rater agreement for the high- and low-risk classes (HEART score, 7 to 10 and 0 to 3, respectively; κ, 0.60 to 0.73) was observed, whereas a moderate agreement was found for the intermediate-risk class (HEART score, 4 to 6; κ, 0.51). Among the different items of the HEART score, history and electrocardiogram had the worse agreement (κ, 0.37 and 0.42, respectively).
Conclusion The HEART score had good inter-rater reliability, particularly among the high- and low-risk classes. The modest agreement for history suggests that major improvements are needed for objectively assessing this component.
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Clin Exp Emerg Med 2019;6(3):196-203. Published online July 12, 2019
Objective Bedside consultation by cardiologists may facilitate safe discharge of selected patients from the emergency department (ED) even when admission is recommended by the History, Electrocardiogram, Age, Risk factors, Troponin (HEART) pathway. If bedside evaluation is unavailable, phone consultation between emergency physicians and cardiologists would be most impactful if the resultant disposition is discordant with the HEART pathway. We therefore evaluate discordance between actual disposition and that suggested by the HEART pathway in patients presenting to the ED with chest pain for whom cardiology consultation occurred exclusively by phone and to assess the impact of phone-consultation on disposition.
Methods We performed a single-center, retrospective study of adults presenting to the ED with chest pain whose emergency physician had a phone consultation with a cardiologist. Actual disposition was abstracted from the medical record. HEART pathway category (low-risk, discharge; high-risk, admit) was derived from ED documentation. For discharged patients, major adverse cardiac events were assessed at 30 days by chart review and phone follow-up.
Results For the 170 patients that had cardiologist phone consultation, discordance between actual disposition and the HEART pathway was 17%. The HEART pathway recommended admission for nearly 80% of discharged patients. Following cardiologist phone-consultation, 10% of high-risk patients were discharged, with the majority having undergone a functional study recommended by the cardiologist. At 30 days, discharged patients had experienced no episodes of major adverse cardiac events or rehospitalization for cardiac reasons.
Conclusion For patients presenting to the ED with chest pain, cardiology phone-consultation has the potential to safely impact disposition, primarily by facilitating functional testing in high-risk individuals.
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Objective The aim of this study was to investigate the effectiveness of a quality improvement activity for pain management in patients with extremity injury in the emergency department (ED).
Methods This was a retrospective interventional study. The patient group consisted of those at least 19 years of age who visited the ED and were diagnosed with International Classification of Diseases codes S40–S99 (extremity injuries). The quality improvement activity consisted of three measures: a survey regarding activities, education, and the triage nurse’s pain assessment, including change of pain documentation on electronic medical records. The intervention was conducted from January to April in 2014 and outcome was compared between May and August in 2013 and 2014. The primary outcome was the rate of analgesic prescription, and the secondary outcome was the time to analgesic prescription.
Results A total of 1,739 patients were included, and 20.3% of 867 patients in the pre-intervention period, and 28.8% of 872 patients in the post-intervention period received analgesics (P< 0.001). The prescription rate of analgesics for moderate-to-severe injuries was 36.4% in 2013 and 44.5% in 2014 (P=0.026). The time to analgesics prescription was 116.6 minutes (standard deviation 225.6) in 2013 and 64 minutes (standard deviation 75.5) in 2014 for all extremity injuries. The pain scoring increased from 1.4% to 51.6%.
Conclusion ED-based quality improvement activities including education and change of pain score documentation can improve the rate of analgesic prescription and time to prescription for patients with extremity injury in the ED.
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Clin Exp Emerg Med 2017;4(4):208-213. Published online December 30, 2017
Objective Chest pain is one of the most common complaints in the emergency department (ED). Cardiac computed tomography angiography (CCTA) is a frequently used tool for the early triage of patients with low- to intermediate-risk acute chest pain. We present a study protocol for a multicenter prospective randomized controlled clinical trial testing the hypothesis that a low-dose CCTA protocol using prospective electrocardiogram (ECG)-triggering and limited-scan range can provide sufficient diagnostic safety for early triage of patients with acute chest pain.
Methods The trial will include 681 younger adult (aged 20 to 55) patients visiting EDs of three academic hospitals for acute chest pain or equivalent symptoms who require further evaluation to rule out acute coronary syndrome. Participants will be randomly allocated to either low-dose or conventional CCTA protocol at a 2:1 ratio. The low-dose group will undergo CCTA with prospective ECG-triggering and restricted scan range from sub-carina to heart base. The conventional protocol group will undergo CCTA with retrospective ECG-gating covering the entire chest. Patient disposition is determined based on computed tomography findings and clinical progression and all patients are followed for a month. The primary objective is to prove that the chance of experiencing any hard event within 30 days after a negative low-dose CCTA is less than 1%. The secondary objectives are comparisons of the amount of radiation exposure, ED length of stay and overall cost.
Results and Conclusion Our low-dose protocol is readily applicable to current multi-detector computed tomography devices. If this study proves its safety and efficacy, dose-reduction without purchasing of expensive newer devices would be possible.
Spinal cord infarction is a rare condition and is easily misdiagnosed owing to its initial non-specific manifestation. We report a case of a 77–year-old man who presented with chest pain and upper back pain initially, and was misdiagnosed with a myocardial infarction. Four hours after admission, he complained of numbness in his entire left leg below the knee, with rapid deterioration of neurological symptoms. After 9 hours, loss of sensation progressed up to the T4 dermatome, strength of both lower extremities deteriorated to grade 0, and decrease in anal tone and deep tendon reflex was observed. Initial magnetic resonance imaging findings were normal; however, a signal change occurred 3 days after symptom onset. When patients present with acute chest pain and neurologic symptoms, the possibility of ischemic cardiac disease as well as any neurological manifestations must be investigated. Emergency physicians must remember the value of serial physical examinations.
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Objective To evaluate intravenous lidocaine’s safety and efficacy as an analgesic agent in the treatment of a variety of painful conditions presenting to the emergency department.
Methods This case series identified seventeen patients who received lidocaine over a six month period and recorded demographic data, amount of lidocaine administered, the amount of opioid medication administered before and after lidocaine, pre- and post-lidocaine pain scores, and any qualitative descriptors of the patient’s pain recorded in the record. Side effects and adverse events were also recorded.
Results Of the seven patients who had a pre- and post-lidocaine pain score recorded, the mean reduction was 3 points on a 10 point scale. Patients who received lidocaine used less opioid medication. One patient received an improperly high dose of lidocaine and suffered a brief seizure and cardiac arrest, but was quickly resuscitated.
Conclusion This series suggests that lidocaine may be a useful adjunct in the treatment of acutely painful conditions in the emergency department.
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Safety and Efficacy of Intravenous Lidocaine for Pain Management in the Emergency Department: A Systematic Review Lucas Oliveira J. e Silva, Kristin Scherber, Daniel Cabrera, Sergey Motov, Patricia J. Erwin, Colin P. West, M. Hassan Murad, M. Fernanda Bellolio Annals of Emergency Medicine.2018; 72(2): 135. CrossRef
A 52-year-old man presented to the emergency department (ED) for left frontotemporal headache and left eye pain. In the ED, visual exam with extra-ocular movement was performed to rule out ocular pathology and brain imaging to rule out cerebral pathology. No abnormal finding was noted after evaluation of ED. Initial exam by an ophthalmologist was also negative with normal intraocular pressure. Left lens dislocation was found only after brain imaging. In subsequent second exam by an ophthalmologist with iridodilator, lens dislocation due to spontaneous zonulysis was finally confirmed. Hence, ED physicians should carefully review ocular as well as brain anatomy in such cases.
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A case of angle‐closure glaucoma caused by spontaneous lens dislocation Keisuke Kondo, Hiroki Isono Clinical Case Reports.2022;[Epub] CrossRef
Pediatric patients at a high risk of headache of ocular origin: the HAMS Score (Hyperopia, Astigmatism, Myopia, and Strabismus) Paulo de Tasso Valença Veloso Siqueira, Luciana Patrízia Alves de Andrade-Valença, Juliana Ramos Andrade, Marcelo Moraes Valença Headache Medicine.2021; 12(2): 134. CrossRef
Ocular Neuropathic Pain: An Overview Focusing on Ocular Surface Pains
Objective Cardiac computed tomography (CCT) is useful for evaluation of acute chest pain in the emergency department (ED). Though the test needs proper interpretation by someone with expertise in cardiovascular imaging, the critical nature of the information the test provides frequently lead emergency physicians (EPs) to act on their own interpretation. We performed this study to assess how often EPs’ interpretations are in agreement with radiologists’.
Methods This study is a prospective observational study. The target population was patients assessed with CCT for acute chest pain or discomfort. EPs with at least one year CCT experience underwent a one-hour training session before study participation. The most significant lesion, if any, in each arterial segment was assessed for coronary stenosis and plaque calcification. The agreement between EPs’ and radiologists’ interpretation was assessed with Cohen’s kappa and Gwet’s AC1.
Results One hundred and three patients were enrolled and 412 segments were analyzed. Stenosis grading was identical in 363 segments (88.1%) and the interrater agreement was good (kappa=0.6439, AC1=0.8810). Similarly, the plaque calcification grading was identical in 354 segments (86.6%) and the kappa and AC1 values were 0.5660 and 0.8501, respectively. EPs classified 6 of the 17 arterial segments with significant stenosis reported by radiologists as non-significant stenosis (n=5) or clear (n=2), all of which were proved to be significant by following subsequent invasive coronary angiography.
Conclusion There was substantial discordance of CCT interpretation between EPs and radiologists. For now, EPs need more education prior to independent CCT reading.
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Comparison of abdominal ct interpretation levels of emergency physicians and radiologists Kasim Turgut Adıyaman Üniversitesi Sağlık Bilimleri Dergisi.2019; 5(2): 1482. CrossRef
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