CONTEXT: The optimal pharmacologic treatment for early convulsive status epilepticus is unclear. OBJECTIVE: To analyze efficacy, tolerability and safety data for anticonvulsant treatment of children and adults with convulsive status epilepticus and use this analysis to develop an evidence-based treatment algorithm. DATA SOURCES: Structured literature review using MEDLINE, Embase, Current Contents, and Cochrane library supplemented with article reference lists. STUDY SELECTION: Randomized controlled trials of anticonvulsant treatment for seizures lasting longer than 5 minutes. DATA EXTRACTION: Individual studies were rated using predefined criteria and these results were used to form recommendations, conclusions, and an evidence-based treatment algorithm. RESULTS: A total of 38 randomized controlled trials were identified, rated and contributed to the assessment. Only four trials were considered to have class I evidence of efficacy. Two studies were rated as class II and the remaining 32 were judged to have class III evidence. In adults with convulsive status epilepticus, intramuscular midazolam, intravenous lorazepam, intravenous diazepam and intravenous phenobarbital are established as efficacious as initial therapy (Level A). Intramuscular midazolam has superior effectiveness compared to intravenous lorazepam in adults with convulsive status epilepticus without established intravenous access (Level A). In children, intravenous lorazepam and intravenous diazepam are established as efficacious at stopping seizures lasting at least 5 minutes (Level A) while rectal diazepam, intramuscular midazolam, intranasal midazolam, and buccal midazolam are probably effective (Level B). No significant difference in effectiveness has been demonstrated between intravenous lorazepam and intravenous diazepam in adults or children with convulsive status epilepticus (Level A). Respiratory and cardiac symptoms are the most commonly encountered treatment-emergent adverse events associated with intravenous anticonvulsant drug administration in adults with convulsive status epilepticus (Level A). The rate of respiratory depression in patients with convulsive status epilepticus treated with benzodiazepines is lower than in patients with convul-

Mortality was higher for patients treated with DCLHb. Although further analysis should investigate whether the mortality difference was solely due to a direct treatment effect or to other factors, DCLHb does not appear to be an effective resuscitation fluid.

Abstract-Objective:To review evidence on the assessment of the child with status epilepticus (SE). Methods: Relevant literature were reviewed, abstracted, and classified. When data were missing, a minimum diagnostic yield was calculated. Recommendations were based on a four-tiered scheme of evidence classification. Results: Laboratory studies (Na ϩϩ or other electrolytes, Ca ϩϩ , glucose) were abnormal in approximately 6% and are generally ordered as routine practice. When blood or spinal fluid cultures were done on these children, blood cultures were abnormal in at least 2.5% and a CNS infection was found in at least 12.8%. When antiepileptic drug (AED) levels were ordered in known epileptic children already taking AEDs, the levels were low in 32%. A total of 3.6% of children had evidence of ingestion. When studies for inborn errors of metabolism were done, an abnormality was found in 4.2%. Epileptiform abnormalities occurred in 43% of EEGs of children with SE and helped determine the nature and location of precipitating electroconvulsive events (8% generalized, 16% focal, and 19% both). Abnormalities on neuroimaging studies that may explain the etiology of SE were found in at least 8% of children. Recommendations: Although common clinical practice is that blood cultures and lumbar puncture are obtained if there is a clinical suspicion of a systemic or CNS infection, there are insufficient data to support or refute recommendations as to whether blood cultures or lumbar puncture should be done on a routine basis in children in whom there is no clinical suspicion of a systemic or CNS infection (Level U). AED levels should be considered when a child with treated epilepsy develops SE (Level B). Toxicology studies and metabolic studies for inborn errors of metabolism may be considered in children with SE when there are clinical indicators for concern or when the initial evaluation reveals no etiology (Level C). An EEG may be considered in a child with SE as it may be helpful in determining whether there are focal or generalized epileptiform abnormalities that may guide further testing for the etiology of SE, when there is a suspicion of pseudostatus epilepticus (nonepileptic SE), or nonconvulsive SE, and may guide treatment (Level C). Neuroimaging may be considered after the child with SE has been stabilized if there are clinical indications or if the etiology is unknown (Level C). There is insufficient evidence to support or refute routine neuroimaging in a child presenting with SE (Level U).

Percutaneous injuries occur regularly during surgery, placing surgical personnel and, to a lesser extent, patients at risk for infection with blood-borne pathogens. Many such injuries may be preventable with changes in devices, techniques, or protective equipment; all such measures require careful evaluation to determine their efficacy in reducing injury and their effect on patient care.

The NISS should not replace the ISS, as they share similar accuracy and calibration.

Objective:The underuse of analgesics, or "oligoanalgesia," is common in emergency departments (EDs). To improve care we must understand our patients' pain experiences as well as our clinical practice patterns. To this end, we examined pain etiology, pain management practices and patient satisfaction in 2 urban EDs. Methods: We conducted a cross-sectional study using structured interviews and chart reviews for patients with pain who presented to either of 2 university-affiliated EDs. We assessed pain etiologies, patient pain experiences, pain management practices, and patient satisfaction with pain management. Results:The 525 study subjects reported high pain intensity levels on presentation, with a median rating of 8 on a 10-point numerical rating scale (NRS). At discharge, pain severity had decreased to a median rating of 4; however, 48% of patients were discharged from the ED in moderate to severe pain (NRS 5-10). Subjects reported spending 57% of their ED stay in moderate to severe pain. Analgesics were administered to only 50% of patients. The mean time to analgesic administration was almost 2 hours. Despite high levels of reported pain at discharge and low rates of analgesic administration, subjects reported high satisfaction with pain management. Conclusions: In the 2 EDs studied, we found high levels of pain severity for our patients, as well as low levels of analgesic use. When used, analgesic administration was often delayed. Despite these findings, patient satisfaction remained high. Despite recent efforts to improve pain management practice; oligoanalgesia remains a problem for our specialty. RÉSUMÉObjectif : La sous-utilisation des analgésiques ou «oligoanalgésie» est courante au département d'urgence (DU). Pour améliorer les soins, nous devons comprendre le niveau de douleur ressentie par nos patients ainsi que nos habitudes de pratique clinique. À cette fin, nous avons examiné l'é-tiologie de la douleur, les pratiques de prise en charge de la douleur et le degré de satisfaction des patients dans deux DU en milieu urbain. Méthodes : Nous avons mené une enquête transversale à l'aide d'entrevues structurées et de revue de dossiers pour des patients en douleur reçus à l'un ou l'autre de deux DU affiliés à une université. Nous avons évalué l'étiologie de la douleur, le niveau de douleur ressentie par les patients, les pratiques de prise en charge de la douleur et la satisfaction des patients face à cette prise en charge.

This clinical policy from the American College of Emergency Physicians addresses key issues in the evaluation and management of adult patients presenting to the emergency department with acute carbon monoxide poisoning. A writing subcommittee conducted a systematic review of the literature to derive evidence-based recommendations to answer the following clinical questions: 1) In emergency department patients with suspected acute carbon monoxide poisoning, can noninvasive carboxyhemoglobin measurement be used to accurately diagnose carbon monoxide toxicity? 2) In emergency department patients diagnosed with acute carbon monoxide poisoning, does hyperbaric oxygen therapy as compared with normobaric oxygen therapy improve long-term neurocognitive outcomes? 3) In emergency department patients diagnosed with acute carbon monoxide poisoning, can cardiac testing be used to predict morbidity or mortality? Evidence was graded and recommendations were made based on the strength of the available data. MEDLINE InProcess, Scopus, Web of Science, and the Cochrane Database were performed. All searches were

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