Objective Millions of patients present to US emergency departments (ED) annually for the treatment of migraine. First‐line treatments, including metoclopramide, prochlorperazine, and sumatriptan, fail to provide sufficient relief in up to one‐third of treated patients. In this narrative review, we discuss the evidence supporting the use of injectable (intravenous, intramuscular, or subcutaneous) medications for patients in the ED who fail to improve sufficiently after treatment with first‐line medication. Methods We used the American Headache Society's guideline, “Management of Adults with Acute Migraine in the Emergency Department: The American Headache Society Evidence Assessment of Parenteral Pharmacotherapies,” published in 2016, to identify first‐line medications for migraine. We then conducted a PubMed search to determine whether any evidence supported the use of these medications as second‐line therapy and whether any evidence existed to support the use of injectable therapies not discussed in the guideline as second‐line therapy. Results We identified only scant high‐quality randomized data of second‐line therapy. Therefore, we based our recommendations on medications that have reliably demonstrated efficacy as first‐line treatment of migraine. These medications include injectable non‐steroidal anti‐inflammatory drugs (NSAIDs) and acetaminophen. Dihydroergotamine and valproic acid have some data supporting efficacy. More recently, greater occipital nerve blocks (GONBs) have been shown to be efficacious. With the exception of meperidine, opioids have been shown to be not efficacious. Most data published to date demonstrate no role for propofol and ketamine. Conclusions There are no evidence‐based second‐line treatments of migraine in the ED setting. For patients with migraine, who fail to improve after treatment with a first‐line medication, it is reasonable to use an intravenous NSAID or intravenous acetaminophen. Alternatively, clinicians adept at performing a GONB may offer this treatment.
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 motorsparing 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. ResultsThe 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. ConclusionIn 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.
Introduction: Over the last several decades simulation, in both graduate and undergraduate emergency medicine education, has continued to develop as a leading and highly effective teaching modality. Limited research exists to evaluate the efficacy of low-fidelity (table-top) simulation, as compared to high-fidelity standards, as it relates to medical knowledge learning outcomes. We sought to assess the efficacy of a low-fidelity simulation modality in undergraduate emergency medicine education, based on quantitative medical knowledge learning outcomes. Methods: A prospective, randomized, crossover-control study comparing objective medical knowledge learning outcomes between simulation modalities. Analysis was designed to evaluate for the statistical equivalence of learning outcomes between the two cohorts. This was done by comparing a calculated 95% confidence interval (CI) around the mean difference in post-test scores, between experimental and control modalities, to a pre-established equivalence margin. Results: Primary outcomes evaluating student performance on post-test examinations demonstrated a total cohort CI (95% CI, -0.22 and 0.68). Additional course-subject subgroup analysis demonstrated non-inferior CIs with: Shortness of Breath (95% CI, -0.35 and 1.27); Chest Pain (95% CI, -0.53 and .94); Abdominal Pain (95% CI, -0.88 and 1.17); Cardiovascular Shock (95% CI, -0.04 and 1.29). Secondary outcome analysis was done to evaluate medical knowledge acquisition by comparing the difference in pre and post-test examination between the cohorts. CI of the full cohort ranged from (95% CI, -0.14 and 0.96). Conclusion: The student’s performance on quantitative medical-knowledge assessment was equivalent between the high-fidelity control and low-fidelity experimental simulation groups. Analysis of knowledge acquisition between the two groups also demonstrated statistical equivalence.
Two-Year-Old With a Limp and Suspected Nonaccidental InjuryA 2-year-old boy of Vietnamese origin with total intestinal aganglionosis and complete parenteral nutrition (PN) dependence presented with 2 weeks of leg pain, limping, and lightening of hair color from black to almost ''dirty blond.'' Physical examination was notable for severe leg tenderness. Nonaccidental trauma, which can mimic bone fragility, was ruled out (1-4). Skeletal survey showed periosteal reaction involving bilateral humerus, radii, and left femur along with distal right tibia and femur fractures (Figs. 1 and 2). Laboratory investigations were significant for mild anemia (Hb 11.3 g/dL, MCV 107 FL, MCHC 32.9%) and copper deficiency (serum copper 31 mg/dL [normal 75-153 mg/dL], serum ceruloplasmin 31 mg/dL [normal 18-37 mg/dL]). His PN was manufactured by an established home-care company with standard PN micronutrients (5). It was discovered that owing to a national shortage, there had been no copper in this patient's PN since 3 months before presentation. Subsequently, copper was added back to his PN at the recommended enteral dosage of 60 mcg Á kg À1 Á day À1 for 4 weeks ( 6). At his 6month follow-up, the patient's serum copper level had normalized, skeletal pain had resolved and hair color had reverted back to its original black. The patient's serum copper levels remain normal on follow-up with standard 20 mcg/kg of copper in his daily PN.
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