Objectives Opioid pain reliever (OPR) prescribing at Emergency Department (ED) discharge has increased in the past decade but specific prescription details are lacking. Prior ED OPR prescribing estimates relied on national survey extrapolation or prescription databases. The main goal of this study was to utilize a research consortium to analyze the characteristics of patients and opioid prescriptions using a national sample of ED patients. We also aimed to examine the indications for OPR prescribing, characteristics of opioids prescribed both in the ED and at the time of discharge, and characteristics of patients who received OPRs compared with those who did not. Methods This observational, multi-centered, retrospective cohort study assessed OPR prescribing to consecutive patients presenting to the consortium EDs during 1 week in October 2012. The consortium study sites consisted of 19 EDs representing 1.4 million annual visits, varied geographically, and were predominantly academic centers. Medical records of all patients aged 18-90 years discharged with an OPR (excluding tramadol) were individually abstracted via standardized chart review by investigators for detailed analysis. Descriptive statistics were generated. Results During the study week, 27,516 patient visits were evaluated in the consortium EDs. 19,321 (70.2%) were discharged and 3,284 patients (11.9% of all patients and 17.0% of discharged patients) received an OPR prescription. For those prescribed an OPR, mean age was 41.1 (SD 14.7) years and 1,694 (51.6%) were female. Mean initial pain score was 7.7 (SD 2.4). The most common diagnoses associated with OPR prescribing were back pain (10.2%), abdominal pain (10.1%), and extremity fracture (7.1%) or sprain (6.5%). The most common OPRs prescribed were oxycodone (52.3%), hydrocodone (40.9%) and codeine (4.8%). >99% were immediate release, 90.0% were combination preparations, and the mean and median number of pills was 16.6 (SD 7.6) and 15 (IQR=12-20) respectively. Conclusion In a study of ED patients treated over a single week across the country, 17% of discharged patients were prescribed OPRs. The majority of the prescriptions had small pill counts and almost exclusively immediate release formulations.

Objectives: The objectives were to determine if nebulized albuterol causes an increase in the serum lactate level compared to placebo and, secondarily, to confirm that albuterol decreases serum potassium levels compared to placebo in patients with normokalemia.Methods: This was a randomized, double-blind, placebo-controlled trial. Twenty-eight healthy adult volunteers were assigned to receive either 10 mg of nebulized albuterol or placebo (nebulized saline) over 1 hour. Serum lactate was measured prior to treatment and at 30 and 70 minutes after the start of treatment. Serum potassium level was measured prior to treatment and at 70 minutes. The primary outcome was the degree of change in lactate level. The secondary outcome was the degree of change in potassium level.Results: In the 14 subjects who received albuterol, the mean increase in lactate was 0.77 mmol/L (95% confidence interval [CI] = 0.52 to 1.02 mmol/L), and the mean decrease in potassium level was 0.5 mEq/L (95% CI = À0.72 to À0.28 mEq/L). Among the subjects who received placebo, the lactate level decreased by 0.15 mmol/L (95% CI = À0.39 to 0.09 mmol/L) and there was no change in potassium level at (0.0 mEq/L [95% CI = À0.21 to 0.21 mEq/L]). These differences are statistically significant (p < 0.0001 and p = 0.003, respectively). Conclusion:Nebulized albuterol increases lactate levels and decreases potassium levels in healthy adults.ACADEMIC EMERGENCY MEDICINE 2016;23:718-721

There are no controlled human studies to determine the efficacy of benzodiazepines or antipsychotic medications for prevention or treatment of acute cocaine toxicity. The only available controlled data are from animal models and these studies have reported inconsistent benefits. The objective of this study was to quantify the reported efficacy of benzodiazepines and antipsychotic medication for the prevention of mortality due to cocaine poisoning. We conducted a systematic review to identify English language articles describing experiments that compared a benzodiazepine or antipsychotic medication to placebo for the prevention of acute cocaine toxicity in an animal model. We then used these articles in a meta-analysis with a random-effects model to quantify the absolute risk reduction observed in these experiments. We found 10 articles evaluating antipsychotic medications and 15 articles evaluating benzodiazepines. Antipsychotic medications reduced the risk of death by 27% (95% CI, 15.2%–38.7%) compared to placebo and benzodiazepines reduced the risk of death by 52% (42.8%–60.7%) compared to placebo. Both treatments showed evidence of a dose-response effect, and no experiment found a statistically significant increase in risk of death. We conclude that both benzodiazepines and antipsychotic medications are effective for the prevention of lethality from cocaine toxicity in animal models.

Background: Cocaine intoxication is a common cause of agitation in emergency department patients. Ziprasidone, an atypical antipsychotic, is being increasingly used for sedation of agitated patients in the emergency department. Objectives: To provide preliminary animal data on the efficacy of ziprasidone for the treatment of acute cocaine poisoning. Methods: This was a randomized, blinded comparison of ziprasidone and placebo for the prevention of seizures and apparent lethality in a mouse model of cocaine intoxication. Animals were assigned to either placebo or 0.4 mg/kg or 1.2 mg/m 2 of ziprasidone intra-