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Objective:The aim of this study was head-to-head comparison of the efficacy and rate of adverse events of metoclopramide, ibuprofen and dexketoprofen for the acute treatment of migraine attack in the real-life conditions of a busy emergency department (ED).Methods:This was a prospective, observational, cross-sectional study. All patients who presented to the ED with a headache fulfilling the inclusion criteria were enrolled. All patients were treated by the attending emergency physicians in their daily routine. If an IV treatment in the ED was found indicated by the EP, they selected one of the options in the written departmental migraine treatment protocol.Results:During the study period, 54 patients met the inclusion criteria. The median change in the pain score was significantly different among treatment options (p<0.0001). The median pain score change at the end of the 30 minutes for treatment groups were 7.5 mm (IQR: 7.0-8.0), 5.0 mm (IQR: 4.75-7.0), and 7.0 mm (IQR: 6.0-7.25), respectively (p=0.0002). All three groups were found to be significantly different from each other in the post-hoc analysis.Conclusion:All drugs compared in this study are effective in the relief of migraine headache. However, IV dexketoprofen seems to be faster and more effective than metoclopramide and ibuprofen.

ObjectiveWe evaluated the sensitivity and specificity of bedside ultrasound (US) for determining the success of reduction of displaced distal radius fractures. In addition, we determined the ability of US to diagnose causes of unsuccessful reduction.MethodsIn a prospective, double-blind fashion, patients over 18 of age whose acute distal radius fracture was to be reduced were approached for inclusion. The closed reductions were performed by orthopedics residents. Post-reduction, the fracture was checked by an Emergency Medicine (EM) resident by US. Ultrasound images were evaluated by an EM attending physician blinded to X-ray findings and post-reduction X-ray images were evaluated by an orthopedic surgeon blinded to the US findings.ResultsSixty patients agreed to participate in the study. Of these, reduction was deemed successful by X-ray in 40 (66.7%). Of these 40, 39 (97.5%) were found to be successful reductions by US. In the 20 of 60 (33.3%) patients with unsuccessful reduction by X-ray, 19 (95%) were considered unsuccessful reductions by US. In evaluating the success of distal radius fracture reduction, compared to X-rays, US was 97.5% (95% CI 86.8 to 99.9) sensitive and 95% (95% CI 75.1 to 99.9) specific; its positive predictive value was 97.5% (95% CI 85.2 to 99.6) and negative predictive value 95% (95% CI 73.2 to 99.2).ConclusionsUltrasonography is highly sensitive and specific in determining the success of distal radius fracture reduction.

Owing to the advancements in medicine, new information is obtained regarding cancer, new antineoplastic agents are developed. Frequent use of these new pharmacological agents emergency physicians to be vigilant about their side effects. We present a case of adrenal crisis in a patient with non-small cell lung cancer (NSCLC), caused by an immunomodulatory drug; nivolumab. While adverse events are related to other immunomodulatory drugs have been reported in literature, our case is the first nivolumab-related adrenal failure to be reported. A patient with lung cancer presented to the emergency room(ER) with nausea and vomiting. Hyponatremia, hyperkalemia, persistent hypoglycemia led to the diagnosis of adrenal crisis. Having direct effect on the immune system, these drugs were claimed to be highly reliable. However, there is no reliable data on the side effect profile of these agents. It should be kept in mind that life-threatening auto-immune reactions may occur.

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Aims and objectivesTo determine the factors affecting the first‐attempt success of peripheral intravenous catheter (PIVC) placement in older emergency department patients.BackgroundIn older patients who require intravenous treatment, establishing a PIVC as fast as possible is clinically important.DesignThis is a prospective, observational, descriptive study.MethodsUsing a data collection form, researchers questioned both the patient and the nurse performing the procedure in terms of patient‐ and operator‐related factors. This study followed the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines (See Supporting Information Appendix S1).ResultsA total of 472 patients were included in the final analyses. According to the logistic regression analysis, independent factors which affected first‐attempt failure were found to be: choosing a nonupper extremity site for PIVC (OR: 4.72, 95% CI: 1.35–16.45, p‐value: 0.015), history of difficult intravenous access (OR: 3.02, 95% CI: 1.72–5.29, p‐value: <0.001), nurse having less than 2 years of professional experience (OR: 3.45, 95% CI: 2.00–5.97, p‐value: <0.001), nonpalpable veins observed after the application of tourniquet (OR: 2.21, 95% CI: 1.10–4.41, p‐value: 0.025), a moderate degree of difficulty anticipated by the nurse prior to the procedure (OR: 4.32, 95% CI: 2.31–8.08, p‐value: <0.001) and a high degree of difficulty anticipated by the nurse prior to the procedure (OR: 8.41, 95% CI: 4.10–17.24, p‐value: <0.001).ConclusionFactors affecting first‐attempt success rates in peripheral intravenous catheter placement in older emergency department patients may be listed as follows: the anticipated difficulty of the procedure rated by the nurse, previous history of a difficult intravenous cannulation, choosing a nonupper extremity site for cannulation, the level of experience of the nurse and the palpability of the vein.Relevance to clinical practiceHealthcare providers should consider alternative methods in the presence of factors affecting first‐attempt success in older emergency department patients.

Objectives: Successful placement of a peripheral intravenous catheter (PIVC) on the first attempt is an important outcome for difficult vascular access (DVA) patients. This study compared standard technique, ultrasonography (USG), and near-infrared light (NIR) in terms of success in the first attempt in patients with DVA. Methods: This was a prospective, randomized controlled study. The study was conducted in a tertiary care hospital. Emergency department patients who describe DVA history, have no visible or palpable veins, and were assessed by the nurse to have a difficult PIVC were included to study. The PIVC procedure was performed on patients by standard, USG, or NIR device techniques. For all approaches, the success of the first attempt was the primary aim. Total procedure time, the total number of attempts, and the need for rescue intervention were secondary aims. Results: This study evaluated 270 patients. The first attempt success rates for USG, standard, and NIR methods were 78.9%, 62.2%, and 58.9%, respectively. The rate of first attempt success was higher in patients who underwent USG (USG versus standard, P = .014; USG versus NIR, P = .004; standard versus NIR, P = .648). The total median (IQR) procedure time for USG, standard, and NIR methods was 107 (69-228), 72 (47-134), and 82 (61-163) seconds, respectively. The total procedure time was longer in patients undergoing USG (standard versus USG, P <.001; NIR versus USG, P = .035; standard versus NIR, P = .055). The total median (IQR) number of attempts of USG, standard, and NIR methods were 1 (1-1), 1 (1-2), and 1 (1-2), respectively. A difference was found among the groups regarding the total number of attempts (USG versus NIR, P = .015; USG versus standard P = .108; standard versus NIR, P = .307). No difference was found among groups in terms of the need for rescue methods. Conclusion: It was found that USG increases the success of the first attempt compared with the standard method and NIR in patients with DVA.