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Bloom B, Fritz CL, Gupta S, Pott J, Skene I, Astin-Chamberlain R, Ali M, Thomas SA, Thomas SH. Older age and risk for delayed abdominal pain care in the emergency department. Eur J Emerg Med 2024:00063110-990000000-00129. [PMID: 38801425 DOI: 10.1097/mej.0000000000001143] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/29/2024]
Abstract
BACKGROUND AND IMPORTANCE Suboptimal acute pain care has been previously reported to be associated with demographic characteristics. OBJECTIVES The aim of this study was to assess a healthcare system's multi-facility database of emergency attendances for abdominal pain, to assess for an association between demographics (age, sex, and ethnicity) and two endpoints: time delay to initial analgesia (primary endpoint) and selection of an opioid as the initial analgesic (secondary endpoint). DESIGN, SETTING, AND PARTICIPANTS This retrospective observational study assessed four consecutive months' visits by adults (≥18 years) with a chief complaint of abdominal pain, in a UK National Health Service Trust's emergency department (ED). Data collected included demographics, pain scores, and analgesia variables. OUTCOME MEASURES AND ANALYSIS Categorical data were described with proportions and binomial exact 95% confidence intervals (CIs). Continuous data were described using median (with 95% CIs) and interquartile range (IQR). Multivariable associations between demographics and endpoints were executed with quantile median regression (National Health Service primary endpoint) and logistic regression (secondary endpoint). MAIN RESULTS In 4231 patients, 1457 (34.4%) receiving analgesia had a median time to initial analgesia of 110 min (95% CI, 104-120, IQR, 55-229). The univariate assessment identified only one demographic variable, age decade (P = 0.0001), associated with the time to initial analgesia. Association between age and time to initial analgesia persisted in multivariable analysis adjusting for initial pain score, facility type, and time of presentation; for each decade increase the time to initial analgesia was linearly prolonged by 6.9 min (95% CI, 1.9-11.9; P = 0.007). In univariable assessment, time to initial analgesia was not associated with either detailed ethnicity (14 categories, P = 0.109) or four-category ethnicity (P = 0.138); in multivariable analysis ethnicity remained non-significant as either 14-category (all ethnicities' P ≥ 0.085) or four-category (all P ≥ 0.138). No demographic or operational variables were associated with the secondary endpoint; opioid initial choice was associated only with pain score (P= 0.003). CONCLUSION In a consecutive series of patients with abdominal pain, advancing age was the only demographic variable associated with prolonged time to initial analgesia. Older patients were found to have a linearly increasing, age-dependent risk for prolonged wait for pain care.
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Affiliation(s)
- Ben Bloom
- Blizard Institute for Neuroscience, Surgery, and Trauma, Barts and The London School of Medicine
- Department of Emergency Medicine, The Royal London Hospital and Barts Health NHS Trust, London, UK
| | - Christie L Fritz
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston and
| | - Shivani Gupta
- Department of Emergency Medicine, The Royal London Hospital and Barts Health NHS Trust, London, UK
| | - Jason Pott
- Blizard Institute for Neuroscience, Surgery, and Trauma, Barts and The London School of Medicine
- Department of Emergency Medicine, The Royal London Hospital and Barts Health NHS Trust, London, UK
| | - Imogen Skene
- Department of Emergency Medicine, The Royal London Hospital and Barts Health NHS Trust, London, UK
| | - Raine Astin-Chamberlain
- Department of Emergency Medicine, The Royal London Hospital and Barts Health NHS Trust, London, UK
| | - Mohammad Ali
- Department of Emergency Medicine, The Royal London Hospital and Barts Health NHS Trust, London, UK
| | - Sarah A Thomas
- Department of Immunology and Molecular Microbiology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, USA
| | - Stephen H Thomas
- Blizard Institute for Neuroscience, Surgery, and Trauma, Barts and The London School of Medicine
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston and
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Miner JR, Rafique Z, Minkowitz HS, DiDonato KP, Palmer PP. Sufentanil sublingual tablet 30 mcg for moderate-to-severe acute pain in the ED. Am J Emerg Med 2018; 36:954-961. [DOI: 10.1016/j.ajem.2017.10.058] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2017] [Revised: 10/24/2017] [Accepted: 10/25/2017] [Indexed: 11/16/2022] Open
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Kim M, Mitchell SH, Gatewood M, Bennett KA, Sutton PR, Crawford CA, Bentov I, Damodarasamy M, Kaplan SJ, Reed MJ. Older adults and high-risk medication administration in the emergency department. Drug Healthc Patient Saf 2017; 9:105-112. [PMID: 29184448 PMCID: PMC5685141 DOI: 10.2147/dhps.s143341] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Older adults are susceptible to adverse effects from opioids, nonsteroidal anti-inflammatory drugs (NSAIDs), and benzodiazepines (BZDs). We investigated factors associated with the administration of elevated doses of these medications of interest to older adults (≥65 years old) in the emergency department (ED). PATIENTS AND METHODS ED records were queried for the administration of medications of interest to older adults at two academic medical center EDs over a 6-month period. Frequency of recommended versus elevated ("High doses" were defined as doses that ranged between 1.5 and 3 times higher than the recommended starting doses; "very high doses" were defined as higher than high doses) starting doses of medications, as determined by geriatric pharmacy/medicine guidelines and expert consensus, was compared by age groups (65-69, 70-74, 75-79, 80-84, and ≥85 years), gender, and hospital. RESULTS There were 17896 visits representing 11374 unique patients >65 years of age (55.3% men, 44.7% women). A total of 3394 doses of medications of interest including 1678 high doses and 684 very high doses were administered to 1364 different patients. Administration of elevated doses of medications was more common than that of recommended doses. Focusing on opioids and BZDs, the 65-69-year age group was much more likely to receive very high doses (1481 and 412 doses, respectively) than the ≥85-year age groups (relative risk [RR] 5.52, 95% CI 2.56-11.90), mainly reflecting elevated opioid dosing (RR 8.28, 95% CI 3.69-18.57). Men were more likely than women to receive very high doses (RR 1.47, 95% CI 1.26-1.72), primarily due to BZDs (RR 2.12, 95% CI 2.07-2.16). CONCLUSION Administration of elevated doses of opioids and BZDs in the older population occurs frequently in the ED, especially to the 65-69-year age group and men. Further attention to potentially unsafe dosing of high-risk medications to older adults in the ED is warranted.
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Affiliation(s)
- Mitchell Kim
- Department of Emergency Medicine, University of Washington
| | | | | | - Katherine A Bennett
- Division of Gerontology and Geriatric Medicine, Department of Medicine, University of Washington
| | - Paul R Sutton
- Division of General Internal Medicine, Department of Medicine, University of Washington
| | | | - Itay Bentov
- Department of Anesthesiology and Pain Medicine, University of Washington
| | - Mamatha Damodarasamy
- Division of Gerontology and Geriatric Medicine, Department of Medicine, University of Washington
| | - Stephen J Kaplan
- Section of General, Thoracic and Vascular Surgery, Department of Surgery, Virginia Mason Medical Center, Seattle, WA, USA
| | - May J Reed
- Division of Gerontology and Geriatric Medicine, Department of Medicine, University of Washington
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Taylor DM, Chen J, Khan M, Lee M, Rajee M, Yeoh M, Richardson JR, Ugoni AM. Variables associated with administration of analgesia, nurse-initiated analgesia and early analgesia in the emergency department. Emerg Med J 2016; 34:13-19. [PMID: 27789567 DOI: 10.1136/emermed-2016-206044] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2016] [Revised: 10/05/2016] [Accepted: 10/07/2016] [Indexed: 11/03/2022]
Abstract
OBJECTIVE To determine the patient and clinical variables associated with administration of any analgesia, nurse-initiated analgesia (NIA, prescribed and administered by a nurse) and early analgesia (within 30 min of presentation). METHODS We undertook a retrospective cohort study of patients who presented to a metropolitan ED in Melbourne, Australia, during July and August, 2013. The ED has an established NIA programme. Patients were included if they were aged 18 years or more and presented with a painful complaint. The study sample was randomly selected from a list of all eligible patients. Data were extracted electronically from the ED records and by explicit extraction from the medical record. Logistic regression models were constructed to assess associations with the three binary study end points. RESULTS 1289 patients were enrolled. Patients were less likely to receive any analgesia if they presented 08:00-15:59 hours (OR 0.67, 95% CI 0.46 to 0.98) or 16:00-24:00 hours (OR 0.55, 95% CI 0.37 to 0.80) were triage category 5 (OR 0.20, 95% CI 0.08 to 0.49) or required an interpreter (OR 0.34, 95% CI 0.14 to 0.86). Patients were less likely to receive NIA or early analgesia if they were aged 56 years or more (OR 0.70 and 0.63; OR 0.57 and 0.21, respectively) or if they had received ambulance analgesia (OR 0.59, 95% CI 0.36 to 0.95; OR 0.38, 95% CI 0.20 to 0.74, respectively). CONCLUSIONS Patients who present during the daytime, have a triage category of 5 or require an interpreter are less likely to receive analgesia. Older patients and those who received ambulance analgesia are less likely to receive NIA or early analgesia.
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Affiliation(s)
- David McD Taylor
- Department of Emergency Medicine, Austin Health, Heidelberg, Victoria, Australia.,Department of Medicine, University of Melbourne, Parkville, Victoria, Australia
| | - Jessie Chen
- Department of Emergency Medicine, Austin Health, Heidelberg, Victoria, Australia
| | - Munad Khan
- Department of Emergency Medicine, Austin Health, Heidelberg, Victoria, Australia
| | - Marina Lee
- Department of Emergency Medicine, Austin Health, Heidelberg, Victoria, Australia
| | - Mani Rajee
- Department of Emergency Medicine, Austin Health, Heidelberg, Victoria, Australia
| | - Michael Yeoh
- Department of Emergency Medicine, Austin Health, Heidelberg, Victoria, Australia
| | - Joanna R Richardson
- Department of Emergency Medicine, Austin Health, Heidelberg, Victoria, Australia
| | - Antony M Ugoni
- Department of Physiotherapy, University of Melbourne, Parkville, Victoria, Australia
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Ko A, Harada MY, Smith EJ, Scheipe M, Alban RF, Melo N, Margulies DR, Ley EJ. Pain Assessment and Control in the Injured Elderly. Am Surg 2016. [DOI: 10.1177/000313481608201001] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Elderly trauma patients may be at increased risk for underassessment and inadequate pain control in the emergency department (ED). We sought to characterize risk factors for oligoanalgesia in the ED in elderly trauma patients and determine whether it impacts outcomes in elderly trauma patients. We included elderly patients (age ≥55 years) with Glasgow Coma Scale scores 13 to 15 and Injury Severity Score (ISS) ≥9 admitted through the ED at a Level I trauma center. Patient characteristics and outcomes were compared between those who reported pain and received analgesics medication in the ED (MED) and those who did not (NO MED). A total of 183 elderly trauma patients were identified over a three-year study period, of whom 63 per cent had pain assessed via verbal pain score; of those who reported pain, 73 per cent received analgesics in the ED. The MED and NO MED groups were similar in gender, race, ED vitals, ISS, and hospital length of stay. However, NO MED was older, with higher head Abbreviated Injury Scale score and longer intensive care unit length of stay. Importantly, as patients aged they reported lower pain and were less likely to receive analgesics at similar ISS. Risk factors for oligoanalgesia may include advanced age and head injury.
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Affiliation(s)
- Ara Ko
- Department of Surgery, Division of Trauma and Critical Care, Cedars-Sinai Medical Center, Los Angeles, California
| | - Megan Y. Harada
- Department of Surgery, Division of Trauma and Critical Care, Cedars-Sinai Medical Center, Los Angeles, California
| | - Eric J.T. Smith
- Department of Surgery, Division of Trauma and Critical Care, Cedars-Sinai Medical Center, Los Angeles, California
| | - Michael Scheipe
- Department of Surgery, Division of Trauma and Critical Care, Cedars-Sinai Medical Center, Los Angeles, California
| | - Rodrigo F. Alban
- Department of Surgery, Division of Trauma and Critical Care, Cedars-Sinai Medical Center, Los Angeles, California
| | - Nicolas Melo
- Department of Surgery, Division of Trauma and Critical Care, Cedars-Sinai Medical Center, Los Angeles, California
| | - Daniel R. Margulies
- Department of Surgery, Division of Trauma and Critical Care, Cedars-Sinai Medical Center, Los Angeles, California
| | - Eric J. Ley
- Department of Surgery, Division of Trauma and Critical Care, Cedars-Sinai Medical Center, Los Angeles, California
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Van Woerden G, Van Den Brand CL, Den Hartog CF, Idenburg FJ, Grootendorst DC, Van Der Linden MC. Increased analgesia administration in emergency medicine after implementation of revised guidelines. Int J Emerg Med 2016; 9:4. [PMID: 26860533 PMCID: PMC4749514 DOI: 10.1186/s12245-016-0102-y] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2014] [Accepted: 02/03/2016] [Indexed: 01/25/2023] Open
Abstract
Background The most common complaint of patients attending the emergency department (ED) is pain, caused by different diseases. Yet the treatment of pain at the ED is suboptimal, and oligoanalgesia remains common. The objective of this study is to determine whether the administration of analgesia at the ED increases by implementation of revised guidelines in pain management. Methods We conducted a prospective pre-post intervention cohort study with implementation of a revised guideline for pain management at our ED, in which nurses are allowed to administer analgesia (including low-dosage piritramid (opioid) intravenous) without doctor intervention. Numeric Rating Scales (NRS) were measured, and administration of medication (main outcome) was documented. We included every adult patient presenting with pain (NRS 4–10) at the ED. Results A total of 2107 patients (1089 pre-implementation phase and 1018 post-implementation phase) were included in our study. During pre-implementation, 25.4 % of the patients with NRS between 4 and 10 received analgesia. After implementation, 32.0 % of these patients received analgesia (p < 0.001). Conclusions After implementation of the revised guidelines in pain management at the ED, the administration of pain medication increased significantly. Nevertheless, the percentage of patients in pain receiving analgesia remain low (32 % after implementation).
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Affiliation(s)
- Geesje Van Woerden
- Emergency Department, Medical Centre Haaglanden, P.O. Box 432, 2501, CK, The Hague, The Netherlands.
| | - Crispijn L Van Den Brand
- Emergency Department, Medical Centre Haaglanden, P.O. Box 432, 2501, CK, The Hague, The Netherlands.
| | - Cornelis F Den Hartog
- Department of Anaesthesiology, Medical Centre Haaglanden, P.O. Box 432, 2501, CK, The Hague, The Netherlands.
| | - Floris J Idenburg
- Department of Surgery, Medical Centre Haaglanden, P.O. Box 432, 2501, CK, The Hague, The Netherlands.
| | - Diana C Grootendorst
- Landsteiner Institute, Medical Centre Haaglanden, P.O. Box 432, 2501, CK, The Hague, The Netherlands.
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Tosounidis TH, Sheikh H, Stone MH, Giannoudis PV. Pain relief management following proximal femoral fractures: Options, issues and controversies. Injury 2015; 46 Suppl 5:S52-8. [PMID: 26323378 DOI: 10.1016/j.injury.2015.08.014] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
The majority of proximal femoral fractures occur in the elderly population. Safe and adequate pain relief is an integral part of the overall management of hip fractures. Inherent difficulties in the assessment of pain in elderly need to be taken into account and unique considerations should be made regarding the effective analgesia due to different elderly physiology, and their response to trauma and subsequent surgery. The pain management should start as soon as possible and special emphasis should be paid to contemporary methods of regional anaesthesia whilst a multimodal approach should be adopted in the perioperative period. The present review summarises the contemporary treatment options and controversies pertaining to the management of pain in elderly patients with proximal femoral fractures.
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Affiliation(s)
- Theodoros H Tosounidis
- Academic Department of Trauma & Orthopaedic Surgery, University of Leeds, Clarendon Wing, Leeds General Infirmary, Floor A, Great George Street, LS1 3EX Leeds, UK; NIHR Leeds Biomedical Research Unit, Chapel Allerton Hospital, LS7 4SA Leeds, West Yorkshire, UK.
| | - Hassaan Sheikh
- Academic Department of Trauma & Orthopaedic Surgery, University of Leeds, Clarendon Wing, Leeds General Infirmary, Floor A, Great George Street, LS1 3EX Leeds, UK
| | - Martin H Stone
- Hip Reconstruction Unit, Chapel Allerton Hospital, Leeds, West Yorkshire, LS7 4SA, UK; NIHR Leeds Biomedical Research Unit, Chapel Allerton Hospital, LS7 4SA Leeds, West Yorkshire, UK
| | - Peter V Giannoudis
- Academic Department of Trauma & Orthopaedic Surgery, University of Leeds, Clarendon Wing, Leeds General Infirmary, Floor A, Great George Street, LS1 3EX Leeds, UK; NIHR Leeds Biomedical Research Unit, Chapel Allerton Hospital, LS7 4SA Leeds, West Yorkshire, UK
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8
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Oligoanalgesia in Blunt Geriatric Trauma. J Emerg Med 2015; 48:653-9. [DOI: 10.1016/j.jemermed.2014.12.043] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2014] [Revised: 10/17/2014] [Accepted: 12/21/2014] [Indexed: 11/16/2022]
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Abstract
This paper is the thirty-sixth consecutive installment of the annual review of research concerning the endogenous opioid system. It summarizes papers published during 2013 that studied the behavioral effects of molecular, pharmacological and genetic manipulation of opioid peptides, opioid receptors, opioid agonists and opioid antagonists. The particular topics that continue to be covered include the molecular-biochemical effects and neurochemical localization studies of endogenous opioids and their receptors related to behavior, and the roles of these opioid peptides and receptors in pain and analgesia; stress and social status; tolerance and dependence; learning and memory; eating and drinking; alcohol and drugs of abuse; sexual activity and hormones, pregnancy, development and endocrinology; mental illness and mood; seizures and neurologic disorders; electrical-related activity and neurophysiology; general activity and locomotion; gastrointestinal, renal and hepatic functions; cardiovascular responses; respiration and thermoregulation; and immunological responses.
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Affiliation(s)
- Richard J Bodnar
- Department of Psychology and Neuropsychology Doctoral Sub-Program, Queens College, City University of New York, Flushing, NY 11367, United States.
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Daoust R, Paquet J, Lavigne G, Sanogo K, Chauny JM. Senior patients with moderate to severe pain wait longer for analgesic medication in EDs. Am J Emerg Med 2014; 32:315-9. [DOI: 10.1016/j.ajem.2013.12.012] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2013] [Revised: 11/03/2013] [Accepted: 12/04/2013] [Indexed: 11/25/2022] Open
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NHAMCS: Does It Hold Up to Scrutiny? Ann Emerg Med 2013; 62:549-551. [DOI: 10.1016/j.annemergmed.2013.04.028] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2013] [Revised: 04/05/2013] [Accepted: 04/10/2013] [Indexed: 11/23/2022]
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Abstract
Since pain is a primary impetus for patient presentation to the Emergency Department (ED), its treatment should be a priority for acute care providers. Historically, the ED has been marked by shortcomings in both the evaluation and amelioration of pain. Over the past decade, improvements in the science of pain assessment and management have combined to facilitate care improvements in the ED. The purpose of this review is to address selected topics within the realm of ED pain management. Commencing with general principles and definitions, the review continues with an assessment of areas of controversy and advancing knowledge in acute pain care. Some barriers to optimal pain care are discussed, and potential mechanisms to overcome these barriers are offered. While the review is not intended as a resource for specific pain conditions or drug information, selected agents and approaches are mentioned with respect to evolving evidence and areas for future research.
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Abstract
Effective treatment of acute pain in older patients is a common challenge faced by emergency providers. Because older adults are at increased risk for adverse events associated with systemic analgesics, pain treatment must proceed cautiously. Essential elements to quality acute pain care include an early initial assessment for the presence of pain, selection of an analgesic based on patient-specific risks and preferences, and frequent reassessments and retreatments as needed. This article describes current knowledge regarding the assessment and treatment of acute pain in older adults.
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Affiliation(s)
- Ula Hwang
- Department of Emergency Medicine, Mount Sinai School of Medicine, New York, NY, USA.
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Oligo-Evidence for Oligoanalgesia: A Non Sequitur? Ann Emerg Med 2013; 61:373-4. [DOI: 10.1016/j.annemergmed.2012.09.018] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2012] [Revised: 09/18/2012] [Accepted: 09/20/2012] [Indexed: 11/24/2022]
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There Is Oligo-Evidence for Oligoanalgesia. Ann Emerg Med 2012; 60:212-4. [DOI: 10.1016/j.annemergmed.2012.06.006] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2012] [Revised: 06/05/2012] [Accepted: 06/05/2012] [Indexed: 11/23/2022]
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