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Nti BK, Phillips W, Sarmiento E, Russell F. Effect of a point-of-care ultrasound (POCUS) curriculum on emergency department soft tissue management. Ultrasound J 2022; 14:41. [PMID: 36269462 PMCID: PMC9587168 DOI: 10.1186/s13089-022-00292-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2021] [Accepted: 10/10/2022] [Indexed: 11/25/2022] Open
Abstract
Background Pediatric emergency department (ED) visits for superficial skin and soft tissue infections (SSTI) have steadily been increasing and point-of-care ultrasound (POCUS) continues to be an effective modality to improve management and shorter ED length of stays (LOS). Objective We sought to determine the impact of a soft tissue POCUS curriculum on POCUS utilization, ED LOS, and cost-effectiveness. Methods This was a retrospective pre- and post-interventional study of pediatric patients aged 0 to 17 years. Patients presenting to ED with international classification of disease 9 or 10 code for abscess or cellulitis were included. Data were collected a year before and after curriculum implementation with a 1-year washout training period. Training included continuing medical education, greater than 25 quality assured examinations, and a post-test. We compared diagnostic imaging type, ED LOS, and mean charges in patients with SSTI. Results We analyzed data on 119 total patients, 38 pre- and 81 post-intervention. We found a significant increase in the total number of POCUS examinations performed pre- to post-curriculum intervention, 26 vs. 59 (p = 0.0017). Mean total charges were significantly decreased from $3,762 (± 270) to $2,622 (± 158; p = 0.0009). There was a significant trend towards a decrease in average ED LOS 282 (standard error of mean [SEM] ± 19) vs 185 (± 13) minutes (p = 0.0001). Conclusions Implementation of a soft tissue POCUS curriculum in a pediatric ED was associated with increased POCUS use, decreased LOS, and lower cost. These findings highlight the importance of POCUS education and implementation in the management of pediatric SSTI.
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Affiliation(s)
- Benjamin K Nti
- Division of Pediatric Emergency Medicine Division of Clinical Ultrasound Department of Emergency Medicine, Indiana University School of Medicine, 720 Eskenazi Avenue, FT 3, Indianapolis, IN 46202, US.
| | - Whitney Phillips
- Department of Pediatrics Riley, Hospital for Children at Indiana University Health, Indiana University School of Medicine, 705 Riley Hospital Drive, Indianapolis, IN 46202, US
| | - Elisa Sarmiento
- Division of Pediatric Emergency Medicine Division of Clinical Ultrasound Department of Emergency Medicine, Indiana University School of Medicine, 720 Eskenazi Avenue, FT 3, Indianapolis, IN 46202, US
| | - Frances Russell
- Division of Pediatric Emergency Medicine Division of Clinical Ultrasound Department of Emergency Medicine, Indiana University School of Medicine, 720 Eskenazi Avenue, FT 3, Indianapolis, IN 46202, US
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Gagnon F, Gravel J, Duranceau C, Vallieres E, Bhatt M, Harman S, Trottier ED. XyloFUNS: Xylocaine to freeze during unpleasant nasopharyngeal swabs in children-a randomized controlled trial. Paediatr Child Health 2022; 27:469-475. [PMID: 36575662 PMCID: PMC9620713 DOI: 10.1093/pch/pxac077] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Accepted: 06/22/2022] [Indexed: 12/30/2022] Open
Abstract
Objectives To evaluate the efficacy of intranasal vaporized lidocaine in reducing pain for children undergoing a nasopharyngeal (NP) swab in the Emergency Department (ED). Study Design A randomized blinded clinical trial was conducted in a paediatric ED. Both participants and the researcher evaluating the primary outcome were blinded. Children aged 6 to 17 years old requiring a NP swab were eligible. Participants were randomly allocated to receive intranasal lidocaine or a sham treatment prior to their NP swab. The primary outcome measure was pain during the swab as assessed by the visual analog scale. Secondary outcome measures were pain using the verbal numeric rating scale, fear using the children fear scale, and adverse effects of the intervention. Results Eighty-eight participants were enrolled-45 in the lidocaine group and 43 controls. The mean visual analog scale scores for pain were 46 mm in the lidocaine group and 53 mm in the control group (mean difference 7 mm; 95% CI: -5 to 19 mm). No serious adverse events were observed. Conclusions Intranasal lidocaine administered prior to NP swabs in the ED failed to show an improvement in pain scores for school-aged children and youth.
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Affiliation(s)
- François Gagnon
- Correspondence: Francois Gagnon, Children’s Hospital of Eastern Ontario (CHEO), 401 Smyth Rd, Ottawa, Ontario, K1H 8L1, Canada. Telephone: 514-412-4400, fax: 514-412-4217, e-mail:
| | - Jocelyn Gravel
- Division of Pediatric Emergency Medicine, CHU Ste-Justine, Université de Montréal, Montreal, Quebec, Canada
| | - Camille Duranceau
- Division of Pediatric Emergency Medicine, CHU Ste-Justine, Université de Montréal, Montreal, Quebec, Canada
| | - Emilie Vallieres
- Division of Microbiology, Clinical Laboratory Medicine Department, Centre Hospitalier Universitaire Sainte-Justine, Université de Montréal, Montreal, Quebec, Canada,Division of Infectious Diseases, Pediatrics Department, Centre Hospitalier Universitaire Sainte-Justine, Université de Montréal, Montreal, Quebec, Canada
| | - Maala Bhatt
- Division of Pediatric Emergency Medicine, Children’s Hospital of Eastern Ontario, Ottawa, Ontario, Canada
| | - Stuart Harman
- Division of Pediatric Emergency Medicine, Children’s Hospital of Eastern Ontario, Ottawa, Ontario, Canada
| | - Evelyne D Trottier
- Division of Pediatric Emergency Medicine, CHU Ste-Justine, Université de Montréal, Montreal, Quebec, Canada
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Tsze DS, Lubell TR, Carter RC, Chernick LS, DePeter KC, McLaren SH, Kwok MY, Roskind CG, Gonzalez AE, Fan W, Babineau SE, Friedman BW, Dayan PS. Intranasal ketorolac versus intravenous ketorolac for treatment of migraine headaches in children: A randomized clinical trial. Acad Emerg Med 2022; 29:465-475. [PMID: 34822214 PMCID: PMC10695685 DOI: 10.1111/acem.14422] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2021] [Revised: 10/31/2021] [Accepted: 11/21/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND Intravenous ketorolac is commonly used for treating migraine headaches in children. However, the prerequisite placement of an intravenous line can be technically challenging, time-consuming, and associated with pain and distress. Intranasal ketorolac may be an effective alternative that is needle-free and easier to administer. We aimed to determine whether intranasal ketorolac is non-inferior to intravenous ketorolac for reducing pain in children with migraine headaches. METHODS We conducted a randomized double-blind non-inferiority clinical trial. Children aged 8-17 years with migraine headaches, moderate to severe pain, and requiring parenteral analgesics received intranasal ketorolac (1 mg/kg) or intravenous ketorolac (0.5 mg/kg). Primary outcome was reduction in pain at 60 min after administration measured using the Faces Pain Scale-Revised (scored 0-10). Non-inferiority margin was 2/10. Secondary outcomes included time to onset of clinically meaningful decrease in pain; ancillary emergency department outcomes (e.g. receipt of rescue medications, headache relief, headache freedom, percentage improvement); 24-h follow-up outcomes; functional disability; and adverse events. RESULTS Fifty-nine children were enrolled. We analyzed 27 children who received intranasal ketorolac and 29 who received intravenous ketorolac. The difference in mean pain reduction at 60 min between groups was 0.2 (95% CI -0.9, 1.3), with the upper limit of the 95% CI being less than the non-inferiority margin. There were no statistical differences between groups for secondary outcomes. CONCLUSIONS Intranasal ketorolac was non-inferior to intravenous ketorolac for reducing migraine headache pain in the emergency department.
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Affiliation(s)
- Daniel S. Tsze
- Department of Emergency Medicine, Division of Pediatric Emergency Medicine, Columbia University College of Physicians and Surgeons, New York, New York, USA
| | - Tamar R. Lubell
- Department of Emergency Medicine, Division of Pediatric Emergency Medicine, Columbia University College of Physicians and Surgeons, New York, New York, USA
| | - Robert C. Carter
- Department of Emergency Medicine, Division of Pediatric Emergency Medicine, Columbia University College of Physicians and Surgeons, New York, New York, USA
| | - Lauren S. Chernick
- Department of Emergency Medicine, Division of Pediatric Emergency Medicine, Columbia University College of Physicians and Surgeons, New York, New York, USA
| | - Kerrin C. DePeter
- Department of Emergency Medicine, Division of Pediatric Emergency Medicine, Columbia University College of Physicians and Surgeons, New York, New York, USA
| | - Son H. McLaren
- Department of Emergency Medicine, Division of Pediatric Emergency Medicine, Columbia University College of Physicians and Surgeons, New York, New York, USA
| | - Maria Y. Kwok
- Department of Emergency Medicine, Division of Pediatric Emergency Medicine, Columbia University College of Physicians and Surgeons, New York, New York, USA
| | - Cindy G. Roskind
- Department of Emergency Medicine, Division of Pediatric Emergency Medicine, Columbia University College of Physicians and Surgeons, New York, New York, USA
| | - Ariana E. Gonzalez
- Department of Emergency Medicine, Division of Pediatric Emergency Medicine, Columbia University College of Physicians and Surgeons, New York, New York, USA
| | - Weijia Fan
- Department of Biostatistics, Mailman School of Public Health, Columbia University, New York, New York, USA
| | - Shannon E. Babineau
- Departments of Pediatrics and Neurology, Sidney Kimmel Medical College of Thomas Jefferson University, Morristown, New Jersey, USA
| | - Benjamin W. Friedman
- Department of Emergency Medicine, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, New York, USA
| | - Peter S. Dayan
- Department of Emergency Medicine, Division of Pediatric Emergency Medicine, Columbia University College of Physicians and Surgeons, New York, New York, USA
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Update on Management of Acute Migraine. CURRENT EMERGENCY AND HOSPITAL MEDICINE REPORTS 2021. [DOI: 10.1007/s40138-021-00235-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Meek R, Graudins A, McDonald M, McGannon D, Limm E. Comparing propofol with placebo for early resolution of acute migraine in adult emergency department patients: A double-blind randomised controlled trial. Emerg Med Australas 2021; 33:465-472. [PMID: 33070469 DOI: 10.1111/1742-6723.13659] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2020] [Revised: 06/23/2020] [Accepted: 09/14/2020] [Indexed: 11/27/2022]
Abstract
OBJECTIVE To compare propofol with placebo in adult ED patients with acute migraine. Primary outcome was headache resolution by 1 h. Secondary outcome was reduction in headache severity by two or more points on a numerical rating scale. METHODS Double-blind randomised controlled clinical trial comparing propofol (10 mg/mL) with placebo (20% intralipid). Adults with acute migraine without aura were included. The study drug was administered as an initial dose of 4 mL followed by up to five doses of 2 mL, delivered 5 min apart. Pain scores were taken prior to each dose and further administration was ceased when either the pain score was zero or the maximum dosage reached (140 mg of propofol or 14 mL of 20% intralipid). RESULTS Of 40 recruited patients, 21 received propofol and 19 placebo. Headache resolution occurred for 5 (24%, 95% CI 13-57) and 6 (32%, 95% CI 13-57) patients, respectively, difference 8% (95% CI -20 to 36). Headache severity reduction by two or more numerical rating scale points was reported by 17 (81%, 95% CI 58-95) and 7 (37%, 95% CI 16-62) patients, respectively, difference 44% (95% CI 17-71). CONCLUSIONS Propofol was not superior to placebo for the primary outcome of early headache resolution. Superiority of propofol for the secondary outcome of headache severity reduction suggests that further research may be warranted.
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Affiliation(s)
- Robert Meek
- Emergency Department, Dandenong Hospital, Melbourne, Victoria, Australia
- Department of Medicine, Monash University, Melbourne, Victoria, Australia
| | - Andis Graudins
- Emergency Department, Dandenong Hospital, Melbourne, Victoria, Australia
- Department of Medicine, Monash University, Melbourne, Victoria, Australia
| | - Micah McDonald
- Emergency Department, Dandenong Hospital, Melbourne, Victoria, Australia
| | - Daniel McGannon
- Emergency Department, Dandenong Hospital, Melbourne, Victoria, Australia
- Department of Medicine, Monash University, Melbourne, Victoria, Australia
| | - Ezra Limm
- Emergency Department, Dandenong Hospital, Melbourne, Victoria, Australia
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Abstract
PURPOSE OF REVIEW This article reviews the approach to a child or adolescent with headache, the criteria for common diagnoses, and the evidence base for treatments. RECENT FINDINGS The guidelines for acute and preventive treatment of migraine were updated in 2019. These guidelines summarize the available evidence and outline the questions that should be addressed in future research. The US Food and Drug Administration (FDA) approval of several new classes of drugs and devices to treat adult migraine in the past few years has resulted in ongoing or planned pediatric trials. SUMMARY Headache is a common symptom in children, and it is important to take a detailed history and perform a thorough physical examination to make the diagnosis. Nearly 1 in 10 children experience recurrent headaches due to migraine, which cause significant impairment in school performance and quality of life. The acute and preventive treatments that are currently available will help at least two-thirds of children with migraine, and several trials of new therapies offer hope for the future.
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Werner K, Qaiser S, Kabbouche M, Murphy B, Maconochie I, Hershey AD. Intravenous Migraine Treatment in Children and Adolescents. Curr Pain Headache Rep 2020; 24:45. [DOI: 10.1007/s11916-020-00867-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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Abstract
Migraine is a frequently disabling neurologic condition which can be complicated by medication overuse headache and comorbid medical disorders, including obesity, anxiety and depression. Although most migraine management takes place in outpatient clinics, inpatient treatment is indicated for migraine refractory to multiple outpatient treatments, with intractable nausea or vomiting, need for detoxification from medication overuse (such as opioids and barbiturates), and significant medical and psychiatric disease. The goals of inpatient treatment include breaking the current cycle of headache pain, reducing the frequency and/or severity of future attacks, monitored detoxification of overused medications, and reducing disability and improving quality of life.
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Affiliation(s)
- Michael J Marmura
- Thomas Jefferson University, Jefferson Headache Center, 900 Walnut Street #200, Philadelphia, PA 19107, USA.
| | - Angela Hou
- Thomas Jefferson University, Jefferson Headache Center, 900 Walnut Street #200, Philadelphia, PA 19107, USA. https://twitter.com/JeffHeadacheCtr
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Imaging Utilization in Children With Headaches: Current Status and Opportunities for Improvement. J Am Coll Radiol 2020; 17:574-583. [DOI: 10.1016/j.jacr.2020.01.008] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2019] [Revised: 01/12/2020] [Accepted: 01/13/2020] [Indexed: 02/08/2023]
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Abstract
PURPOSE OF REVIEW This article reviews treatment options for patients presenting with headache in the emergency department (ED) and for inpatients, including red flags and status migrainosus (SM). RECENT FINDINGS Most patients presenting with headache in the ED will have migraine, but red flags must be reviewed to rule out secondary headaches. SM refractory to home treatment is a common reason for ED presentation or inpatient admission, but high-quality treatment evidence is lacking. Common treatments include intravenous fluids, anti-dopaminergic agents with diphenhydramine, steroids, divalproex, nonsteroidal anti-inflammatory drugs, intravenous dihydroergotamine, and nerve blocks. Other therapies (e.g., ketamine and lidocaine) are used with limited or inconsistent evidence. There is evidence for inpatient behavioral management therapy. This article details red flags to review in the workup of headache presentation in the ED and provides a step-wise approach to ED and inpatient management. However, more studies are needed to better optimize care.
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Affiliation(s)
- Jennifer Robblee
- Jan and Tom Lewis Migraine Treatment Program, Department of Neurology, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ, USA.
| | - Kate W Grimsrud
- Cerebrovascular and Hospital Neurology, Penrose Neuroscience, Colorado Springs, CO, USA
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Piatka C, Beckett RD. Propofol for Treatment of Acute Migraine in the Emergency Department: A Systematic Review. Acad Emerg Med 2020; 27:148-160. [PMID: 31621134 DOI: 10.1111/acem.13870] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2019] [Revised: 09/24/2019] [Accepted: 10/13/2019] [Indexed: 01/10/2023]
Abstract
OBJECTIVES Propofol has not been extensively studied as an acute migraine therapy; however, based on the limited evidence from outpatient and inpatient settings, propofol has been proposed as an option for patients who present to the emergency department (ED). The purpose of this review was to evaluate the existing literature regarding the safety and efficacy of propofol for acute migraine treatment in the ED. METHODS A systematic review of clinical studies of propofol treatment for acute migraine in the ED was performed using Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) guidelines. Trials were identified through PubMed, Google Scholar, clinical trial registries, research registries, and key journals through May 2019. A modified Jadad scoring system was used to assess the methodologic quality of the included randomized controlled trials, and the Newcastle-Ottawa Scale was used for the retrospective cohort study. RESULTS Nine studies, including five case reports or series, one retrospective cohort study, and three randomized controlled trials, consisting of 290 patients, were reviewed. All studies in adults reported propofol to be an effective therapy for migraine, but the strength of these results was limited by dosing variations, small sample sizes, and limited generalizability. Pediatric studies produced mixed results. CONCLUSIONS Propofol may be an effective rescue therapy for patients presenting to the ED for acute migraine, but its place in therapy based on the limited available evidence is unknown. The safety of propofol for migraine management in the ED has not been adequately examined.
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Chua AL, Grosberg BM, Evans RW. Status Migrainosus in Children and Adults. Headache 2019; 59:1611-1623. [DOI: 10.1111/head.13676] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/12/2019] [Indexed: 01/01/2023]
Affiliation(s)
- Abigail L. Chua
- Hartford Healthcare Headache Center University of Connecticut School of Medicine West Hartford CT USA
| | - Brian M. Grosberg
- Hartford Healthcare Headache Center University of Connecticut School of Medicine West Hartford CT USA
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Barbanti P, Grazzi L, Egeo G. Pharmacotherapy for acute migraines in children and adolescents. Expert Opin Pharmacother 2018; 20:455-463. [DOI: 10.1080/14656566.2018.1552941] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Affiliation(s)
- P. Barbanti
- Headache and Pain Unit, Department of Neurological, Motor and Sensorial Sciences; IRCCS San Raffaele Pisana, Rome, Italy
- San Raffaele University, Rome, Italy
| | - L. Grazzi
- Neuroalgology Unit, Headache Center Fondazione IRCCS Istituto Neurologico “Carlo Besta”, Milan, Italy
| | - G. Egeo
- Headache and Pain Unit, Department of Neurological, Motor and Sensorial Sciences; IRCCS San Raffaele Pisana, Rome, Italy
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Orr SL, Richer L, Barrowman N, Zemek R. Oral dexamethasone for the prevention of acute migraine recurrence in pediatric patients presenting to the emergency department with migraine. CEPHALALGIA REPORTS 2018. [DOI: 10.1177/2515816318804158] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
Objective: To assess the feasibility of a randomized controlled trial protocol that aims to determine the efficacy and safety of oral dexamethasone compared to placebo for the prevention of migraine recurrence in children and adolescents visiting the pediatric emergency department (ED) with migraine. Methods: This study was a two-arm, parallel-group, randomized, placebo-controlled, double-blind pilot trial of patients presenting to the pediatric ED with migraine. Eligible participants were randomized at 1:1 ratio to receive either oral dexamethasone 0.6 mg/kg (maximum 15 mg) or matched placebo as a single dose. Efficacy and safety outcomes were assessed at discharge, 48 h and 7 days after discharge. The primary outcome of the trial was feasibility and was assessed through participant recruitment rate, follow-up completion rates, participant satisfaction ratings and comparison of enrolled versus non-enrolled participants. Efficacy and safety outcomes were not analyzed given that this was a pilot study. Results: Twelve participants were enrolled over the 6-month recruitment period. This represents 60% of the planned sample size and a 10.5% recruitment rate. No other feasibility issues were identified and patients expressed high satisfaction rates with their treatment: 90.9% were satisfied with their treatment at discharge and at 48-h follow-up and 81.8% were satisfied with their treatment at 7-day follow-up (81.8%). There were no significant differences observed when comparing enrolled participants to those not enrolled. Conclusion: This pilot randomized controlled trial is the first to assess dexamethasone in the pediatric ED for the prevention of migraine recurrence. The protocol is feasible but recruitment in a single center was lower than expected. Future pediatric ED migraine studies may use innovative or pragmatic trial designs to maximize feasibility from a recruitment standpoint.
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Affiliation(s)
- Serena L Orr
- Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio, USA
| | - Lawrence Richer
- Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
- Women and Children’s Health Research Institute, Edmonton, Alberta, Canada
| | - Nick Barrowman
- Children’s Hospital of Eastern Ontario, Ottawa, Ontario, Canada
- Department of Pediatrics, University of Ottawa, Ottawa, Ontario, Canada
| | - Roger Zemek
- Children’s Hospital of Eastern Ontario, Ottawa, Ontario, Canada
- Department of Pediatrics, University of Ottawa, Ottawa, Ontario, Canada
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